ji-jioiJXJLJi'jioi^iJiJiJiJiji-ir>)i-ji'ji'jrjioi-ji-ji-jiJiJi~>i'j^ 


§ 


Presented  by 
Helen  G.  Fletcher,  D.o. 


COLLEGE    OF    OSTEOPATHIC    PHYSICIANS 


AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA      U 


a(a(a(aaS(S0(»(9®($9®(»®(»(i®($0(S(»®(#99(S9®9(d900(9« 


UNIVERSITY  OF  CALIFORNIA 

CALIFORNIA  COLLEGE  OF  MEDICINE 

LIBRARY 

.IIIN       81971 

IRVINE.  CALIFORNIA  92664 


Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/diseasesofinfancOOholtiala 


THE  DISEASES  OF  INFANCY 
AND  CHILDHOOD 


THE 

DISEASES  OF  INFANCY 
AND  CHILDHOOD 

FOR  THE   USE   OF  STUDENTS 
AND   PRACTITIONERS   OF   MEDICINE 


BY 


L.   EMMETT 


HOLT, 


M.D.,  Sc.D.,   LLD. 


PROFESSOR   OF   DISEASES   OF   CHILDREN    IN   THE   COLLEGE   OF   PHYSICIANS   AND   SURGEONS 

(COLUMBIA    UNIVERSITY),    NEW    YORK  ;    ATTENDING     PHYSICIAN    TO    THE    BABIES' 

AND    FOUNDLING    HOSPITALS,     NEW    YORK;    CORRESPONDING    MEMBER    OF 

THE  GESELLSCHAFT  FUR  INNERE  MEDIZIN  UND  KINDERHEILKUNDE, 

VIENNA,   AND    HONORARY    MEMBER   OF   THE    GESELLSCHAFT 

FUR    KINDERHEILKUNDE,    GERMANY 

ASSISTED   BY 

JOHN   HOWL  AND,   A.B.,   M.D. 

PROFESSOR   OF   DISEASES   OF   CHILDREN   IN    WASHINGTON    UNIVERSITY,    ST.    LOUIS; 

LATE  ASSOCIATE    IN    DISEASES   OF   CHILDREN    IN   TH"   COLLEGE   OF 

PHYSICIANS  AND   SURGEONS,    NEW   YORK 


SIXTH    EDITION.  FULLY    REVISED 

IVITH  TJVO  HUNDRED  AND  FORTY  ILLUSTRATIONS 
INCLUDING  EIGHT  COLOURED  PLATES 


NEW   YORK   AND   LONDON 

D.     APPLETON    AND    COMPANY 

191 1 


I  1  I' 


Copyright,  1897.  1902,  1905,  1907,  1909,  1911, 
By  D.  APPLETON  AND  COMPANY 


PKINTKD   AT  THE  APPLETON   PRESS 
NEW   YORK,    V.   8.    A. 


TO 
VIRGIL  P.   GIBNEY,  M.D.,   LL.D., 

PROFESSOR    OF    ORTHOPEDIC    SURGERY    IN    THE    COLLEGE    OF    PHYSICIANS    AND 

SURGEONS    (COLUMBIA   UNIVERSITY),    NEW   YORK;    SURGEON-IN-CHIEF 

TO.  THE   HOSPITAL   FOR  THE   RUPTURED    AND   CRIPPLED, 

THIS  VOLUME  IS   INSCRIBED 

AS   A   TRIBUTE  TO   HIS   PERSONAL   WORTH    AND   HIGH   PROFESSIONAL    ATTAINMENTS. 
AND  IN   GRATEFUL   REMEMBRANCE  OF  MANY   ACTS  OF  KINDNESS 

BY  THE  AUTHOR. 


1) 
nil 


PREFACE  TO  THE  SIXTH   EDITION 


In  the  preparation  of  this  edition  the  author  lias  associated  with 
Z,    him  Dr.   John  Howland,  his  former  assistant,  who   will   hereafter   he 

^    connected  with  the  work  as  joint  author. 

<~ 

^  Progress  along  many  lines  in  paediatrics  has  heen  rapid  during  the 

>) 

^   last  two  years.      To   make   room   for   new   knowledge   without   unduly 

ni  enlarging  the  size  of  the  volume  has  made  it  necessary  to  cut  out  about 
,  seventy-five  pages  of  old  material.  It  is  believed  that  this  has  been 
accomplished  without  impairing  the  value  of  the  chapters  which  have 
I  been  abridged.  The  decision  of  the  publishers  to  make  entirely  new 
■^    plates  has  made  this  comparatively  easy. 

There  is  scarcely  a  page  in  the  book  which  has  not  been  subject  to 
>    some  revision.     Many  articles  have  been  entirely  rewritten  and  several 
^    new  ones  appear  for  the  first  time  in  this  edition.     The  greater  part  of 
u    the  new  material  will  be  found  in  the  chapters  upon  Nutrition  and 
—    Infant  Feeding,  Infant  Mortality,  Intestinal  Intoxication,  Pyloric  Ste- 
nosis,  Appendicitis,   Acute   Peritonitis,   Endocarditis   and   Pericarditis, 
Cerebro-spinal  and  Other  Forms  of  Acute  Meningitis,  Acute  Poliomye- 
litis, Hereditary  Syphilis  and  Tuberculosis. 

A  number  of  the  old  illustrations  have  been  omitted  as  no  longer 
•^    necessary;  others  have  been  replaced  by  better  ones.     In  all,  thirty-six 
new  illustrations  have  been  introduced,  including  twelve   radiographs. 
All  illustrations  are  from  original  sources  unless  otherwise  stated. 

The  authors  desire  to  acknowledge  their  indebtedness  to  Dr.  F.  H. 
Bartlett  for  much  assistance  rendered  in  every  way  in  the  work  of 
revision;  to  Dr.  H.  H.  Mason  for  correction  of  the  proof  sheets,  and 
to  Dr.  N.  C.  Holt  for  the  preparation  of  the  index. 

14  West  Fifty-fifth  Street, 
New  York. 


vu 


23706 


TABLE   OF   CONTENTS. 


PART  I. 

CHAPTER  PAGE 

I. — Hygiene  and  General  Care  of  Infants  and  Young  Children  .  1 
Care  of  the  newly-born  child  ;  bathing ;  clothing ;  care  of  the  eyes  ; 
care  of  the  month  and  teeth  ;  care  of  the  skin  ;  care  of  the  genital 
organs ;  vaccination ;  training  to  proper  control  of  rectum  and 
bladder ;  general  hygiene  of  the  nervous  system ;  sleep ;  exercise ; 
airing ;  the  nursery ;  the  nurse ;  the  amount  of  air  space  required 
by  inf-ants ;  the  care  of  premature  and  delicate  infants ;  incubators ; 
the  feeding  of  the  premature  infant. 

II. — Growth  and  Development  of  the  Body 15 

Weight ;  height ;  growth  of  extremities  as  compared  with  the 
trunk  ;  the  head  ;  the  chest ;  the  abdomen  ;  muscular  development ; 
development  of  special  senses ;  speech  ;  dentition. 

III. — Peculiarities  of  Disease  in  Children 29 

Etiology  ;  symptomatology  and  diagnosis  ;  pathology  ;  prognosis  and 
infant   mortality  ;   prophylaxis  ;   therapeutics. 


PART   II. 
Section  I. — Diseases  of  the  Newly  Born. 

I. — Asphyxia 68 

II. — Congenital  Atelectasis 73 

III. — Icterus 76 

IV. — The  Acute  Infections  of  the  Newly  Born 80 

The  acute  pj'ogenic  diseases ;  ophthalmia  ;  tetanus ;  epidemic  haemo- 
globinuria  ;  fatty  degeneration  of  the  newly  born  ;  pemphigus. 

V. — HAEMORRHAGES 94 

Traumatic  or  accidental  haemorrhages ;   spontaneous  haemorrhages. 

VI. — Birth  Paralyses 104 

Cerebral     paralysis ;     facial     paralysis ;     paralysis     of     the     upper 
extremity. 

VII. — Tumours  of  the  Umbilicus,  etc 110 

Umbilical   hernia ;    mastitis ;   intestinal   obstruction ;   diaphragmatic 
hernia  ;  sclerema  ;  oedema  ;  inanition  fever. 

ix 


X  TABLE  OF  CONTENTS. 

Section  II. — Nutrition. 

CHAPTER  PAGE 

I. — Intboductoby 122 

The  food  constituents  and  the  purposes  they  subserve  in  nutrition. 

II. — The  I:nfant's  Dietaby 127 

Woman's  milk ;  cow's  milk ;  condensed  milk ;  buttermilk ;  dried 
milk ;  kumyss ;  matzoon ;  junket,  curds  and  whey ;  beef  prepara- 
tions ;   cereals ;   infant   foods. 

III. — Infant  Feeding 163 

Choice  of  methods  ;  breast  feeding ;  maternal  nursing ;  wet-nursing ; 
weaning ;   mixed  feeding ;  artificial  feeding. 

IV. — Feeding  afteb  the  Fibst  Yeab 209 

Healthy  infants  during  the  second  year;  difficult  cases  during  the 
second  year ;  feeding  from  the  third  to  the  sixth  year ;  feeding 
during  acute  illness. 

V. — The  Debangements  of  Xutbition 216 

Acute  inanition  ;  malnutrition  ;  marasmus. 

VI. — Diseases  Bite  to  Faulty  Nutrition 233 

Scorbutus ;  rickets. 

Section  III. — Diseases  of  the  Digestive  System. 

I. — Diseases  of  the  Lips,  Tongue,  and  Mouth 262 

Malformations ;  diseases  of  the  lips ;  diseases  of  the  tongue ; 
alveolar  abscess ;  difficult  dentition  ;  dental  caries ;  catarrhal  stoma- 
titis ;  herpetic  stomatitis ;  ulcerative  stomatitis ;  thrush ;  gonor- 
rhoea! stomatitis ;  syphilitic  stomatitis ;  diphtheritic  stomatitis ; 
gangrenous  stomatitis. 

11. — Diseases  of  the  Phabynx 282 

Acute  pharyngitis ;  uvulitis ;  elongated  uvula ;  retro-pharyngeal  ab- 
scess ;  adenoid  vegetations  of  the  vault  of  the  pharynx. 

III. — Diseases  of  the  Tonsils 294 

Membranous  tonsillitis ;  ulce^'o-membranous  tonsillitis ;  follicular 
tonsillitis ;  phlegmonous  tonsillitis ;  chronic  hypertrophy  of  the 
tonsils. 

IV. — Diseases  of  the  CEsophagus 304 

Malformations ;  acute  oesophagitis ;  retro-oesophageal  abscess. 

V. — Diseases  of  the  Stomach 308 

Digestion  in  infancy ;  malformations  and  malpositions  of  the  stom- 
ach ;  hypertrophic  stenosis  of  the  pylorus;  vomiting;  cyclic  vomit- 
ing ;  gastralgia  ;  acute  gastric  indigestion  ;  acute  gastritis ;  gastro- 
duodenitis ;  chronic  gastric  indigestion  ;  dilatation  of  the  stomach  ; 
ulcer  of  the  stomach ;  tumours  of  the  stomach ;  haemorrhage  from 
the  stomach. 

VI. — Diseases  of  the  Intestines •  ■  341 

Malformations  and  malpositions ;  diarrha-a :  acute  intestinal  indi- 
gestion  and   intoxication ;   cholera   infantum. 


TABLE  OF  CONTENTS.  xi 

CHAPTER  PAGE 

VII. — Diseases  of  the  Intestines    {continued) 365 

Acute  colitis  and  ileo-colitis ;  chronic  iloo-colitis ;  ama'bic  colitis : 
amyloid  degeneration  of  the  intestines  ;  tuberculosis  of  the  intestines 
and  mesenteric  lymph  nodes. 

VIII. — Diseases  of  the  Intestines    [continued] 393 

Chronic  intestinal  indigestion ;  intestinal  colic ;  chronic  constipa- 
tion ;   intussusception. 

IX. — Diseases  of  the  Intestines    (continued) 415 

Appendicitis  ;  intestinal  worms. 

X. — Diseases  of  the  Rectum 420 

Prolapsus  ani ;  fissure  of  the  anus ;  proctitis  ;  ischio-rectal  abscess  ; 
haemorrhoids ;   incontinence  of  fa?ces. 

XI. — Diseases  of  the  Liver 433 

Chronic  family  jaundice ;  catarrhal  jaundice ;  functional  disorders  ; 
new  growths ;  acute  yellow  atrophy ;  congestion  of  the  liver ;  ab- 
scess of  the  liver;  cirrhosis;  amyloid  degeneration;  fatty  liver; 
hydatids ;   biliary  calculi. 

XII. — Diseases  of  the  Peritoneum 441 

Acute  peritonitis;  chronic  (non-tuberculous)  peritonitis;  tuber- 
culous peritonitis  ;  ascites  ;  subphrenic  abscess. 

Section  IV. — Diseases  on  the  Respiratory  System. 

I. — Nasal  Cavities 454 

Acute  nasal  catarrh ;  chronic  nasal  catarrh ;  chronic  rhinitis ; 
epistaxis. 

II. — Diseases  of  the  Larynx 462 

Catarrhal  spasm  of  the  larynx ;  acute  catarrhal  laryngitis :  sub- 
mucous laryngitis  ;  chronic  laryngitis  ;  new  growths  ;  foreign  bodies 
in  the  lai'ynx  and  bronchi. 

III. — Diseases  of  the  Lungs ^f       .     472 

The  peculiarities  of  the  lungs  in  infancy  and  early  childhood  :  acute 
catarrhal  bronchitis ;  fibrinous  bronchitis ;  chronic  bronchitis ;  re- 
flex cough  ;  asthma. 

IV. — Diseases  of  the  Lungs    [continued) 489 

Pneumonia ;  acute  broncho-pneumonia. 

V. — Diseases  of  the  Lungs    [continued) .        .     520 

Lobar  pneumonia ;  pleuro-pneumonia ;  hypostatic  pneumonia ; 
chronic  broncho-pneumonia ;  abscess  of  the  lung ;  gangrene  of  the 
lung  ;  acquired  atelectasis  ;  emphysema. 

VI. — Pleurisy 549 

Dry   pleurisy ;   pleurisy   with   serous   effusion ;    empyema. 

Section  V. — Diseases  of  the  Circulatory  System. 
I. — Peculiarities  of  the  Heart  and  Circulation  iic  Early  Life     .     564 
II. — Congenital  Anomalies  of  the  Heart 567 


XU  TABLE  OF  CONTENTS. 

CHAPTEB  PAGH 

III. — Pebicaeditis 576 

Acute   pericarditis ;   chronic   pericarditis   with   adhesions. 

IV. — Endocarditis  and  Valvular  Disease 582 

Malignant  endocarditis ;  myocarditis ;  ansemic  murmurs ;  func- 
tional disorders  of  the  heart ;  diseases  of  the  blood-vessels. 

Section  VI. — Diseases  of  the  Uro-Genital  System. 

I. — The  Urine  in  Infancy  and  Childhood 598 

Cyclic  or  orthostatic  albuminuria ;  hsematuria ;  haemoglobinuria ; 
pyuria  ;  indicanuria  ;  acetonuria  ;  anuria  ;  diabetes  insipidus. 

II. — Diseases  of  the  Kidneys 606 

Malformations  and  malpositions ;  uric-acid  infarctions ;  chronic 
congestion  of  the  kidney ;  acute  degeneration  of  the  kidneys ;  acute 
diffuse  nephritis ;  chronic  nephritis ;  tuberculosis  of  the  kidney ; 
malignant  tumours  of  the  kidney ;  pyelitis — pyelo-cystitis ;  renal 
calculi ;  traumatic  hydronephrosis ;  perinephritis. 

III. — Diseases  of  the  Genital  Organs 631 

Malformations ;  diseases  of  the  male  genitals ;  diseases  of  the 
female  genitals. 

IV.— Enuresis 641 

Vesical  siiasm ;   vesical  calculi. 

Section  VII. — Diseases  of  the  Nervous  System. 

I. — Introductory 647 

II. — General  and  Functional  Nervous  Diseases 649 

Convulsions  ;  tetany  ;  laryngismus  stridulus  ;  holding-breath  spells  ; 
epilepsy  ;  chorea  ;  other  spasmodic  affections  ;  hysteria  ;  headaches  ; 
disorders  of  speech  ;  disorders  of  sleep ;  injurious  habits  of  infancy 
and  childhood. 

III. — Diseases  of  the  Brain  and  Meninges 694 

Malformations  ;  pachymeningitis  ;  cerebro-spinal  meningitis  ;  acute 
meningitis  from  other  causes ;  tuberculous  meningitis ;  chronic 
basilar  meningitis  in  infants ;  thrombosis  of  the  sinuses  of  the  dura 
mater  ;  cerebral  abscess  ;  cerebral  tumour  ;  hydrocephalus  ;  infantile 
cerebral  paralysis ;  mental  defects ;  chondro-dystrophy ;  sporadic 
cretinism ;  insanity ;  the  stigmata  of  degeneration  ;  deaf-mutism. 

IV. — Diseases  of  the  Spinal  Cord 772 

Malformations  ;  spinal  meningitis  ;  myelitis  ;  compression-myelitis  ; 
acute  poliomyelitis ;  tumours  of  the  spinal  cord ;  syringo-myelia ; 
Friedreich's  ataxia ;  Landry's  paralysis ;  the  muscular  ati'ophies. 

V. — Diseases  of  the  Peripheral  Nerves 800 

Multiple  neuritis ;  diphtheritic  paralysis ;  facial  paralysis. 

Section  VIII. — Diseases  of  the  Blood,  Lymph  Nodes,  Bones,  etc. 

I. — Diseases  of  the  Blood 809 

Leucocytosis ;  simple  anaemia ;  chlorosis ;  pseudo-leukaemic  ana?mia 
of  infancy  ;  pernicious  anaemia  ;  leukaemia  ;  haemophilia  ;  purpura. 


TABLE  OF  CONTENTS.  Xlll 

CHAPTER  PAGE 

II. — Diseases  of  the  Lymph  Nodes 830 

Status  lymphaticu.s  ;  simple  acute  adenitis  ;  simple  chronic  adenitis  ; 
syphilitic  adenitis  ;  tuberculous  adenitis  ;  Ilodgkin's  disease. 

III. — Diseases  of  the  Spleen 848 

IV. — Diseases  of  the  Bones  and  Joints 850 

Acute  arthritis  of  infants  ;  tuberculous  diseases  of  the  bones  and 
joints ;  sjphilitic  diseases  of  bone. 

V. — Diseases  of  the  Skin 875 

Congenital  ichth.vosis  ;  miliaria  ;  seborrhoea  ;  eczema  ;  furunculosis  ; 
gangrenous  dermatitis ;  impetigo  contagiosa  ;  urticaria  ;  scabies  ; 
tinea  tonsurans. 

VI. — Acute  Otitis 894 

Section  IX. — The  Specific  Infectious  Diseases. 

I. — Scarlet  Fever 903 

II.— Measles 927 

III.— Rubella 943 

IV.— Varicella .946 

V. — Vaccinia — Vaccination .        .  948 

VI. — Pertussis 954 

VII.— Mumps 965 

VIII. — Diphtheria   and   Intubation 969 

IX. — Typhoid  Fever 1009 

X. — Tuberculosis 1017 

XL— Syphilis 1052 

XII. — Influenza 1070 

XIIL— Malaria 1075 

Section  X. — Other  General  Diseases. 

I. — Rheumatism 1085 

II. — Diabetes  Mellitus 1091 


LIST   OF   ILLUSTRATIONS. 


-PL/ A  1  xLo .  FACING 

PLATE  PAGE 

I.     Chart  showing  by  months  the  mortality  of  New  York  City  for  the 

different  ages  for  three  years 43 

II.     Meningeal  haemorrhage  in  the  newly  born 104 

III.  Chart  showing  composition  of  various  infant  foods  compared  with 

woman's  milk 163 

IV.  Bone  in  rickets 246 

V.     Typical   rickets 248 

VI.     Deformity  of  the  chest  in  severe  rickets 252 

VII.     The  stomach  at  the  different  periods  of  infancy 308 

VIII.     Extensive  superficial  ulceration  of  the  colon 368 

IX.     Deep  follicular  ulcers  of  the  colon 370 

X.     Membranous  inflammation  of  the  ileum 372 

XI.     Acute  broncho-pneumonia 494 

XII.     Acute  pleuro-pneumonia 538 

XIII.  Chronic  broncho-pneumonia 540 

XIV.  Acute  meningitis,   complicating  pleuro-pneumonia               .        .        .718 
XV.     The  blood  in  leukaemia  and  pernicious  anaemia,  etc 810 

XVI.     Eruption  of  measles 932 

XVII.     The  pathognomonic  sign  of  measles    (Koplik's  spots)                 .  940 

XVIII.     The  diphtheritic  membrane 978 

XIX.     Tuberculosis  of  the  tracheo-bronchial  lymph  nodes     ....  1028 


ILLUSTRATIONS   IN  THE  TEXT. 

FIGURE  PAGE 

1.  Breck's  feeding  tube 13 

2.  Scales 15 

3.  Weight  curve  for  the  first  twenty  days 16 

4.  Weight  curve  for  the  first  year 17 

5.  Skull,  showing  premature  ossification 23 

6.  Deaths,  New  York  City,  per  1,000  of  population 43 

7.  Deaths  by  months,  New  York  City 43 

8.  Chief  causes  of  death  first  year 44 

9.  Nasal   syringe 58 

10.  Position   for  nasal  syringing    ...                59 

11.  Croup  kettle 60 

12.  Apparatus  for  stomach-washing 61 

XV 


xvi  LIST  OF  ILLUSTRATIONS. 

FIGURE  FAOB 

13.  Position  for  stomach-washing 62 

14.  Colon  of  a  child  six  months  old 64 

15.  Carrel's  apparatus  for  inflating  the  lungs 73 

16.  Pemphigus    Neonatorum 93 

17.  Triple   cephalhaematoma 96 

18.  Erb's   paralysis 109 

19.  Umbilical  fistula  and  tumours Ill 

20.  Diaphragmatic   hernia 115 

21.  Temperature  chart  in  inanition  fever 120 

22.  Human  milk:  A,  colostrum  period;  B,  later  period 128 

23.  Apparatus  for  examination  of  human  milk 132 

24.  A,  Babcock  tubes ;   B,  Lewi's  modification  for  human  milk              .        .  133 

25.  Freeman   pasteuriser 152 

26.  Weight  curve  of  nursing  and  artificial  feeding  compared                         .  165 

27.  Weight  curve  showing  effect  of  bad  nursing  and  good  feeding                  .  173 

28.  Chart  showing  effect  of  pregnancy  on  weight  of  nursing  infant      .  175 

29.  Weight  curve  of  infant   properly  weaned 176 

30.  Weight   curve   of   artificially   fed   infant,   showing   effect   of   beginning 

with  too  high   percentages 192 

31.  Weight  chart  showing  the  effect  of  intelligent  care 201 

32.  Case  of  marasmus 230 

33.  Case  of  scurvy 236 

34.  Normal  bone 246 

35.  Rachitic  bone 247 

36.  Rachitic  skull,  inside  view 249 

37.  Rachitic   head 250 

38.  Rachitic   skull,   external   view 250 

39.  Rachitic  thorax  in  outline 251 

40.  Rachitic  spine 252 

41.  Multiple  fractures  in  rickets 253 

42.  Rachitic  bow-legs 253 

43.  Rachitic   knock-knees • 254 

44.  Epithelial   desquamation  of  the  tongue 265 

45.  Thrush .  276 

46.  Gangrenous   stomatitis 281 

47.  Adenoid   vegetations 289 

48.  Temperature  chart,  streptococcus  angina  following  measles             .        .  297 

49.  Gastric  peristalsis  in  pyloric  stenosis 315 

50.  Malformations  of  the   rectum 341 

51.  Chart  showing  mortality  from  diarrhoeal  diseases  in  New  York  344 

52.  Chart  showing  deaths   under  one  year  per   1,000  of  population   under 

one  year,  New  York  City,  summer  months 345 

53.  Temperature  chart  of  acute   intestinal   intoxication  witli   fatal   relapse  354 

54.  Acute  catarrhal   ileocolitis,   superficial   type 368 

55.  Acute  catarrhal   ileo-colitis,  severe  form 369 

56.  Follicular  ulceration  of  the  colon,  early  stage 370 

57.  Follicular  ulceration  of  the  colon,  later  stage 371 

58.  Membranous   colitis 373 

59.  Weight  curve  showing  loss  from  ileo-colitis 375 

60.  Temperature  chart  in  ileo-colitis 377 

61.  Temperature  chart  in  membranous  colitis             379 

62.  Temperature  chart  in  membranous  colitis 380 


LIST  OF   ILLUSTRATIONS. 


XVll 


after 


FIGURK 

63.  Chronic  catarrhal  inflammation  of  the  ileum 

64.  Chronic  intestinal  indigestion 

65.  Ileo-caecal  intussusception 

66.  Mechanism  of  intussusception  .... 

67.  Ascaris  lumbricoides 

68.  Oxyuris  vermicularis 

69.  Prolapsus  ani 

70.  An  air  vesicle  in  broncho-pneumonia 
7L  An  air  vesicle  in  lobar  pneumonia 

72.  Broncho-pneumonia  with  thickened  bronchus 

73.  Broncho-pneumonia  with  emphj'sema 

74.  Broncho-pneumonia,  diff"use   purulent   infiltration 

75.  Persistent  broncho-pneumonia  .... 

76.  Temperature  chart  in  mild  uncomplicated  bronclio-pneumonia 

77.  Temperature  chart,  prolonged   broncho-pneumonia 

78.  Temperature  chart,  relapsing  broncho-pneumonia 

79.  Temperature  chart,  rapidly  fatal  broncho-pneumonia 
80-83.  Physical  signs  in  broncho-pneumonia 

84.  Temperature  chart,  persistent   broncho-pneumonia 

85.  Temperature  chart,  broncho-pneumonia  following  pertussis 

86.  Temperature  chart,  typical   lobar  pneumonia 

87.  Temperature  chart,  remittent   tjpe,   lobar   pneumonia 

88.  Temperature  chart,  lobar  pneumonia,  subnormal  temperature 

89.  Temperature  chart,  abortive   pneumonia 
90-92.  Physical  signs,  lobar   pneumonia       .... 

93.  Section  of  lung,  showing  distribution  of  fluid  in  chest 

94.  Temperature   chart,  empyema   following   pneumonia 

95.  Temperature  chart,   empyema  following   pneumonia 

96.  Deformity  after   old   empyema 

97.  Apparatus  for  inducing  pulmonary  expansion  after  empyema 

98.  Congenital    cardiac   disease 

99.  Clubbing  of  fingers  in  congenital  cardiac  disease 
100-101.  Pericarditis  with  effusion — X-ray   .... 

102.  Congenital  malformations  of  the  kidneys  and  ureters 

103.  Sarcoma  of  the  kidney 

104.  Tetany 

105.  Spasmodic   torticollis 

106.  Meningocele 

107.  Encephalocele 

108.  Hydrencephalocele 

109.  Meningocele 

110.  Frontal  meningocele 

111.  Naso-frontal  meningocele 

112.  Incidence  of  cerebro-spinal  meningitis    .... 

113.  Posture  in  cerebro-spinal   meningitis 

114.  Temperature  chart,  cerebro-spinal  meningitis,  recovery 

115.  Temperature  chart,  cerebro-spinal  meningitis,  treated  by  serum 

116.  Temperature    chart,   cerebro-spinal    meningitis,   with   late   injection   of 

serum 

117.  Temperature  chart,  cerebro-spinal  meningitis,  termination  by 

118.  Seasonal  occurrence  of  tuberculous  meningitis    . 

119.  Tracing  of  respiration  in  tuberculous  meningitis 


PAGE 

384 
396 
408 
409 
422 
424 
427 
489 
490 
494 
497 
498 
499 
505 
505 
506 
506 
508 
510 
511 
526 
526 
526 
527 
530 
555 
.556 
557 
562 
563 
569 
572 
579 
608 
623 
657 
678 
694 
694 
694 
695 
695 
695 
701 
705 
708 
714 


xviii  LIST  OF  ILLUSTRATIONS. 

FIGLKE  PAOH 

120.  Temperature  chart  in  tuberculous  meningitis 725 

121.  Chronic  basilar  meningitis 728 

122.  Chronic  basilar  meningitis 729 

123.  Brain   in  external   hydrocephalus 741 

124.  Vertical  transverse  section  of  a  brain  in  congenital  hydrocephalus       .      743 

125.  Head  in  chronic  hydrocephalus 744 

126.  Brain  showing  atrophy 748 

127.  Convulsions   in   spastic   paraplegia 749 

128.  Spastic    paraplegia 750 

129.  Recent  meningeal  haemorrhage 752 

130.  Infantile  hemiplegia  showing  contractures 754 

131-136.  Various  types  of  mental  defect 757 

137.  Brain  in  idiocy 758 

138.  Chondro-dystrophy,  radiograph  of  skull .  762 

139.  Chondro-dystrophy,   long   lx)nes 763 

140.  Chondro-dystrophy,   infantile  figure 763 

141.  Chondro-dystrophy,  trident  hand     .        . 764 

142.  Chondro-dystrophy,  adult   figure 764 

143.  A  typical   cretin 766 

144-145.  Cretins,  showing  effect  of  thyroid  treatment  .        ...  767 

140-147.  Cretins,  showing  effect  of  thyroid  treatment 768 

148.  Spina  bifida,  meningocele    (partially  diagrammatic)  ....  773 

149.  Spina  bifida,   meningocele 774 

150.  Spina  bifida,   meningo-myelocele    (partially   diagrammatic)  774 

151.  Spina  bifida,  syringo-myelocele 775 

152.  Spina  bifida,   sacral 776 

153.  Epidemic  of  poliomyelitis 784 

154.  Infantile  spinal  paralysis  of  lower  extremity 789 

155.  Infantile  spinal  paralysis  of  shoulder 790 

156.  Muscular  pseudo-hypertrophy 798 

157.  Alcoholic  neuritis 802 

158.  Diphtheritic  paralysis 803 

159.  Facial    paralysis 808 

160.  Enlarged  thymus  833 

161.  Acute  suppurative  adenitis,  cervical 837 

162.  Acute  suppurative  adenitis,  inguinal 838 

163.  Chain  of  tuberculous  lymph  nodes 843 

164.  Cicatrices   following   tuberculous   adenitis 845 

165.  Section  of  the  spine  in  Pott's  disease 855 

166.  Hip-joint  di.sea.se 861 

167.  Tuberculous  dactylitis 866 

168.  Hereditary  syphilis 868 

169.  Syphilitic  periostitis  of  the  fibula,  radiograph 869 

170.  Syphilitic  osteo-periostitis  of  the  tibia 870 

171.  Syphilitic  osteo-periostitis  of  the  tibia,  radiograph 871 

172.  Syphilitic  bone  disease  in  a  boy  four  years  old 872 

173-174.  Syphilitic  dactylitis 874 

175-176.  Syphilitic  dactylitis,  radiograph 874 

177.  Congenital  ichthyosis 876 

178.  Temperature  chart,  acute  otitis,  following  influenza  ....  896 

179.  Temperature  chart,  acute  otitis,  early  paracentesis 897 

180.  Temperature  charts  in  scarlet  fever,  mild  cases 910 


LIST  OF  ILLUSTRATIONS. 


XIX 


fever 


tis 


pneumonia 


FIGURE 

18L  Temperature  chart  in  scarlet   fever,   typical   curve 

182.  Temperature  chart  in  severe  uncoin])licate(I   scarlet 

183.  Temperature  chart  in  fatal    septic   scarlet   fever 

184.  Temperature  chart  in  scarlet  fever  with   late  otitis 

185.  Temperature  chart  in  scarlet  fever  with  late  nephr 
186-187.  Temperature   charts  in  measles,  typical   curve 

188.  Temperature  chart  in  measles,  occasional    course 

189.  Temperature  chart  in  measles,  prolonged  course 
190-191.  Temperature  charts  in  measles  complicated  by 
192.  Table  showing  protective  power   of  vaccination 
193-197.   Vaccination   vesicles 

198.  Generalised  vaccinia  

199.  O'Dwyer's  intubation  set 

200.  Temperature  chart  in  typhoid  fever,  short  course 

201.  Temperature  chart  in  typhoid  fever,  with  relapse 

202.  Tuberculous  broncho-pneumonia,  diffuse  consolidation 

203.  Cavity  from  tuberculous  broncho-pneumonia 

204.  Pulmonary  tuberculosis,  extensive  caseation 
Miliary  tuberculosis   of   the  lungs 
Temperature  chart  of  tuberculosis  following  measles 
Temperature   chart   of   tuberculous   broncho-pneumonia,    general   tuber 

culosis 

Temperature  chart  of  tuberculous  broncho-pneumonia 
Tuberculous  bronchial  glands 

210.  Early  eruption  of  hereditary  syphilis,  legs 

211.  Early  eruption  of  hereditary  syphilis,  face  . 

212.  Syphilitic   scaling  of   the   sole  .... 
A  later  form  of  eruption  in  hereditary  syphilis 

Syphilitic  notched   teeth 

Syphilitic  teeth,   variously   deformed     . 
Temperature  chart  of  severe  influenza  in  an  infant 

217.  Temperature  chart  of  acute  broncho-pneumonia  complicating  influenza 

218.  Temperature  chart,   influenza,  bronchitis,  otitis 

219.  Temperature  chart,  quotidian   intermittent   fever 

220.  Temperature  chart,  tertian   intermittent   fever    . 

221.  Temperature  chart  in  malaria,  irregular  type    . 


203 
20G 
207 

208 
209 


213 
214 
21.5 
216 


with  softening 


PAGE 

911 

912 

913 

917 

918 

934 

934 

935 

935 

949 

952 

953 

1003 

1012 

1012 

1025 

1025 

1026 

1033 

1037 

1038 
1039 
1047 
1059 
1060 
1060 
1061 
1062 
1063 
1071 
1072 
1074 
1077 
1078 
1079 


THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

PART  I. 


CHAPTER    I. 

HYGIENE  AND  GENERAL   CARE  OF  INFANTS   AND    YOUNG 

CHILDREN. 

The  physical  development  of  the  child  is  essentially  the  product  of 
the  three  factors — inheritance,  surroundings,  and  food.  The  first  of  these 
it  is  beyond  the  physician's  power  to  alter;  the  second  is  largely  and  the 
third  almost  entirely  within  his  control,  at  least  in  the  more  intelligent 
classes  of  society.  These  two  subjects,  infant  hygiene  and  infant  feeding, 
are  the  most  important  departments  of  paediatrics. 

The  Care  of  the  Newly-Born  Child. — After  the  ligature  of  the  cord  the 
child  should  be  wrapped  in  a  thick  blanket  and  placed  in  a  warm  room. 
In  hospital  practice  the  eyes  should  be  cleansed  with  absorbent  cotton 
and  water  which  has  been  boiled,  and  then  two  or  three  drops  of  a  two- 
per-cent  solution  of  nitrate  of  silver,  after  Crede's  method,  instilled  into 
each  eye  by  means  of  a  glass  rod  or  eye-dropper.  In  private  practice  a 
ten-per-cent  solution  of  argyrol  may  be  substituted,  unless  the  mother 
has  had  a  purulent  vaginal  discharge,  in  which  case  the  silver  solution 
should  always  be  used.  The  bath  should  now  be  given  in  a  warm  room ; 
the  body  being  first  oiled  thoroughly  in  order  to  remove  the  vernix  caseosa 
and  then  washed  in  water  at  a  temperature  of  100°  F.  The  mouth  should 
be  cleansed  with  sterile  water  and  a  soft  cloth,  and  no  violence  em- 
ployed. The  cord  may  be  covered  with  sterilised  talcum  or  bismuth 
powder,  and  wrapped  in  sterile  gauze  or  surgeon's  lint.  The  abdomen 
should  now  be  enveloped  in  a  flannel  band,  eight  or  ten  inches  wide,  and 
pinned  rather  snugly.  Before  dressing  is  completed,  the  child  should 
be  submitted  to  a  thorough  examination  for  injuries  received  during 
delivery,  congenital  deformities,  also  as  to  the  condition  of  the  respira- 
tion, circulation,  etc. 

After  dressing,  the  child  should  be  placed  in  his  crib  and  covered 

with  blankets,  and  if  the  feet  are  cold,  or  the  fingers  and  lips  a  little  blue, 

he  should  be  surrounded  by  hot-water  bottles  covered  with  flannels,  and 

placed  near,  but  not  in  contact  with,  the  body.    The  crib  should  be  placed 

2  1 


2  HYGIENE  AND  GENERAL  CARE. 

in  a  quiet,  darkened  room.  The  young  infant  should  not  occupy  the 
same  bed  as  the  mother,  unless  he  greatly  needs  the  warmth  of  her  body, 
other  means  of  artificial  heat  not  being  at  hand. 

The  cord  should  be  kept  dry  and  disturbed  as  little  as  possible  until 
it  falls  off.  Under  ordinary  circumstances  the  cord  separates  from  the 
fourth  to  the  seventh  day,  the  average  being  the  fifth  day.  The  stump 
should  then  be  covered  with  the  sterilised  talcum  or  bismuth  powder, 
and  a  pad  of  sterile  gauze  about  one-fourth  of  an  inch  thick  and  two 
inches  square  applied  and  secured  in  position  by  means  of  the  abdominal 
band.  The  purpose  of  this  is  to  prevent  umbilical  hernia.  The  pad 
should  be  continued  for  the  first  month.  The  use  of  stronger  antiseptic 
dressings  than  those  recommended  is  somewhat  objectionable,  since  it 
preserves  the  cord  too  long  and  delays  separation.  The  full  bath  should 
not  be  given  until  the  cord  has  separated. 

The  physician  should  always  see  to  it  that  the  infant  cries  enough  to 
keep  the  lungs  properly  expanded. 

The  question  of  food  for  the  newly-born  infant  is  considered  in  the 
chapter  upon  infant  feeding. 

Bathing. — For  the  first  few  months  the  bath  should  be  given  at  98° 
F.  The  room  should  be  warm,  preferably  there  should  be  an  open  fire. 
The  bath  should  be  short  and  the  body  dried  quickly,  without  too  vigor- 
ous rubbing.  The  addition  of  salt  to  the  bath  is  an  advantage  where  the 
skin  is  unusually  delicate  or  excoriations  are  present.  One  large  handful 
should  be  used  to  a  gallon  of  water.  By  the  sixth  month  the  temperature 
of  the  bath  for  healthy  infants  may  be  lowered  to  95°  F.,  and  by  the  end 
of  the  first  year  to  90°  F.  Older  children  who  are  healthy  should  be 
sponged  or  douched  for  a  moment  at  the  close  of  the  tepid  bath  with 
water  at  65°  or  70°  F.  During  childhood  the  warm  bath  is  preferably 
given  at  night.  In  the  morning  a  cold  sponge  bath  is  desirable.  This 
should  be  given  in  a  warm  room  and  while  the  child  stands  in  a  tub 
partly  filled  with  warm  water.  This  cold  sponge  should  last  but  half  a 
minute,  and  be  followed  by  a  brisk  rubbing  of  the  entire  body. 

In  some  young  infants  and  even  older  children  there  is  no  proper 
reaction  after  the  bath,  even  when  given  at  the  temperatures  mentioned ; 
children  being  pale,  slightly  blue  about  the  lips  and  under  the  eyes.  All 
tub  bathing,  and  especially  all  cold  bathing,  should  then  be  stopped,  since 
a  continuance  can  only  be  a  drain  upon  the  child's  vitality. 

Clothiiig. — The  clothing  of  infants  should  be  light,  warm,  non-irri- 
tating to  the  skin,  and  loose  enough  to  allow  free  motion  of  the  ex- 
tremities; nor  should  bands  be  pinned  so  tightly  about  the  trunk  as  to 
embarrass  the  movements  either  of  the  chest  or  of  the  abdomen.  The 
chest  should  be  covered  with  a  woollen  shirt,  high  in  the  neck  and  with 
long  sleeves.  All  petticoats  should  be  supported  from  the  shoulders  and 
not  from  waistbands.    Canton  flannel  and  stockinet  are  both  superior  as 


CARE   OF  THE  EYES,   MOUTH,   AND  TEETH.  3 

absorbents  to  the  more  commonly  used  linen  diapers.  Stockinet  has  the 
advantage  of  being  very  soft  and  pliable.  Care  should  be  taken  that  in 
infants  the  feet  be  kept  warm.  If  the  circulation  is  very  poor,  a  bag  of 
hot  water  should  always  be  in  the  crib.  Cold  feet  are  responsible  for 
many  attacks  of  colic. 

The  abdominal  band  is  usually  worn  during  infancy.  It  cannot  be 
considered  in  any  sense  a  necessity  after  the  first  few  months,  excepting 
in  cases  of  very  thin  infants  whose  supply  of  fat  in  the  abdominal  walls 
is  an  insufficient  protection  to  the  viscera.  For  the  first  few  weeks  a  band 
of  plain  flannel  is  to  be  preferred;  later,  a  knitted  band  with  shoulder- 
straps.  The  fashion  of  low  neck  and  short  sleeves  for  infants  and  very 
young  children  has  fortunately  passed  away — let  us  hope,  never  to 
return. 

During  the  summer  the  outer  clothing  should  be  light  and  the  under 
clothing  of  the  thinnest  flannel  or  gauze.  The  changes  in  the  tempera- 
ture of  morning  and  evening  may  be  met  by  extra  wraps.  The  custom  of 
allowing  young  children  to  go  with  legs  bare  has  many  enthusiastic  advo- 
cates; while  it  may  not  be  objectionable  during  the  heat  of  summer,  its 
advantages  at  any  season  are  very  questionable  in  a  changeable  climate 
like  that  of  New  York  or  the  Atlantic  coast.  Many  delicate  children  are 
certainly  injured  by  such  ill-advised  attempts  at  hardening. 

The  night  clothing  of  infants  should  be  similar  tp  that  worn  during 
the  day,  but  should  be  loose,  the  material  being  of  the  lightest  flannel. 
The  night  clothing  for  older  children  should  consist  of  a  thin  woollen 
shirt  and  a  union  suit  with  waist  and  trousers,  and  in  some  cases  with 
feet,  if  there  is  a  tendency  to  get  outside  the  coverings.  The  common 
mistake  is  to  overload  all  children,  but  especially  infants,  with  covering 
at  night.  This  is  an  explanation  of  much  of  the  restless  sleep  which  is 
seen  particularly  in  delicate  children. 

Care  of  the  Eyes. — During  the  first  few  days  at  the  daily  bath  the 
eyes  should  be  cleansed  with  a  saturated  solution  of  boric  acid.  They 
should  be  carefully  protected  from  too  strong  light  during  early  infancy. 
It  is  desirable  that  a  child  should  always  sleep  in  a  darkened  room. 

Care  of  the  Mouth  and  Teeth. — The  mouth  of  the  newly-born  infant 
should  be  gently  cleansed  at  each  morning  bath  with  boiled  water  and 
a  soft  cloth.  On  the  first  appearance  of  thrush  the  mouth  should  be 
washed  after  every  feeding  with  a  solution  of  bicarbonate  of  soda  or 
boric  acid  (ten  grains  to  the  ounce).  It  should  be  applied  with  a  swab 
made  by  twisting  a  bit  of  cotton  upon  a  wooden  toothpick,  and  not  by 
the  nurse's  finger.  Harm  is  often  done  by  the  use  of  too  much  zeal  in 
cleansing  the  mouth  of  a  young  infant. 

The  primary  teeth  as  well  as  those  of  the  permanent  set  should  receive 
daily  attention.  Too  often  they  are  neglected  altogether.  Dirty  teeth 
are  likely  sooner  or  later  to  become  carious;  and  carious  teeth,  besides 


4  HYGIENE  AND  GENERAL  CARE. 

being  a  cause  of  bad  breath  and  neuralgia,  are  a  constant  menace  to  the 
health  of  the  child,  since  they  may  harbour  infectious  germs  of  all  varie- 
ties.    Such  teeth  should  either  be  filled  or  removed. 

Care  of  the  Skin. — The  skin  of  a  young  infant  is  exceedingly  deli- 
cate, and  excoriations,  intertrigo,  and  eczema  are  of  very  common  occur- 
rence. These  conditions  are  much  easier  of  prevention  than  of  cure. 
The  first  essential  in  the  care  of  the  skin  is  cleanliness,  and  this  must 
be  secured  without  the  use  of  strong  soaps  or  too  much  rubbing.  Nap- 
kins must  be  removed  as  soon  as  soiled  or  wet.  Some  bland  absorbent 
powder,  like  starch,  talcum,  or  the  stearate  of  zinc,  should  be  used  in  all 
the  folds  of  the  skin,  in  the  neck,  in  the  axillae,  groins,  and  about  the 
genitals,  and  in  the  folds  of  the  thighs,  particularly  in  very  fat  infants. 
If  plain  water  produces  an  undue  amount  of  irritation,  the  salt  or  bran 
bath  should  be  employed. 

Care  of  the  Genital  Organs. — The  female  genitals  need  but  little 
attention  in  young  children,  excepting  as  to  cleanliness.  This  is  more 
often  neglected  in  older  children  than  in  infants. 

In  males  the  prepuce  should  receive  attention  during  the  first  few 
weeks  of  life.  If  the  foreskin  is  long  and  the  preputial  orifice  small, 
circumcision  should  be  done.  If  it  is  not  long,  but  is  only  adherent, 
these  adhesions  should  be  broken  up,  the  parts  thoroughly  cleansed  and 
the  foreskin  retracted  daily  until  there  is  no  disposition  to  a  recurrence 
of  the  adhesions.  These  operations  will  be  discussed  more  at  length  in 
a  subsequent  chapter.  The  only  thing  to  be  emphasised  in  the  present 
connection  is  that  the  prepuce  should  receive  proper  attention  in  early 
infancy,  since  this  can  now  be  done  with  less  pain  and  discomfort  to  the 
child,  and  at  the  same  time  better  results  are  obtained.  If  this  matter 
is  neglected  during  infancy,  it  is  apt  to  be  overlooked  until  harm  has 
been  produced  by  local  or  reflex  irritation  which  phimosis  or  adherent 
prepuce  may  have  excited. 

Vaccination. — This,  although  considered  elsewhere,  should  be  men- 
tioned in  this  connection  as  among  the  things  requiring  the  physician's 
attention  during  the  first  months  of  life. 

Training  to  Proper  Control  of  Rectum  and  Bladder. — It  is  surprising 
to  see  what  can  be  accomplished  by  intelligent  efforts  at  training  in 
these  particulars.  An  infant  can  often  be  trained  at  three  months  to 
have  its  movements  from  the  bowels  when  placed  upon  a  small  cham- 
ber. This  not  only  saves  a  great  amount  of  washing  of  napkins,  but 
there  is  soon  formed  a  habit  of  having  the  bowels  move  at  a  regular  time 
or  times  each  day.  The  infant  must  be  put  upon  the  chamber  soon  after 
his  feeding.  The  importance  of  training  young  children  to  regular  habits 
regarding  evacuations  from  the  bowels  can  hardly  be  overestimated.  It 
should  be  impressed  upon  every  mother  and  nurse  by  the  physician,  and 
especially  the  necessity  of  beginning  training  during  infancy.    Much  of 


SLEEP.  5 

course  will  depend  upon  the  food  and  the  digestion ;  but  habit  is  a  very 
large  factor  in  the  case. 

The  training  of  the  bladder  is  not  quite  so  important,  but  the  proper 
education  of  this  organ  adds  much  to  the  comfort  of  the  child  and  the  ease 
with  which  it  is  cared  for.  Before  the  end  of  the  first  year  many  intelli- 
gent children  can  be  trained  to  indicate  a  desire  to  empty  the  bladder. 
Many  mothers  and  nurses  succeed  in  training  children  so  well  that  by 
the  tenth  or  eleventh  month  napkins  are  dispensed  with  during  the  day. 
On  the  other  hand,  it  is  very  common  to  see  children  of  two  and  even  two 
and  a  half  years  still  wearing  napkins  because  of  the  lack  of  proper 
training.  Before  it  has  reached  the  age  of  three  years  a  healthy  child 
will  usually  go  from  10  p.m.  until  morning  without  emptying  the  bladder. 
The  annoyance  and  discomfort  from  the  neglect  of  early  training  in  this 
particular  are  very  great.  Night  feeding  is  responsible  for  much  of  the 
difficulty  experienced  in  training  children  to  hold  the  water  during  the 
night. 

General  Hygiene  of  the  Nervous  System. — Great  injury  is  done  to 
the  nervous  system  of  children  by  the  influences  with  which  they  are 
surrounded  during  infancy,  especially  during  the  first  year.  The  brain 
grows  more  during  the  first  two  years  than  in  all  the  rest  of  life.  Nor- 
mal healthy  development  of  the  nervous  centres  demands  quiet,  rest, 
peaceful  surroundings,  and  freedom  from  everything  which  causes  ex- 
citement or  undue  stimulation. 

The  steadily  increasing  frequency  of  functional  nervous  diseases 
among  young  children  is  one  of  the  most  powerful  arguments  for  greater 
attention  by  physicians  to  the  subject  of  the  hygiene  of  the  nervous  sys- 
tem during  infancy.  Most  parents  err  through  ignorance.  Playing  with 
young  children,  stimulating  to  laughter  and  exciting  them  by  sights, 
sounds,  or  movements  until  they  shriek  with  apparent  delight,  may  be  a 
source  of  amusement  to  fond  parents  and  admiring  spectators,  but  it  is 
almost  invariably  an  injury  to  the  child.  This  is  especially  harmful  when 
done  in  the  evening.  It  is  the  plain  duty  of  the  physician  to  enlighten 
parents  upon  this  point,  and  insist  that  the  infant  shall  be  kept  quiet, 
and  that  all  such  playing  and  romping  as  has  been  referred  to  shall, 
during  the  first  year  at  least,  be  absolutely  prohibited. 

Sleep. — The  sleep  of  the  newly-born  infant  is  profound  for  the  first 
two  or  three  days  and  under  normal  conditions  almost  continuous.  In 
the  case  of  prolonged  or  tedious  labour,  or  where  from  any  cause  undue 
compression  has  been  exerted  upon  the  head,  it  may  approach  the  con- 
dition of  semi-coma  for  twenty-four  or  forty-eight  hours.  This  may  be 
so  deep  as  to  excite  apprehensions  of  serious  brain  lesions.  If,  however, 
there  are  associated  with  it  no  convulsions  and  no  rigidity,  this  early 
stupor  usually  passes  away  on  the  second  or  third  day. 

The  sleep  of  early  infancy  is  quiet  and  peaceful,  but  not  very  deep 


6.  HYGIENE  AND  GENERAL  CARE. 

after  the  first  month.  After  the  third  year  the  lieavy  sleep  of  childhood 
is  commonly  seen.  A  healthy  infant  during  the  first  few  weeks  sleeps 
from  twenty  to  twenty-two  hours  out  of  the  twenty-four,  waking  only 
from  hunger,  discomfort,  or  pain.  During  the  first  six  months  a 
healthy  infant  will  usually  sleep  from  sixteen  to  eighteen  hours  a  day, 
the  waking  periods  being  only  from  half  an  hour  to  two  hours  long.  At 
the  age  of  one  year  most  infants  sleep  from  fourteen  to  fifteen  hours, 
viz.,  from  eleven  to  twelve  hours  at  night,  and  two  or  three  hours  during 
the  day,  usually  in  two  naps.  When  two  years  old  usually  thirteen  to 
fourteen  hours'  sleep  is  taken;  eleven  or  twelve  hours  at  night  and  one 
or  two  hours  during  the  day,  generally  in  a  single  nap.  At  the  age  of 
four  years  children  require  from  eleven  to  twelve  hours'  sleep.  It  is 
always  desirable,  and  in  most  cases  with  regularity  it  is  possible,  to  keep 
up  the  daily  nap  until  children  are  four  years  old.  From  six  to  ten 
years  the  amount  of  sleep  required  is  ten  or  eleven  hours,  and  from  ten 
to  sixteen  years  nine  hours  should  be  the  minimum. 

Training  in  proper  habits  of  sleep  should  be  begun  at  birth.  From 
the  outset  an  infant  should  be  accustomed  to  being  put  into  his  crib  while 
awake  and  to  go  to  sleep  of  his  own  accord.  Rocking  and  all  other  habits 
of  this  sort  are  useless  and  may  even  be  harmful.  An  infant  should  not 
be  allowed  to  sleep  on  the  breast  of  the  nurse,  nor  with  the  nipple  of  the 
bottle  in  his  mouth.  Other  devices  for  putting  infants  to  sleep,  such  as 
allowing  the  child  to  suck  a  rubber  nipple  or  anything  else,  are  positively 
injurious.  If  such  means  of  inducing  sleep  are  resorted  to  the  infant 
soon  acquires  the  habit  of  not  sleeping  without  them.  I  have  known  of 
one  instance  where  the  habit  of  rocking  during  sleep  was  continued  until 
the  child  was  two  years  old;  the  moment  the  rocking  was  stopped  the 
infant  would  wake,  and  in  consequence  this  practice  was  continued  by 
the  devoted  but  misguided  parents.  A  quiet,  darkened  room,  a  warm 
and  comfortable  bed,  an  appetite  satisfied,  and  dry  napkins  are  all  that 
are  needed  to  induce  sleep  in  a  healthy  child. 

The  periods  of  sleep  in  young  infants  are  usually  from  two  to  three 
hours  long,  with  the  exception  of  once  or  twice  in  the  twenty-four  hours, 
when  a  long  sleep  of  five  or  six  hours  occurs.  The  purpose  of  training 
is  to  have  the  child  take  this  long  sleep  at  night.  The  habit  of  regular 
sleep  is  best  established  by  wakening  the  infant  regularly  every  two  or 
two  and  a  half  hours  during  the  day  for  feeding,  and  allowing  it  to  sleep 
as  long  as  possible  during  the  night.  This  training  goes  hand-in-hand 
with  regular  habits  of  feeding.  Such  habits  are  easily  formed  if  tlie 
plan  be  systematically  followed  from  the  outset. 

By  the  fifth  month  all  feeding  between  10  p.m.  and  7  a.m.  should  be 
discontinued.  If  this  is  done  most  infants  can  be  trained  by  this  time 
to  sleep  all  night.  If  the  room  is  lighted,  and  the  child  taken  from  the 
crib  or  rocked  or  fed  as  soon  as  he  wakens  at  night,  there  is  no  such  thing 


EXERCISE.  7 

as  the  formation  of  good  habits  of  sleep.  Eegularity  in  sleep  and  feeding 
not  only  make  the  care  of  young  infants  very  much  easier,  but  they  are 
of  a  good  deal  of  importance  for  the  health  of  the  child. 

The  causes  of  disturbed  or  irregular  sleep  in  young  infants  are  mainly 
two — hunger  and  indigestion.  In  nursing  infants  it  is  usually  the  for- 
mer; in  those  artificially  fed  usually  the  latter.  Sleeplessness  from  hun- 
ger is  often  seen  in  children  who  are  nursed  thirty  or  forty  minutes  and 
then  fall  asleep,  but  wake  in  fifteen  or  twenty  minutes  crying  and  fretful. 
After  being  quieted  they  may  fall  asleep  again  for  half  an  hour,  but 
wake  at  short  intervals.  The  peaceful  sleep  of  two  or  three  hours  which 
should  follow  a  proper  feeding  is  never  seen.  With  this  restlessness,  in 
indigestion  other  signs  are  usually  present,  stationary  weight,  etc.  The 
disturbed  sleep  due  to  overfeeding  shows  itself  by  much  the  same  symp- 
toms, excepting  that  the  first  sleep  after  the  meal  is  usually  longer. 

Exercise. — This  is  no  less  important  in  infancy  than  in  later  child- 
hood. An  infant  gets  his  exercise  in  the  lusty  cry  which  follows  the  cool 
sponge  of  the  bath,  in  kicking  his  legs  about,  waving  his  arms,  etc.  By 
these  means  pulmonary  expansion  and  muscular  development  are  in- 
creased and  the  general  nutrition  promoted.  An  infant's  clothing  should 
be  such  as  not  to  interfere  with  his  exercise.  Confinement  of  the  legs 
should  not  be  permitted.  In  hospital  practice  I  have  often  had  a  chance 
to  observe  the  bad  results  which  follow  when  very  young  infants  are 
allowed  to  lie  in  the  cribs  nearly  all  the  time.  Little  by  little  the  vital 
processes  flag,  the  cry  becomes  feeble,  the  weight  is  first  stationary,  then 
there  is  a  steady  loss.  The  appetite  fails  so  that  food  is  at  first  taken 
without  relish,  then  at  times  altogether  refused;  later,  vomiting  ensues 
and  other  symptoms  of  indigestion.  This,  in  many  cases,  is  the  begin- 
ning of  a  steady  downward  course  which  goes  on  until  a  condition  of 
hopeless  marasmus  is  reached.  Such  infants  must  be  taken  up  every  few 
hours  and  carried  about  the  wards;  the  position  should  be  frequently 
changed,  and  general  friction  of  the  entire  body  employed  at  least  twice 
a  day.  Every  means  must  be  made  use  of  to  stimulate  the  vital  activity. 
The  value  of  systematic  attention  to  these  matters  cannot  be  overesti- 
mated in  hospitals  for  infants.  Infants  who  are  old  enough  to  creep  or 
stand  usually  take  sufficient  exercise  unless  they  are  restrained.  At  this 
age  they  should  be  allowed  to  do  what  they  are  eager  to  do.  Every 
facility  should  be  afforded  for  using  their  muscles.  Exercise  may  be 
encouraged  by  placing  upon  the  floor  in  a  warm  room  a  mattress  or  a 
thick  "  comfortable,"  and  allowing  the  infant  to  roll  and  tumble  upon  it 
at  will.    A  large  bed  may  answer  the  same  purpose. 

In  older  children  every  form  of  out-of-door  exercise  should  be  encour- 
aged— ball,  tennis,  and  all  running  games,  horseback  riding,  the  bicycle, 
tricycle,  swimming,  coasting,  and  skating.  Up  to  the  eleventh  year  no 
difference  need  be  made  in  the  exercise  of  the  two  sexes.     Companion- 


8  HYGIENE  AND  GENERAL  CARE. 

ship  is  a  necessity.  Cliildren  brouglii  up  alone  are  at  a  great  disadvantage 
in  this  respect,  and  are  not  likely  to  get  as  much  exercise  as  they  require. 
The  amount  of  exercise  allowed  delicate  children  should  be  regulated 
with  some  degree  of  care.  It  may  be  carried  to  the  ]X)int  of  moderate 
muscular  fatigue,  but  never  to  muscular  exhaustion.  The  latter  is  par- 
ticularly likely  to  be  the  case  in  competitive  games. 

Exercise  should  have  reference  to  the  symmetrical  development  of  the 
whole  body.  In  prescribing  it  the  specific  needs  of  the  individual  child 
should  be  considered.  By  carefully  regulated  exercises  very  much  may 
be  done  to  check  such  deformities  as  round  shoulders  and  slight  lateral 
curvature  of  the  spine,  and  also  to  develop  narrow  chests  and  feeble 
thoracic  muscles.  For  purposes  like  these,  gymnastics  are  exceedingly 
valuable  to  supplement  out-of-door  exercise,  but  they  can  never  take 
their  place. 

There  are  two  important  points  with  reference  to  exercise  indoors. 
First,  the  playroom  should  be  cool — about  60°  F.  Secondly,  during  all 
active  exercise  the  clothing  should  be  loose  and  light,  so  as  to  allow  the 
freest  possible  motion  of  the  body. 

Airing. — In  summer  there  can  be  no  possible  objection  to  a  young 
infant  being  allowed  out  of  doors  at  the  end  of  the  first  week.  He  should 
be  kept  in  the  open  air  as  much  as  possible  during  the  day.  In  the  fall 
and  spring  this  should  not  be  permitted  until  the  child  is  at  least  a 
month  old,  and  then  only  when  the  out-of-door  temperature  is  above  60° 
F.  During  his  outing  the  head  should  be  protected  from  the  wind  and 
the  eyes  from  the  sun.  The  duration  of  the  outing  at  first  should  be 
only  fifteen  or  twenty  minutes,  the  time  being  gradually  lengthened  to 
two  or  three  hours.  The  child  should  be  gradually  accustomed  to  changes 
of  temperature  in  the  room  by  opening  wide  the  windows  for  a  few  min- 
utes each  day  even  before  it  is  taken  out  of  doors,  the  child  being 
dressed  meanwhile  as  for  an  outing.  In  the  case  of  children  born  late 
in  the  fall  or  in  the  winter  this  means  of  giving  fresh  air  may  be  ad- 
vantageously begun  at  one  month  and  followed  throughout  the  first  win- 
ter. It  is  only  necessary  in  all  such  cases  that  the  changes  be  made  very 
gradually  both  as  to  the  length  of  the  airing  and  as  to  the  temperature. 
The  great  advantage  of  this  plan  over  that  more  commonly  followed 
of  keeping  young  infants  closely  housed  for  the  first  six  months  in  case 
they  are  born  in  the  fall  or  early  winter,  I  can  positively  affirm  from 
quite  a  wide  observation  of  both  methods.  It  is  a  matter  of  very  serious 
importance  that  every  infant  be  furnished  an  abundance  of  pure  fresh 
air  in  winter  as  well  as  in  summer.  When  tlie  plan  above  outlined  is 
carefully  and  judiciously  followed,  the  tendency  to  catarrhal  affections 
instead  of  being  increased  is  thereby  greatly  lessened. 

When  four  or  five  months  old,  there  is  no  reason  why  a  healthy  child 
should  not  go  out  of  doors  on  pleasant  days  if  the  temperature  is  not 


NURSERY.  9 

below  20°  F.  While  there  is  a  prejudice  on  the  part  of  many  mothers 
and  some  physicians  against  a  child's  sleeping  out  of  doors  in  cold 
weather,  it  is  a  practice  which  I  have  always  urged  upon  mothers,  and 
have  never  seen  followed  by  any  but  the  most  beneficial  results.  The 
days  of  all  others  when  infants  and  very  young  children  should  not  be 
out  of  doors  are  when  there  are  high  winds,  especially  those  from  the 
northeast,  an  atmosphere  of  melting  snow,  and  during  severe  storms. 
Delicate  infants  must  of  course  be  more  carefully  guarded  during  the 
cold  season.  With  most  of  these  the  plan  of  house-airing  is  all  that 
should  be  attempted. 

Nursery. — This  should  be  the  sunniest  and  best-ventilated  room  in 
the  house.  It  is  the  physician's  duty  to  see  that  proper  attention  is  paid 
to  the  hygiene  of  the  room  in  which  the  child  spends  at  least  four-fifths 
of  his  time  during  the  first  year,  and  two-thirds  of  his  time  during  the 
first  two  or  three  years  of  life.  Sunlight  is  absolutely  indispensable. 
Sunny  rooms  always  contain  less  organic  matter  and  less  humidity,  and 
hence  a  room  upon  the  north  side  of  the  house  should  always  be  avoided, 
preferably  one  in  the  second  story  should  be  chosen.  Nothing  which  can 
in  any  way  contaminate  the  air  of  the  room  should  be  allowed.  There 
should  be  no  drying  of  clothes  or  of  napkins,  and  no  plumbing.  No 
food  should  be  allowed  to  stand  about  the  room.  The  gas  should  not  be 
allowed  to  burn  at  night;  a  small  wax  night-light  furnishes  all  that  is 
needed  in  the  nursery.  If  possible  the  heat  should  be  from  an  open  fire ; 
the  next  best  thing  is  the  Franklin  heater.  Nothing  in  the  room  is 
worse  than  steam  heat  from  a  radiator  unless  it  be  a  gas  stove,  which 
under  no  circumstances  should  be  allowed,  excepting  possibly  for  a  few 
minutes  each  morning  during  the  bath. 

The  temperature  of  the  room  during  the  day  should  not  be  over 
70°  F.  It  is  important  that  every  nursery  should  have  a  thermometer, 
and  that  this  and  not  the  sensations  of  the  nurse  should  be  the  guide. 
It  is  almost  invariably  true  that  the  nursery  is  overheated.  Often  no 
other  explanation  can  be  found  for  chronic  indigestion  and  falling  weight 
excepting  a  nursery  whose  habitual  temperature  ranges  from  75°  to  80° 
F.  At  night  for  the  first  few  weeks  the  temperature  should  not  be 
allowed  to  fall  below  65°  F.  After  two  months  the  night  temperature 
may  fall  to  60°  or  even  50°  F. 

Free  ventilation  without  draughts  is  an  absolute  necessity.  This  is 
best  accomplished  by  ventilators  in  the  windows,  of  which  there  are 
many  excellent  devices  sold  in  the  shops.  While  the  child  is  absent  from 
the  room  the  windows  should  be  widely  opened  and  free  airing  of  the 
nursery  accomplished.  The  room  should  always  be  thoroughly  aired  at 
night  before  the  child  is  put  to  bed.  The  window  may  be  kept  open 
after  the  third  month.  After  the  first  year  the  window  may  be  open, 
unless  the  outside  temperature  is  as  low  as  20°  F.     If  the  window  is 


10  HYGIENE  AND  GENERAL  CARE. 

open  the  door  of  the  nursery  should  be  closed,  that  currents  of  air  may 
be  avoided.  The  ventilation  by  means  of  an  open  fire  is  the  most 
efficient. 

The  furniture  of  the  nursery  should  be  as  simple  as  possible,  heavy 
hangings  should  be  positively  forbidden,  and  upholstered  furniture  used 
only  to  a  small  extent.  Floors  covered  by  large  rugs  are  much  more 
cleanly  than  carpets,  and  hence  are  to  be  preferred. 

The  child,  whenever  it  is  possible,  should  have  a  separate  bed;  and 
80  should  the  newly-bom  infant,  in  order  to  prevent  the  danger  of  over- 
lying by  the  mother,  which  among  the  lower  classes  is  a  frequent  cause 
of  death,  and  also  to  avoid  the  danger  of  too  frequent  night  nursing, 
which  is  injurious  alike  to  mother  and  child.  Separate  beds  for  older 
children  will  prevent  the  spread  of  many  forms  of  infection.  The  cradle 
for  infants  should  be  one  which  does  not  rock,  in  order  that  this  unnec- 
essary and  vicious  practice  may  not  be  carried  on.  The  mattress  should 
be  of  hair  and  quite  firm.  The  pillow  should  be  small ;  in  the  summer, 
hair  pillows  are  an  advantage  but  not  a  necessity.  The  position  of  the 
child  during  sleep  should  be  changed  from  time  to  time  from  one  side 
to  the  other  and  then  to  the  back.  Attention  to  all  these  details- should 
not  be  beneath  the  physician's  notice,  since  the  violation  of  these  plain 
rules  of  hygiene  is  at  the  bottom  of  many  of  the  milder  disorders  and 
even  of  some  of  the  more  serious  diseases  seen  in  infancy. 

The  Nurse. — The  nurse  of  a  young  child  should  be  healthy,  young 
or  in  middle  life,  free  from  tuberculous  or  syphilitic  taint,  from  catar- 
rhal affections  of  the  nose  and  throat,  and  not  of  a  nervous  or  excitable 
temperament.  She  should  be  neat  in  habit,  of  quiet  disposition,  and, 
most  of  all,  she  should  be  a  person  of  intelligence. 

The  Amount  of  Air  Space  required  by  Infants. — The  nursery  should 
always  be  as  large  a  room  as  possible.  One  of  the  reasons  why  young 
infants  do  so  badly  in  institutions  is  because  of  overcrowding.  In  a 
well-ventilated  ward  there  should  be  allowed  to  each  infant  at  least  1,000 
cubic  feet.  Children  over  two  years  old  are  not  so  sensitive  to  their 
surroundings,  and  may  thrive  in  wards  where  only  700  or  800  cubic  feet 
are  allowed  to  each  child. 

THE  CARE  OF  PREMATURE  AND  DELICATE  INFANTS. 

Infants  bom  before  term,  and  some  exceedingly  delicate  ones  who 
are  born  at  full  term,  require  very  special  and  particular  care.  The 
vitality  is  so  feeble  in  these  children  that  if  they  are  handled  in  the 
ordinary  way  they  survive  at  most  but  a  few  weeks.  The  symptom  which 
indicates  that  such  special  care  is  necessary  is  most  of  all  the  weight  of 
the  child.  Either  congenital  feebleness  or  prematurity  may  be  assumed 
in  most  of  the  children  weighing  less  than  four  pounds ;  also  if  the  length 


PREMATURE  AND  DELICATE  INFANTS.  11 

of  the  body  is  less  than  nineteen  inches.  In  these  children  all  the  organs 
are  likely  to  be  imperfectly  developed  and  they  are  not  ready  for  their 
work.    Especially  is  this  true  of  the  lungs  and  of  the  organs  of  digestion. 

The  clinical  picture  presented  by  these  cases  is  quite  characteristic. 
The  body  is  limp ;  the  skin  very  soft  and  delicate  and  almost  transparent ; 
the  cry,  a  low  feeble  whine  not  unlike  the  mew  of  a  kitten;  the  respira- 
tory movements,  extremely  irregular,  sometimes  scarcely  perceptible  for 
several  seconds;  the  movements  of  the  extremities  infrequent  and  never 
vigorous.  The  general  appearance  is  one  of  torpor.  The  muscles  of  the 
mouth  and  cheek  and  tongue  may  lack  the  requisite  force  for  sucking, 
so  that  this  is  practically  impossible,  and  even  deglutition  is  slow,  dif- 
ficult, and  prolonged.  It  is  difficult  to  maintain  the  normal  body  tem- 
perature; unless  closely  watched  this  may  fall  far  below  the  normal, 
and  may' rise  quite  as  much  above  it  with  the  use  of  too  much  artificial 
heat.  I  once  saw  a  fiuctuation  of  13°  F.  occur  in  a  few  hours  from  such 
causes.  All  the  symptoms  mentioned  vary  much  according  to  the  degree 
of  prematurity. 

In  the  management  of  these  cases  there  are  three  problems  to  be 
solved:  the  first  to  maintain  the  animal  heat,  the  second  to  nourish  the 
infant,  the  third  to  prevent  infection.  Difficult  as  it  always  is  to  rear 
a  premature  infant,  these  difficulties  are  much  increased  in  cases  where 
proper  means  are  not  adopted  immediately  after  birth.  The  loss  which 
these  children  sustain  during  the  first  few  days  is  in  very  many  cases 
so  great  that  subsequent  measures,  however  well  carried  out,  are  futile. 
The  heat-producing  power  is  so  feeble  that  the  body  temperature  quickly 
falls  below  normal  unless  artificial  heat  is  constantly  used.  The  effect 
of  cold  upon  these  delicate  infants  is  very  serious,  and  -not  only  growth 
but  even  life  depends  upon  maintaining  the  body  temperature  steadily 
and  uniformly.  Their  extreme  susceptibility  is  something  which  it  is 
difficult  for  one  to  appreciate  who  has  not  had  experience  in  these  cases. 

One  of  the  simplest  means  of  maintaining  the  temperature  is  to  oil 
the  skin  and  then  roll  the  entire  body,  including  extremities,  in  absorbent 
cotton  or  lamb's  wool ;  even  the  neck  and  cranium  may  be  covered,  leav- 
ing only  the  face  exposed.  The  usual  diaper  may  be  replaced  by  a  pad 
of  gauze  and  absorbent  cotton.  The  body  is  then  wrapped  in  blankets, 
placed  in  a  clothes-basket  or  bassinet  with  protected  sides,  and  sur- 
rounded by  bottles  or  bags  containing  hot  water.  A  blanket  or  sheet 
should  partially  cover  the  top  of  the  basket,  forming  a  sort  of  hood  to 
protect  the  eyes  from  light  and  the  face  and  head  from  draughts.  In 
using  hot-water  bags,  some  caution  must  be  exercised  or  too  much  heat 
may  be  secured.  I  have  seen  the  temperature  of  an  infant  raised  six 
or  seven  degrees  from  this  cause.  The  temperature  of  the  child  should 
at  first  be  taken  every  few  hours  to  make  sure  that  a  proper  amount  of 
external  heat  is  supplied. 


12  HYGIENE  AND  GENERAL  CARE. 

A  more  efficient  means  of  furnishing  artificial  heat  is  by  the  electric 
pad.  These  small  heaters  are  attached  to  an  electric  fixture  like  a  drop- 
light.  A  convenient  size  is  ten  by  fifteen  inches.  The  pad,  which  can  be 
obtained  of  any  electric  supply  company,  is  placed  beneath  two  or  three 
thicknesses  of  blanket,  upon  which  the  infant  lies  in  its  basket.  Since 
the  pads  occasionally  get  out  of  order  they  must  be  used  with  some  cau- 
tion, as  they  have  been  known  to  burn  the  bedclothes  and  even  the  baby. 

With  such  means  as  those  described  it  is  possible  to  maintain  the 
body  temperature  at  normal  even  in  a  room  kept  at  the  ordinary  tem- 
perature. Jt  is  preferable  to  have  a  warmer  room ;  7-5°  or  even  80°  F. 
is  desirable  for  feeble  infants.  Adequate  ventilation,  however,  is  indis- 
pensable. With  intelligent  care  excellent  results  can,  however,  often  be 
obtained  with  no  other  means  for  maintaining  heat  than  the  padded 
basket  and  hot- water  bottles ;  but  the  other  accessories  make  th6  problem 
an  easier  one. 

Premature  infants  should  be  fed  without  being  removed  from  the 
basket,  until  they  are  strong  enough  to  take  the  breast.  The  posi- 
tion should  be  frequently  changed  and  some  freedom  of  movement  of  the 
limbs  permitted,  but  the  infants  should  be  handled  as  little  as  possible. 
The  body  should  be  oiled  and  fresh  cotton  applied  every  other  day.  The 
rectal  temperature  at  first  should  be  taken  several  times  a  day  in  order 
to  be  sure  that  sufficient  artificial  heat  is  being  supplied,  but  not  too 
much.  The  latter  condition  is  one  that  often  obtains.  So  long  as  the 
rectal  temperature  varies  only  between  98°  and  100°  F.  one  should  be 
satisfied. 

Incubators. — Personally,  I  have  not  found  the  usual  small  incubator 
a  very  satisfactory  means  of  caring  for  the  premature  infant.  The  dif- 
ficulties in  successful  operation  are  many  and  the  dangers  consequent 
upon  the  mode  of  ventilation  are  considerable.  Except  by  persons 
experienced,  their  use  is  not  to  be  advised.  In  hospitals  with  spe- 
cially trained  nurses  they  may  give  excellent  results,  but  in  the  aver- 
age home  the  simpler  measures  above  described  are  much  safer  and 
quite  efficient. 

Every  institution  receiving  and  caring  for  premature  infants  should 
have  a  specially  equipped  room  for  that  purpose.  It  should  be  of  suffi- 
cient size  to  accommodate  several  patients.  We  have  had  such  a  room  con- 
structed in  the  Babies'  Hospital  wliich  seems  to  fulfill  all  the  requirements. 
The  room  has  a  floor  space  of  thirteen  by  sixteen  feet  with  ceiling  eleven 
feet  high.  This  is  arranged  for  five  infants,  which  gives  each  child  450 
cubic  feet  of  air.  The  cribs  are  separated  by  glass  plates,  which  project 
three  feet  from  the  side  wall  and  are  four  feet  in  height,  forming  for 
each  infant  a  sort  of  alcove.  The  purpose  of  this  is  to  diminish  the 
chances  of  bed-to-bed  infection.  The  room  has  double  partition  walls 
and  double  windows.     The  temperature  is  controlled  by  a  thermostat 


PREMATURE   AND   DELICATE   INFANTS. 


13 


regulator  and  is  maintained  at  about  90°  F.  The  room  is  provided 
with  a  special  ventilating  apparatus  by  means  of  which  the  entire  air 
of  the  room  can  be  changed  in  a  few  minutes.  This  is  done  several 
times  a  day.  Such  a  room  possesses  all  the  advantages  of  the  small  in- 
cubator without  any  of  its  drawbacks.  The  infants  are  clothed  in  a 
single  loose  garment  of  absorbent  cotton  and  cheese-cloth  and  lightly 
covered.  In  this  room  the  normal  body  temperature  is  easily  maintained. 
For  wet-nursing,  bathing,  and  changing  of  napkins,  the  children  are 
removed  to  an  anteroom  which  is  kept  at  a  temperature  of  about  75°  F. 
When  the  bottle  is  given  they  are  fed  in  their  cribs.  After  reaching  the 
weight  of  five  and  a  half  or  six  pounds  they  are  removed  to  the  anteroom 
for  a  few  days,  after  which  they  are  placed  in  the  ward  or  sent  home. 

Feeding. — The  feeding  of  the  premature  infant  is  not  less  important 
than  the  maintenance  of  heat  and  proper  ventilation.  Infants  at  eight 
months  and  those  weighing  five  pounds  or  thereabouts 
can  usually  be  made  to  take  the  breast  after  the  first  few 
days.  Few  below  this  age  or  weight  will  do  so.  Some 
will  suck  from  a  bottle,  but  the  majority  must  be  fed 
by  other  means.  A  medicine  dropper  may  be  used,  or 
the  Breck  feeder  ^  ( Fig.  1 )  ;  the  smallest  and  feeblest, 
however,  must  be  fed  by  gavage,  using  a  funnel  and 
small  rubber  catheter.  The  food  should  be  slowly  given ; 
if  rapidly,  some  is  liable  to  be  regurgitated,  and  this  may 
produce  attacks  of  asphyxia  or  even  an  aspiration  pneu- 
monia. The  quantity  of  food  and  frequency  of  feeding 
Avill  depend  upon  the  size  and  age  of  the  child.  A  seven 
months'  baby  weighing  three  and  a  half  pounds  should 
have,  for  the  first  twenty-four  to  thirty-six  hours,  only 
water,  one  to  three  teaspoonfuls  every  hour.  Then  regu- 
lar food,  half  an  ounce  every  hour,  gradually  increased 
to  an  ounce  every  two  hours  at  the  end  of  two  weeks,  and 
an  ounce  and  a  half  every  two  hours  at  the  end  of  three 
weeks. 

Artificial  feeding  is  seldom  very  successful  with  pre- 
mature infants.  With  some  of  the  larger  and  more  vig- 
orous, cow's  milk  modified  according  to  the  directions 
given  in  the  chapters  on  Infant  Feeding  gives  good  re- 
sults. I  once  succeeded  with  a  child  of  three  pounds  two  ounces.  For 
most  of  them  under  four  and  a  half  pounds,  breast-milk  is  essential. 
If  the  child  is  born  near  term,  the  mother  may  be  able  to  nurse  it.  Oc- 
casionally this  may  be  done  at  eight  months,  but  seldom  earlier,  so  that 
the  milk  of  some  other  woman  must  usually  be  depended  upon. 


Fig.  1. — Breck's 
Feeding-Tube. 


*  Obtained  at  any  of  the  Walker-Gordon  laboratories. 


14 


HYGIENE  AND  GENERAL  CARE. 


As  the  premature  baby  requires  only  from  six  to  twelve  ounces  of 
breast-milk  a  day  for  the  first  few  weeks,  this  may  be  secured  from  some 
other  nursing  woman ;  a  friend  might  be  willing  to  furnish  it  or  it  could 
be  purchased  from  any  healthy  woman  who  has  an  abundant  supply.  It 
is  sufficient  if  it  is  drawn  fresh  twice  a  day,  the  utmost  precautions,  of 
course,  being  taken  to  secure  cleanliness.  At  first  equal  parts  of  breast- 
milk  and  a  four-  or  five-per-cent  solution  of  milk  sugar  may  be  given; 
the  degree  of  dilution  being  gradually  lessened  until  pure  milk  is  taken. 
Twelve  feedings  a  day  are  usually  necessary,  the  amount  at  one  feeding 
may  be  from  two  drachms  to  one  ounce  depending  upon  the  size,  age, 
and  digestive  powers  of  the  infant.  Since  the  breast-milk  must  always 
be  diluted,  at  least  at  first,  it  is  not  important  that  the  baby  of  the 
woman  furnishing  the  milk  should  be  of  the  same  age  as  the  foster 
infant.  The  milk  of  any  woman  whose  baby  is  between  one  and  eight 
months  old  will  answer.  I  have  successfully  fed  premature  infants  with 
breast-milk  of  women  whose  children  were  older  than  this.  Another 
plan  is  to  secure  a  wet-nurse  and  permit  her  to  bring  her  own  baby  into 
the  house.  She  pumps  for  the  premature  infant  the  required  amount 
three  or  four  times  a  day,  and  the  rest  of  the  time  nurses  her  own  child. 
In  this  way  her  flow  of  milk  is  maintained ;  but  if  the  breasts  are  pumped 
exclusively  the  supply  rapidly  diminishes.  The  secretion  of  the  milk  in 
the  mother  may  be  promoted  by  her  suckling  the  wet-nurse's  baby  or 
some  other  vigorous  infant.  The  above  are  temporary  expedients  and 
in  most  instances  need  not  be  continued  more  than  two  or  three  weeks, 
at  the  end  of  which  time  the  mother  may  be  able  to  nurse  her  own  child. 

The  results  with  premature  babies  will  depend  very  much  upon  how 
soon  after  birth  they  receive  proper  care.  Immediately  after  birth  meas- 
ures should  be  taken  to  secure  the  best  care  and  provide  adequately  for 
maintaining  the  body  heat.  If  an  incubator  is  to  be  used  it  should  be 
in  readiness,  so  that  the  child  can  be  put  into  it  as  soon  as  it  is  breathing 
properly.  The  age  and  vigour  of  the  infant  are  of  the  greatest  impor- 
tance in  estimating  the  chances  of  survival.  The  following  table  gives 
Tarnier's  statistics,  showing  the  percentage  of  premature  infants  saved 
during  a  period  of  five  years  without  the  incubator,  and  during  the 
succeeding  five  years  with  the  incubator;  also  the  percentage  saved  at 
the  Sloane  Hospital  (New  York),  as  published  by  Voorhees: 


Voorhees  saved 

Tarnier  saved 

Tamier  saved 

Voorhees 

excluding  cases 

AOE. 

without  incu- 

with incubators. 

saved  with 

dying  a  few 

bators. 

incubators. 

hours  after  birth. 

Born  at  6    months 

0.0% 

16.0% 

"     "  6i       "       

21.5% 

36.6% 

22.0% 

66.6% 

"     "  7         "       

39.0% 

49.8% 

41.0% 

71.0% 

"     "7h       "      

54.0% 

77.0% 

75.0% 

89.0% 

"     "  8         "       

78.0% 

88.8% 

70.0% 

91.0% 

"     "  8i        "       

88.0% 

96.0% 

^t:ight. 


15 


Results  will  improve  with  the  experience  of  the  physician  in  the  feed- 
ing and  care  of  these  very  sensitive  patients.  Much  is  yet  to  be  learned 
about  them. 


CHAPTER    II. 
GROWTH  AND  DEVELOPMENT  OF   THE  BODY. 

Observations  upon  growth  and  development  are  of  the  utmost  im- 
portance during  infancy  and  childhood.  Only  by  this  means  are  very 
many  diseases  detected  in  their  incipiency.  Early  recognition  carries 
with  it  in  most  cases  the  possibility  of  checking  such  pathological  proc- 
esses as,  if  allowed  to  go  on,  may  affect  the  health  not  only  in  infancy 
but  even  throughout  life. 

By  familiarity  with  what  is  normal,  detection  of  the  abnormal  soon 
becomes  easy.  Investigation  in  regard  to  these  subjects  should  be  made 
a  part  of  the  physical  examination  of  every  child. 


WEIGHT. 

The  weight  of  the  infant  is  the  best  means  we  have  to  measure  his 
nutrition.  It  is  as  valuable  a  guide  to  the  physician  in  infant  feeding  as 
is  the  temperature  in  a  case  of  continued  fever.  Although  the  weight  is 
not  to  be  taken  as  the  only  guide  to  the  child's  condition,  it  is  of  such 
importance  that  we  cannot  afford  to  dispense  with  it  during  the  first  two 
years.  It  is  a  great  advantage  to  keep  up  regular  observations  during 
childhood. 

Weekly  weighings  should  be  made  for  the  first  six  months,  bi-weekly 
for  the  rest  of  the  first  year,  and  monthly  during  the  second  year. 
Delicate  children  should  be 
weighed  even  more  frequently. 
Balance  scales  only  should  be 
used.  The  spring  scales  are 
not  reliable.  A  useful  pat- 
tern of  balance  scales  is  shown 
in  Fig.  3. 

Weight  at  Birth.— The  fol- 
lowing figures  are  taken  con- 
secutively in  nearly  equal  pro- 
portion from  the  records  of  ^la.  2. 
the  Nursery  and  Child's  Hos- 
pital, the  Sloane  Maternity,  and  the  New  York  Infant  Asylum,  and 
include  only  full-term  children: 


16 


GROWTH  AND  DEVELOPMENT. 


Average  weight  of  568  females 7. 16  lbs.  (3,260  grammes). 

590  males 7.55   "     (3,400  "      ). 

1,158  infants 7.35  "     (3,330  "      ). 

Weight  Curve  during  the  First  Few  Weeks. — The  aeeompanyiiig 
chart  represents  the  variations  in  weight  for  the  first  twenty  days.  These 
observations  were  made  upon  one  hundred  healthy,  nursing  infants,  fifty 
males  and  fifty  females,  at  the  Nursery  and  Child's  Hospital.  The 
children  were  weighed  daily  during  the  period  of  observation.     The 


Name, Date  of  Birth, ISO 

Qms. 

Lbs. 

1 

2 

s 

1 

5 

8 

7 

8 

9 

10 

11 

12 

IS 

11 

15 

IC 

17 

18 

19 

20 

1310 
ISOO 
1080 
3970 
3860 
3710 
3C30 
3510 
3100 
3290 
3180 
3060 
2910 
2830 
2780 
2810 
2190 
2380 

«K 
9 

8X 

8X 

8 

^H 

7 
«X 

eK 

6 

BX 
6X 

8X 

.a^ 

^ 

r^ 

f— * 

^ 

^ 

\ 

^ 

--' 

^ 

\ 

^ 

^ 

\ 

1, 

^ 

X 

s 

--' 

-^ 

-J 

J 

J 

Fio.  3. — ^Weight  Cubvb  op  the  First  Twenty  Days. 


average  weight  at  birth  was  7.1  pounds.  The  curve  shows  a  very 
marked  loss  of  weight  on  the  first  day  and  a  slight  loss  on  the  second 
day,  the  lowest  point  being  touched  at  the  beginning  of  the  third  day; 
but  from  this  time  there  was  a  steady  gain.  The  average  initial  loss  in 
these  cases  was  ten  ounces,  being  in  each  sex  exactly  eleven  per  cent  of 
the  body  weight.  In  eight  hundred  and  thirty-five  cases,  including  those 
above  mentioned,  the  average  loss  was  nine  and  a  half  ounces.  The  loss 
of  the  first  days  is  chiefly  due  to  the  discharge  of  the  meconium  and 
urine,  but  is  in  part  from  the  excess  of  tissue  waste  over  the  nutriment 
derived  from  the  breasts.  After  the  third  day,  coincident  with  an  abun- 
dant secretion  of  milk,  there  is  a  steady,  daily  increase  in  weight.  If 
the  milk  is  very  scanty  or  is  wanting  altogether,  the  loss  in  weight 
continues. 


WEIGHT. 


17 


The  birth-weight  of  nursing  children  \vlio  thrive  normally  is  regained 
on  the  average  on  the  tenth  day.  The  most  frequent  deviation  from  the 
normal  curve  consists  in  a  continued  loss  or  stationary  weight  after  the 
third  day.  This  may  be  due  to  acute  illness,  such  as  bronchitis,  diar- 
rhoea, pyaemia,  or  haemorrhage,  but  in  the  majority  ol'  cases  there  is  a 
disturbance  of  nutrition  from  improper  or  insuthcient  food. 

The  weight  curve  of  infants  who  are  artificially  fed,  even  though 
they  are  strong  and  vigorous  and  the  feeding  properly  done,  rarely  fol- 
lows for  the  first  month  the  same  lines  as  that  of  nursing  infants.  We 
usually  see  an  initial  loss  which  is  about  the  same  as  in  nursing  infants, 
then  a  period  of  nearly  stationary  weight  lasting  from  one  to  two  weeks. 

Excessive  loss  in  weight  during  the  first  few  days  from  any  cause 
whatsoever,  seriously  handicaps  an  infant  during  the  first  weeks  of  its 
life.     The  great  importance  of  this  has  not  been  sufficiently  appreciated. 


WEIGHT    CHART. 
Name, Date  of  Birth, 191 

E 
C5 

Si 

WEEK  OF  AGE. 

1              .                 13                                 26                               39                            52 

10890 
10430 
9980 
9530 
0070 
8620 
8160 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
40gO 
3630 
3180 
2720 
2270 

24 

23 

22 

21 

20 

19 

18 

17 

16 

15 

14 

13 

12 

II 

10 

9 

8 

7 

6 

5 

~ 

r 

~ 

" 

' 

" 

" 

~ 

■ 

" 

- 

r^ 

^ 

^ 

f^ 

--' 

^ 

** 

' 

^ 

^ 

' 

/ 

/ 

> 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

I 

/ 

- 

3  MOS.  6  MOS.  9  MOS. 

Fig.  4. — Weight  Curve  of  the  First  Year.* 


12  MOS. 


Weight  Curve  of  the  First  Year. — The  curve  of  the  accompanying 
chart  is  made  up  from  complete  weight  charts  of  one  hundred  healthy 
nursing  infants  who  were  thriving  and  weighed  every  week,  and  the  in- 
complete charts  of  about  three  hundred  other  infants.     There  are  repre- 

*  Blank  weight  charts  are  made  by  Geo.  L.  Goodman  &  Co.,  101  Beekman  Street, 
New  York. 

3 


18  GROWTH  AND  DEVELOPMENT. 

sented  in  round  numbers  about  twenty  thousand  observations  on  children 
under  one  year.  The  period  of  most  rapid  increase  is  during  the  first 
three  months.  It  is  slowest  from  the  sixth  to  the  ninth  month.  This 
curve  is  not  to  be  regarded  as  a  normal  line,  like  the  normal  line  of  the 
temperature  chart,  but  as  an  average  line.  An  infant  who  is  at  birth  a 
pound  above  the  average  may  keep  this  distance  above  the  line  for  the 
whole  year;  another,  weighing  one  pound  less  than  the  average,  may  be 
as  far  below  it.  Girls  throughout  the  year  are  on  the  average  half  a 
pound  lighter  than  boys.  No  single  child  exactly  follows  the  line  all 
the  way,  but  it  is  surprising  how  close  to  it  a  very  large  number  of  the 
cases  come. 

In  artificially-fed  infants — provided  the  feeding  is  properly  done — the 
curve  does  not  diifer  essentially  from  that  of  breast-fed  infants,  except- 
ing in  the  slower  gain  of  the  first  month,  although  this  difference  is 
usually  made  up  before  the  sixth  month  is  readied. 

At  the  end  of  the  first  year  the  average  child  weighs  nearly  three 
times  as  much  as  at  birth.  Perfect  health  during  the  first  year  is  seen 
only  in  children  who  are  gaining  steadily  in  weight.  A  child  may  not 
always  gain  rapidly,  but  it  should  gain  steadily,  and  if  it  does  not,  some- 
thing is  wrong.  All  the  conditions  surrounding  the  infant  should  be 
investigated,  but  especially  the  food.  One  should  not  be  satisfied  unless 
the  average  weekly  gain  during  the  first  six  months  is  at  least  four 
ounces.  In  the  second  six  months  it  may  be  slightly  less.  As  a  rule,  a 
child  who  gains  regularly  in  weight  is  thriving;  an  exception  must,  how- 
ever, be  made  in  the  case  of  some  infants  who  are  fed  chiefiy  upon  carbo- 
hydrate foods. 

Weight  from  the  Second  to  the  Fifth  Year. — Comparatively  few  obser- 
vations have  been  published  upon  the  weight  during  this  period.  From 
nearly  one  thousand  personal  observations  it  appears  that  the  normal 
gain  of  a  healthy  child  is  about  six  pounds  during  the  second  year,  about 
five  during  the  third  year,  and  about  four  pounds  during  the  fourth 
year;  the  actual  weights  are  given  in  the  large  table  on  page 
20.  During  this  period  the  gain  is  rarely  uniform  after  the  first  year. 
With  most  children  it  is  slowest  or  the  weight  is  stationary  in  the  sum- 
mer months,  while  the  most  rapid  increase  is  usually  seen  in  autumn. 
Throughout  this  period  the  girls  gain  in  about  the  same  ratio  as  boys,  but 
remain  on  the  average  nearly  one  pound  lighter.  During  almost  every 
illness,  no  matter  of  what  character,  the  gain  in  weight  ceases,  and  usu- 
ally there  is  a  loss,  the  rapidity  and  extent  of  which  are  somewhat  pro- 
portionate to  the  severity  of  the  attack;  but  it  is  always  much  more 
rapid  in  diseases  of  the  digestive  tract  than  in  any  other  form  of  illness. 

Weight  of  Older  Children. — The  weights  given  in  the  table  of  children 
from  five  to  fourteen  years  are  from  Bowditch.  Observations  were  made 
upon  children  of  American  parentage  in  the  public  schools  of  Boston — 


HEIGHT. 


19 


upon  4,337  boys  and  3,681  girls. ^  It  is  to  be  remembered  that  these 
weights  include  the  ordinary  clothing,  while  those  below  five  years  are 
without  clothing.  2 

The  slowest  gain  is  from  the  fifth  to  the  eighth  year,  when  it  is  about 
four  pounds  a  year.  From  the  eighth  to  the  eleventh  year  it  rises  to 
about  six  pounds  a  year.  Up  to  the  eleventh  year  the  two  sexes  gain 
in  about  the  same  ratio.  From  the  eleventh  to  the  thirteenth  year  the 
girls  gain  much  more  rapidly,  passing  the  boys  for  the  first  time  and 
maintaining  this  lead  until  the  fifteenth  year,  when  again  the  boys 
pass  them. 

HEIGHT. 

The  figures  showing  the  height  at  different  ages  are  given  in  the  fol- 
lowing table.  The  measurements  of  infants  at  birth  are  taken  in  about 
equal  numbers  from  the  records  of  the  New  York  Infant  Asylum  and 
the  Sloane  Maternity  Hospital.    They  were  made  upon  full-term  infants. 

Average  length  of  231  males 20.61  inches  (52.5  cm.); 

"  "  211  females 20.47     "        (52.2    "  ); 

-"  442  infants 20.54     "        (52.35"). 

The  most  rapid  gain  in  length  is  in  the  first  year.  During  this  period 
the  child  grows  on  an  average  a  little  over  eight  inches  (21  cm.).  This 
gain  is  usually,  but  not  always,  proportionate  to  the  increase  in  weight. 
During  the  second  year  the  average  increase  is  three  and  a  half  inches  (9 


*  W.  T.  Porter  has  published  (1894)  observations  made  upon  14,744  children  of 
American  parentage  in  the  public  schools  of  St.  Louis.  His  figures  show  quite  a 
variation  from  those  of  Bowditch.  and  are  as  follows : 


Age. 

boys' 

WEIGHT. 

girls'  weight. 

Kilos. 

Pounds. 

Kilos. 

/    Pounds. 

6  years 

7  "    

19.66 
21.67 
23.91 
26.08 
28.49 
31.26 
33.45 
35.96 
40.34 
47.25 
52.10 

43.2 
47.7 
52.6 
57.4 
62.7 
68.8 
73.6 
79.1 
88.7 
103.9 
114.6 

18.76 
20.82 
22.71 
25.07 
27.43 
29.93 
33.17 
38.29 
43.12 
46.90 
50.06 

41.3 

45.8 

8      "    

50.0 

9      "    

55  1 

10      "    

60  3 

11       "    

65  8 

12      "    

73  0 

13      "    

84  2 

14      "    

94.9 

15      "    

103.2 

16      "    

110.1 

'  The  average  weight  of  the  ordinary  house  clothing  of  school  children,  according 
to  Bowditch,  is  at  five  years,  2.8  pounds  for  both  sexes;  at  seven  years,  3.5  for  both 
sexes;  at  ten  years,  5.7  pounds  for  boys  and  4.5  pounds  for  girls;  at  thirteen  years,  7.4 
pounds  for  boys  and  5.6  pounds  for  girls;  at  sixteen  years,  9.7  pounds  for  boys  and  8.1 
pounds  for  girls.     This  must  be  deducted  from  weights  given  to  obtain  the  net  weight. 


GROWTH  AND   DEVELOPMENT. 


/able  showing  Weight,  Height,  and  Circumference  of  the  Head  and  Chest  from 
Birth  to  the  Sixteenth  Year.^ 


WEIGHT. 

HEIGHT. 

CHEST. 

HEAD. 

AOE. 

Sex 

Pounds. 

Kilos. 

Inches. 

Cm. 

Inches. 

Cm. 

Inches. 

Cm. 

Birth  2 

Boys. 

Girls. 

7.55 

7.16 

3.43 

3.26 

20.6 

20.5 

52.5 

52.2 

13.4 

13.0 

34.2 

33.2 

13.9 

13.5 

35.5 

34.5 

6  months  ^. . . 

Boys. 

Girls. 

16.0 

15.5 

7.26 

7.03 

25.4 

25.0 

64.8 

63.6 

16.5 

16.1 

42.0 

41.0 

17.0 

16.6 

43.5 

42.2 

12  months' . . 

Boys. 

Girls. 

21.0 

20.5 

9.29 

8.84 

29.0 

28.7 

73.8 

73.2 

18.0 

17.4 

45.9 

44.4 

18.0 

17.6 

45.9 

44.6 

18  months' . . 

Boys. 

Girls. 

24.0 

23.0 

10.35 

9.98 

30.0 

29.7 

76.3 

75.6 

18.5 

18.0 

47.1 

45.9 

18.5 

18.0 

47.1 

45.9 

2  years ' — 

Boys. 

Girls. 

27.0 

26.0 

12.02 

11.56 

32.5 

32.5 

82.8 

82.8 

19.0 

18.5 

48.4 

47.0 

18.9 

18.6 

48.2 

47.2 

3  years ' 

Boys. 

Girls. 

32.0 

31.0 

14.14 

13.60 

35.0 

35.0 

89.1 

89.1 

20.1 

19.8 

51.1 

50.5 

19.3 

19.0 

49.0 

48.4 

4  years^ .... 

Boys. 

Girls. 

36.0 

35.0 

15.87 

15.41 

38.0 

38.0 

96.7 

96.7 

20.7 

20.7 

52.8 

52.2 

19.7 

19.5 

50.3 

49.6 

5  years 

Boys. 

Girls. 

41.2 

39.8 

18.71 

18.06 

41.7 

41.4 

106.0 

105.3 

21.5 

21.0 

54.8 

53.5 

20.5 

20.2 

52.2 

51.3 

6  years 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

45.1 

43.8 

49.5 

48.0 

54.5 

52.9 

60.0 

57.5 

66.6 

64.1 

20.48 

19.87 

22.44 

21.78 

24.70 

24.01 

26.58 

26.10 

30.22 

29.07 

44.1 

43.6 

46.2 

45.9 

48.2 

48.0 

50.1 

49.6 

52.2 

51.8 

112.0 

110.9 

117.4 

116.7 

122.3 

122.1 

127.2 

120.0 

132.6 

131.5 

23.2 

22.8 

23.7 

23.3 

24.4 

23.8 

25.1 

24.5 

25.8 

24.7 

59.1 

5S.3 

60.6 

59.5 

62.2 

60.8 

63.9 

62.5 

65.6 

63.0 

7  years 

8  years 

9  years 

10  years 

21.0 

20.7 

53.5 

52.8 

11  years 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

72.4 

70.3 

79.8 

81.4 

88.3 
91.2 

99.3 

100.3 

110.8 

108.4 

32.83 

31.87 

36.21 

36.90 

40.04 

41.36 

45.03 

45.50 

50.26 

49.17 

54.0 

53.8 

55.8 
57.1 

58.2 

58.7 

61.0 

60.3 

63.0 

61.4 

137.2 

136.6 

141.7 

145.2 

147.7 

149.2 

155.1 

153.2 

159.9 

155.9 

26.4 

25.8 

27.0 

26.8 

27.7 

28.0 

28.8 
29.2 

30.0 

30.3 

67.2 

65.8 

68.8 

68.3 

70.6 

71.3 

73.3 

74.1 

76.6 

76.8 

12  years 

13  years 

14  years 

15  years 

21.8 

21.5 

55.5 

54.8 

16  years 

Boys. 

Girls. 

123.7 

113.0 

56.09 

51.24 

65.6 

61.7 

166.5 

156.7 

31.2 

30.8 

79.2 

78.8 

*  The  observations  of  Boas  (Science,  April  12,  1895)  upon  4,319  children  over  six 
years  old  show  that  first  born  exceed  children  born  at  a  later  period  both  in  height 
and  weight. 

'  These  weights  are  without  clothes;  after  five  years  clothes  are  included. 


THE  HEAD.  21 

cm.).  From  this  time  on  the  rate  of  increase  is  quite  uniform  in  both 
sexes  until  the  eleventh  year,  it  being  between  two  and  three  inches  a  year. 

After  the  eleventh  year  in  girls  and  the  twelfth  in  boys  the  growth  is 
much  more  rapid.  In  height  the  girls  exceed  the  boys  at  the  twelfth 
and  thirteenth  years  for  the  only  time  in  their  growth. 

In  the  figures  given  in  the  preceding  table  those  of  five  years  and  over 
are  taken  from  Bowditch,  the  observations  being  made  upon  the  same 
children  as  those  whose  weights  were  taken.  The  observations  from  six 
months  to  four  years  inclusive  are  from  original  sources,  and  are  drawn 
from  about  five  hundred  cases.  The  height  much  more  than  the  weight 
of  children  is  modified  by  hereditary  influences. 

Eachitic  children  during  infancy  and  early  childhood  are,  as  a  rule, 
shorter  than  others.  I  have  frequently  measured  such  children  during 
the  third  year  who  were  six  inches  below  the  average  for  that  age.  The 
effect  of  malnutrition  upon  the  length  of  the  body  is  much  less  than 
upon  the  w^eight. 

GROWTH  OF  THE  EXTREMITIES  AS  COMPARED  WITH  THE  TRUNK. 

At  birth  the  trunk  is  relatively  long  and  the  extremities  short.  The 
centre  of  the  body  at  birth,  according  to  one  hundred  observations  made 
for  me  by  Dr.  Wilbur  Ward  at  the  Sloane  Maternity  Hospital,  is  three- 
quarters  of  an  inch  (2  cm.)  below  the  centre  of  the  umbilicus.  Sub- 
sequently the  growth  of  the  extremities  is  much  more  rapid  than  that 
of  the  trunk.  Thus  I  have  found  at  birth  the  length  of  the  lower  ex- 
tremities (measuring  from  the  anterior  superior  spine  of  the  ileum  to 
the  sole  of  the  foot)  to  be  forty-three  per  cent  of  the  length  of  the  body; 
at  five  years,  fifty-four  per  cent,  and  at  sixteen  years,  sixty  per  cent.  The 
above  figures  are  from  one  hundred  and  fifty  observations,  which,  al- 
though not  numerous  enough  for  exact  percentages,  are  still  sufficient 
to  give  a  very  good  idea  of  the  general  relation  of  the  length  of  the  ex- 
tremities to  that  of  the  body  as  a  whole.  These  facts  are  of  some  assist- 
ance in  the  diagnosis  of  diseases  attended  by  abnormalities  of  growth, 
such  as  rickets,  cretinism,  and  chondrodystrophy. 

THE   HEAD. 

Circumference. — The  average  circumference  of  the  head  at  birth  in 
four  hundred  and  forty-six  full-term  infants  observed  at  the  Sloane 
Maternity  Hospital  and  New  York  Infant  Asylum  was  as  follows : 

Average  circumference  of  the  head,  231  males 13.90  inches  (35.5  cm.); 

"      215  females. ...  13.52     "        (34.5    "  ); 

Total 446  infants....  13.71     "        (35.0"). 

The  occipito-frontal  measurement  was  the  one  taken. 


22  GROWTH  AND  DEVELOPMENT. 

The  growth  of  the  head  is  most  rapid  during  tlie  first  year,  the  in- 
crease being  about  four  inches  (10  cm.).  It  is  about  half  an  inch  a 
month  during  the  early  months,  and  a  fourth  of  an  inch  a  month  dur- 
ing the  later  months  of  the  first  year.  During  the  second  year  the 
increase  is  about  one  inch  (2.5  cm.).  From  the  second  to  the  fifth  year 
the  growth  is  slower,  being  only  about  one  and  a  half  inches  (4  cm.)  for 
the  three  3'ears.  After  the  fifth  year  the  increase  in  the  circumference 
of  the  head  is  very  slow  (see  table). 

Closure  of  the  Sutures. — The  main  sutures  of  the  cranium  are  not 
commonly  ossified  before  the  end  of  the  sixth  month,  and  very  frequently 
some  mobility  may  be  detected  at  the  end  of  the  nintli  month.  Distinct 
separation  of  the  cranial  bones  after  birth  is  abnormal.  It  is  most  fre- 
quently seen  in  premature  and  in  syphilitic  infants. 

Closure  of  the  Fontanels. — The  posterior  fontanel  is  usually  oblit- 
erated by  the  end  of  the  second  month.  The  anterior  fontanel  under 
normal  conditions  closes  on  an  average  at  about  the  eighteenth  month. 
The  usual  variations  are  between  the  fourteenth  and  twenty-second 
months.  At  the  end  of  the  first  year  the  fontanel  is  generally  about 
one  inch  in  diameter.  An  open  fontanel  at  the  end  of  the  second  year 
may  be  considered  abnormal.  The  closure  of  the  fontanel  is  not  al- 
ways early  in  well-nourished  children,  nor  is  it  always  delayed  in  those 
suffering  from  malnutrition.  In  very  rare  cases  the  anterior  fontanel 
may  either  be  closed  at  birth  or  may  close  during  the  first  few  weeks  of 
life.  Closure  of  the  fontanel  by  the  middle  of  the  first  year  is  often  seen 
in  cases  of  arrested  cerebral  development.  This  indicates  a  serious  con- 
dition, usually  microcephalus.  Closure  of  the  fontanel  in  the  early 
months  of  the  second  year  may  be  due  to  the  slow  growth  of  the 
brain  in  a  child  suffering  from  general  malnutrition  but  otherwise 
normal. 

By  far  the  most  frequent  cause  of  delayed  closure  of  the  fontanel  is 
rickets,  in  which  condition  it  may  be  open  up  to  the  end  of  the  third 
year.  A  large  fontanel  is  one  of  the  striking  features  of  cretinism,  and 
in  untreated  cases  is  often  seen  as  late  as  the  eighth  year  or  later.  In 
infancy  an  open  fontanel  with  a  rapid  growth  of  the  liead  should  at 
once  suggest  hydrocephalus.  There  is  an  hereditary  condition  in  which 
the  fontanel  remains  open  6ven  to  adult  life.  Two  such  cases  in  father 
and  son  were  shown  me  by  Marie  in  Paris.  In  both  there  was  also  lack 
of  union  between  the  two  portions  of  the  clavicle. 

Shape  of  the  Head. — The  deformity  which  results  from  compression, 
during  labour  usually  disappears  by  the  end  of  the  first  month.  During 
the  first  year  the  head  often  becomes  flattened  at  the  occiput  in  conse- 
quence of  the  child's  lying  too  much  upon  the  back.  This  is  easily 
remedied  by  changing  his  position.  A  slight  obliquity  of  the  head  may 
result  from  a  habitual  position  during  nursing  or  sleep.     A  marked  de- 


THE   CHEST.  23 

gree  of  obliquity  is  sometimes  congenital,  but  usually  disappears  by  the 
third  or  fourth  year. 

The  other  abnormities  in  the  shape  of  the  head  are  chiefly  due  to 
rickets  and  hydrocephalus,  more  rarely  to  congenital  malformations  of 
the  brain.    They  will  be  considered  in  the  chapter  devoted  to  these  topics. 

Premature  ossification  of  the  sutures  of  the  cranium  occasionally  gives 
rise  to  a  very  striking  deformity  of  the  head.     I  have  soon  two  cases  of 


Fig.  5. — Premature  Ossification  of  the  Sagittal  Suture.     Death  at  six  weeks. 

such  deformity  from  premature  ossification  of  the  sagittal  suture.  The 
heads  in  both  cases  were  very  narrow  and  long  in  the  antero-posterior 
diameter.  The  forehead  was  narrow,  prominent,  and  slightly  project- 
ing. The  illustration  on  this  page  shows  the  skull  of  one  of  these  cases. 
There  is  a  complete  obliteration  of  the  sagittal  suture.  In  this  case 
there  was  a  wide  separation  of  the  sutures  at  the  junction  of  the  parietal 
and  temporal  bones. 

THE   CHEST. 

The  figures  showing  the  circumference  of  the  chest  at  the  different 
periods  of  childhood  have  already  been  given.     The  measurements  up  to 


24  GROWTH  AND   DEVELOPMENT. 

and  including  five  years  are  from  personal  observations,  those  from  the 
sixth  to  the  sixteenth  are  taken  from  Porter,  and  are  drawn  from  obser- 
vations on  31,371  school  children.  The  measurement  of  the  chest  is  that 
taken  midway  between  full  inspiration  and  expiration,  and  at  the  level 
of  the  nipples. 

In  the  newly-born  child  the  antero-posterior  and  the  transverse  diam- 
eters of  the  chest  are  nearly  the  same.  As  age  advances,  the  transverse 
diameter  increases  very  much  more  rapidly,  so  that  the  outline  of  the 
chest  gradually  assumes  an  elliptical  shape,  which  it  maintains  during 
childhood. 

At  birth,  the  circumference  of  the  chest  is  about  one-lialf  inch  less 
than  that  of  the  head,  but  throughout  infancy  the  two  measurements 
are  nearly  the  same.  It  is  not  until  the  third  year  that  the  average 
circumference  of  the  chest  exceeds  that  of  the  head.  The  chest  measure- 
ment in  infants  is  always  much  modified  by  the  amount  of  fat ;  but,  after 
making  due  allowance  for  this,  a  large  chest  always  indicates  a  robust 
child  and  a  small  chest  a  delicate  one.  If  at  any  age  the  circumference 
of  the  child's  chest  is  found  to  be  below  the  average,  means  should  be 
taken,  by  gymnastics  and  otherwise,  to  develop  it. 

In  infants  deformities  of  the  thorax  result  chiefly  from  rickets,  some- 
times from  empyema,  emphysema,  and  cardiac  disease ;  in  older  children, 
from  lateral  curvature  of  the  spine,  or  from  Pott's  disease.  A  peculiar 
deformity,  usually  congenital,  but  sometimes  rachitic,  is  the  funnel- 
shaped  chest,  the  Trichter-hrust  of  the  Germans.  It  consists  in  a  deep 
pit-like  central  depression  at  the  lower  end  of  the  sternum.  It  is  usually 
permanent. 

THE  ABDOMEN. 

Throughout  infancy  the  circumference  of  the  abdomen  is,  as  a  rule, 
about  the  same  as  that  of  the  chest.  At  the  end  of  the  second  year 
the  measurements  of  the  head,  chest,  and  abdomen  are  very  often  identi- 
cal; after  this  time  the  chest  measurement  increases  much  more  rapidly 
than  the  other  two.  Marked  enlargement  of  the  abdomen  is  seen  in 
many  varieties  of  chronic  intestinal  disorders.  It  is,  however,  most 
marked  in  the  tympanites  which  so  constantly  accompanies  rickets. 

MUSCUIiAR   DEVELOPMENT. 

The  first  voluntary  movements  are  usually  in  the  fourth  month,  when 
the  infant  deliberately  attempts  to  grasp  some  object  placed  before  it. 
During  the  fourth  month,  as  a  rule,  the  head  can  be  held  erect  when  the 
trunk  is  supported.  In  many  infants  this  is  possible  in  the  early  part 
of  the  third  month.  At  seven  or  eight  months  a  healthy  child  is  usually 
able  to  sit  erect  and  support  the  trunk  for  several  minutes. 

In  the  ninth  or  tenth  month  are  usually  seen  the  first  attempts  to 


DEVELOPMEJ^T  OF  THE   SPECIAL  SENSES.  25 

bear  the  weight  upon  the  feet.  At  eleven  or  twelve  months  a  child 
usually  stands  with  slight  assistance.  The  first  attempts  at  walking  are 
commonly  seen  in  the  twelfth  or  thirteenth  month.  The  average  age  at 
which  children  walk  freely  alone  has  been,  in  my  experience,  the  four- 
teenth or  fifteenth  month.  Quite  wide  variations  are  seen  in  healthy 
children.  Very  much  depends  upon  the  surroundings.  I  have  known 
infants  to  walk  at  ten  months  and  many  others  not  until  seventeen  or 
eighteen  months,  although  showing  no  evidences  of  disease,  and  although 
their  development  had  not  been  retarded  by  previous  illness.  A  very 
marked  difference  is  seen  in  different  families  with  respect  to  the  time 
of  walking. 

The  physician  is  often  consulted  because  of  backward  muscular  devel- 
opment, most  frequently  because  the  child  is  late  in  walking.  General 
malnutrition,  or  any  other  severe  or  prolonged  illness,  may  postpone  for 
several  months  this  or  any  of  the  other  functions  mentioned.  When 
there  is  no  such  explanation  of  the  backwardness,  a  child  who  does  not 
hold  up  his  head,  sit  alone,  or  make  efforts  to  stand  or  walk  at  the  proper 
time,  should  be  submitted  to  a  careful  examination  for  mental  deficiency 
or  cerebral  or  spinal  paralysis,  but  especially  for  rickets  which  is  the 
most  frequent  explanation  of  the  symptoms. 

Contrivances  for  teaching  infants  to  walk  are  unnecessary,  and  their 
effect  may  even  be  injurious.  An  infant  should  be  allowed  the  greatest 
possible  freedom  in  the  use  of  his  limbs.  He  should  not  be  restrained 
from  walking  when  inclined  to  do  so,  nor  continually  urged  to  walk  when 
no  voluntary  attempts  are  made.  Nothing  short  of  mechanical  restraint 
will  prevent  a  healthy  child  from  walking  or  standing  when  he  is  strong 
enough  to  do  so. 

DE\^LOPMENT  OF  THE  SPECIAL  SENSES.' 

Sight. — The  newly-born  infant  avoids  the  light.  The  pupils  contract 
in  a  light  room,  and  if  a  bright  light  is  brought  before  the  eyes  they 
close.  During  the  first  few  weeks  the  infant  indicates  by  every  sign  that 
excessive  light  is  unpleasant.  As  early  as  the  sixth  day  the  eyes  will 
sometimes  follow  a  light  in  the  room,  and  the  child  may  even  turn  the 
head  for  this  purpose.  The  muscles  of  the  eyes  of  the  newly-born  infant 
act  irregularly  and  not  in  harmony.  Co-ordinate  action  for  general  pur- 
poses is  not  established  until  about  the  end  of  the  third  month.  Even 
after  this  time  inco-ordinate  action  is  occasionally  seen.  The  eyelids 
also  move  irregularly,  and  are  often  partly  separated  during  sleep.  The 
cornea  is  but  slightly  sensitive  during  the  first  weeks.  In  Preyer's  child 
it  was  not  until  the  third  month  that  the  lids  closed  when  the  water  in 

'  For  many  of  the  facts  in  this  paragraph  I  am  indebted  to  Preyer's  The  Senses 
and  the  Will,  American  edition,  D.  Appleton  and  Company. 


26  GROWTH   AND   DEVELOPMENT. 

the  bath  touched  the  lashes  or  the  cornea.  The  recognition  of  objects 
Been  is  usually  evident  in  the  sixth  month. 

It  is  important  that  the  room  in  which  the  newly-born  child  is  placed 
should  be  darkened,  and  that  for  the  first  few  weeks  the  eyes  should  be 
protected  against  strong  light. 

Hearing. — For  the  first  twenty-four  hours  after  birth  infants  are 
deaf.  This  deafness  sometimes  persists  for  several  da3'S.  It  is  believed 
to  be  due  to  absence  of  air  from  the  middle  ear  and  to  swelling  of  the 
mucous  membrane  which  lines  the  tympanum.  With  the  movements  of 
respiration,  air  gradually  finds  its  way  into  the  middle  ear,  and  the  swell- 
ing subsides  during  the  first  few  days.  After  this  the  hearing  gradually 
improves,  and  during  the  early  months  of  life  it  is  very  acute.  The  child 
starts  at  the  slamming  of  a  door,  and  even  moderately  loud  noises  will 
waken  him  from  sleep.  By  the  end  of  the  second  month  he  will  some- 
times turn  his  head  in  the  direction  from  which  the  sound  comes,  and 
by  the  end  of  the  third  month  this  will  usually  be  done.  Demme  found, 
in  observations  upon  one  hundred  and  fifty  infants,  that  the  voices  of 
parents  were  recognised  on  an  average  at  three  and  a  half  months. 

Not  only  are  the  ears  unusually  sensitive  to  sound  in  infancy,  but 
the  impression  produced  upon  the  brain  is  often  marked — very  loud 
sounds  causing  great  fright,  and  sometimes  even,  it  is  reported,  con- 
vulsions. 

Touch. — Tactile  sensibility  is  present  at  birth,  but  is  not  highly  devel- 
oped except  in  the  lips  and  tongue,  where  it  is  very  acute  for  the  obvious 
necessity  of  sucking.  After  the  third  month  it  is  fairly  acute  over  the 
surface  of  the  body  generally.  Two  especially  sensitive  areas,  according 
to  Preyer,  are  the  forehead  and  external  auditory  meatus. 

Sensibility  to  painful  impressions  is  present  in  early  infancy,  but 
very  dull  as  compared  with  later  childhood. 

Temperature  is  also  distinguished.  This  recognition  is  especially 
acute  in  the  tongue.  A  young  infant  is  often  seen  to  refuse  to  take  the 
bottle  because  the  milk  is  only  a  few  degrees  too  cold  or  too  warm. 

The  localisation  of  sensory  impressions  comes  later,  probably  not 
much  before  the  middle  of  the  sixth  month,  and  is  very  imperfect 
throughout  the  first  year. 

Taste. — This  is  highly  developed,  even  from  birth.  According  to  the 
experiments  of  Kussmaul,  the  ability  to  distinguish  sweet,  sour  and  bit- 
ter, exists  in  the  newly-born  child — sweet  exciting  sucking  movements, 
and  bitter,  grimaces.  A  young  infant  detects  with  surprising  accuracy 
the  slightest  variation  in  the  taste  of  its  food,  and  the  smallest  difference 
is  often  enough  to  cause  it  to  refuse  the  bottle  altogether.  Sweet  sub- 
stances are  always  easily  administered,  and  in  combination  with  sirups 
even  very  bitter  substances  can  be  given;  but  to  aromatic  powders  and 
elixirs  he  usually  objects. 


DENTITION.  27 

Smell. — Observations  upon  the  sense  of  smell  in  newly-born  infants 
are  few  and  not  altogether  conelusive.  Kroner's  experiments  appear  to 
show  that  smell  is  present  in  the  newly  born.  It  lias  been  noted  to  be 
especially  acute  in  infants  born  blind.  The  sense  of  smell  is  developed 
much  later  than  the  other  senses.  Detection  of  fine  differences  in  odours 
is  not  acquired  until  quite  late  in  childhood. 

SPEECH. 

There  is  a  very  wide  variation  in  children  with  reference  to  the  time 
of  development  of  the  function  of  speech.  Girls,  as  a  rule,  talk  from 
two  to  four  months  earlier  than  boys.  Towards  the  end  of  the  first 
year  the  average  child  begins  with  the  words  "  papa,"  "  mamma."  By 
the  end  of  the  second  year  he  is  able  to  put  words  together  in  short 
sentences  of  two  or  three  words.  Progress  in  speech  from  this  time  is 
very  rapid,  each  month  showing  great  improvement.  Names  of  persons 
are  commonly  first  acquired,  then  the  names  of  objects.  Next  to  this 
the  verbs  are  learned,  and  then  adverbs  and  adjectives.  Conjunctions, 
prepositions,  and  articles  follow  in  order,  and  last  of.  all  the  personal 
pronouns. 

If  a  child  of  two  years  makes  no  attempt  to  speak,  some  mental  defect 
may  usually  be  inferred  or  that  the  child  is  a  deaf  mute. 

DENTITION. 

The  teeth  are  enclosed  at  birth  in  dental  sacs  which  are  situated  in 
the  gums.  Superficially  they  are  covered  by  the  submucous  connective 
tissue  and  the  mucous  membrane;  the  dental  sacs  rest  in  depressions  in 
the  alveolar  process  of  the  jaw.  The  tooth  grows  in  length  mainly  as  the 
result  of  the  calcification  of  its  roots,  and  being  thus  fixed  below,  it 
pushes  upward  towards  the  mucous  membrane.  This  growth  undoubtedly 
goes  on  steadily  from  birth  until  the  tooth  pierces  the  gum. 

The  deciduous  or  milk  teeth  are  twenty  in  number.  The  time  at 
which  they  appear  is  subject  to  considerable  variation  even  under  normal 
conditions.  The  following  is  the  order  and  the  average  time  of  appear- 
ance of  the  different  teeth: 

(1)  Two  lower  central  incisors 6  to    9  months. 

(2)  Foiir  upper  incisors 8  "  12        " 

(3)  Two  lower  lateral  incisors  and  four  anterior  molars. ...    12  "  15        " 

(4)  Four  canines  . 18  "  24        " 

(5)  Four  posterior  molars 24  "  30        " 

At  1    year  a  child  should  have 6  teeth. 

At  1|     "  "  "        "    12      " 

At  2    years         "  "        "     16      " 

At2i       "  "  "        "    20      " 


28  GROWTH  AND  DEVELOPMENT. 

Quite  wide  variations  on  both  sides  of  the  average  are  common,  and 
are  not  always  easy  of  explanation.  In  many  cases  it  seems  to  be  a  family 
idiosyncrasy,  since  in  the  different  members  of  a  family  the  teeth  are 
apt  to  appear  at  about  the  same  time.  The  order  in  which  the  teeth 
appear  is  much  more  regular  than  the  time  of  their  appearance.  Slight 
variations  are  exceedingly  common,  but  marked  irregularities  in  the 
order  of  the  appearance  of  the  teeth  are  the  rule  in  idiotic  children  or 
those  suffering  from  slighter  mental  defects. 

The  teeth  may  pierce  the  gum  without  any  local  manifestations. 
Very  frequently,  however,  just  before  a  tooth  comes  through  there  is 
noticed  a  moderate  swelling  and  redness  of  the  mucous  membrane  of  the 
gum  overlying  it,  and  to  a  slight  degree  this  may  affect  the  general 
mucous  membrane  of  the  mouth.  This  condition  may  be  accompanied 
by  a  little  fretfulness  and  increased  salivation,  or  both  of  these  may  be 
entirely  wanting.  These  symptoms  usually  disappear  when  the  tooth 
has  pierced  the  gum.  The  symptoms  of  difficult  dentition  will  be  dis- 
cussed in  connection  with  Diseases  of  the  Mouth. 

Infants  may  be  born  with  teeth.  I  know  of  one  family  in  which 
this  occurred  in  three  members  of  three  successive  generations.  It  is, 
however,  rare.  It  is  almost  invariably  one  of  the  lower  central  incisors 
that  is  present.  In  case  this  interferes  with  nursing,  or  if  it  is  very 
loosely  attached  to  the  gum,  it  should  be  extracted,  but  under  other 
circumstances  it  should  be  allowed  to  remain,  since,  if  it  is  removed, 
a  second  tooth  is  not  likely  to  appear  in  its  place  in  the  first  set.  It  is 
not  at  all  uncommon  for  the  first  teeth  to  appear  in  the  fourth  month. 
Such  teeth,  in  my  experience,  do  not  usually  differ  in  character  from 
those  appearing  later,  unless  they  are  in  children  who  are  syphilitic. 
Sj'philitic  children  are  rather  prone  to  early  dentition,  and  under  such 
circumstances  rapid  and  early  decay  is  likely  to  take  place.  Nursing 
infants  are,  as  a  rule,  a  little  earlier  in  their  dentition  than  those  arti- 
ficially fed. 

Delayed  dentition  is  usually  due  to  rickets.  However,  in  many 
healthy  infants  no  teeth  appear  before  the  tenth  month.;  and  I  have 
occasionally  seen  the  first  ones  at  thirteen  months  in  those  who  seemed 
perfectly  healthy  and  showed  no  other  evidence  of  rickets.  On  the  other 
hand,  it  is  by  no  means  invariable  that  dentition  is  late  in  rachitic  chil- 
dren. The  latest  dentition  is  seen  in  cases  of  cretinism.  In  such  chil- 
dren it  is  not  rare  for  the  first  teeth  to  appear  as  late  as  eighteen 
months  or  two  years.  As  a  rule,  dentition  and  ossification  of  the  bones 
of  the  head  go  on  in  a  corresponding  manner;  where  one  is  early  the 
other  is  likely  to  be  rapid,  and  conversely.  Great  irregularities  in  denti- 
tion are  common  in  children  with  defective  cerebral  development. 

Provided  an  infant  is  well  nourished  and  thrives  properly  for  the 
first  six  or  eight  months,  the  eruption  of  the  teeth  is  likely  to  go  on 


PECULIARITIES  OF  DISEASE  IN  CHILDREN.  29 

steadily  after  this  time,  even  though  the  child  may  later  have  chronic 
indigestion  or  suffer  from  extreme  malnutrition  from  any  cause  excepting 
rickets.  If,  however,  the  symptoms  of  malnutrition  date  from  birth, 
dentition  is  almost  invariably  delayed.  It  is  often  a  matter  of  very 
great  surprise  to  see  children  who  are  markedly  emaciated  as  a  result  of 
chronic  indigestion  or  ileo-colitis  and  yet  go  on  cutting  their  teeth  reg- 
ularly. I  once  had  under  my  care  a  delicate  infant  of  sixteen  months, 
whose  body  length  was  twenty-eight  inches  and  whose  weight  was  less 
than  nineteen  pounds — almost  exactly  what  they  were  eight  months 
previously — and  yet  he  had  thirteen  teeth. 

Eruption  of  the  Permanent  Teeth. — The  first  to  a])pear  are  the  first 
molars,  which  usually  come  in  the  sixth  year,  and  hence  the  name  six- 
year-old  molars,  which  is  applied  to  them.  These  appear  posterior  to  the 
second  molars  of  the  first  set.  The  following  table  from  Forchheimer 
gives  the  average  time  of  the  appearance  of  the  second  teeth : 

First  molars 6  years. 

Incisors 7  to    8 

Bicuspids 9  "  10 

Canines 12  "  14 

Second  molars 12  "  15 

Third  molars 17  "  25 

The  incisors  and  canines  replace  the  corresponding  teeth  of  the  first 
set.  The  eight  bicuspids  take  the  place  of  the  eight  molars  of  the  first 
set.  The  molars  of  the  permanent  set  appear  back  of  the  bicuspids,  room 
being  made  for  them  by  the  growth  of  the  jaw.  As  they  grow  and  push 
upward  they  cause  atrophy  of  the  roots  of  the  first  teeth,  and  gradually 
cut  off  their  blood  supply,  so  that  they  loosen  and  fall  out. 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  in- 
fancy will  be  considered  in  the  chapter  on  Difficult  Dentition. 


CHAPTER    III. 
PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

In  many  particulars  disease  in  children  differs  from  that  of  later  life. 
These  differences  relate  to  etiology,  pathology,  symptomatology,  diagno- 
sis, and  prognosis.  The  greatest  contrast  to  adult  life  is  presented  by 
infancy  and  early  childhood.  After  seven  years,  children  in  their  dis- 
eases resemble  adults  more  than  they  do  infants. 

ETIOLOGY. 

1.  Inheritance  is  an  important  factor.  The  disease  most  frequently 
transmitted   directly  is  syphilis.     Occasionally  tuberculosis  and  other 


30  PECULIARITIES  OF  DISEASE  IN   CHILDREN. 

infectious  diseases  have  been  conveyed  directly  from  the  mother  to  the 
child.  In  cases  where  no  distinct  disease  is  transmitted,  children  may 
inherit  from  parents  constitutional  weaknesses  or  tendencies,  which  may 
manifest  themselves  in  infancy,  or  in  some  cases  not  until  later  child- 
hood. Under  this  head  we  may  place  the  influence  of  alcoholism,  lead 
poisoning,  rheumatism,  gout,  epilepsy,  and  insanity. 

2.  Malfonnations  must  be  considered,  particularly  in  the  first  two 
years  of  life.  The  most  important  of  these,  from  a  medical  standpoint, 
are  those  of  the  heart,  brain,  stomach  and  intestines,  and  kidney.  The 
various  malformations  of  the  mouth,  nose,  bladder,  rectum,  and  genital 
organs  belong  more  particularly  to  the  domain  of  surgery. 

3.  The  Diseases  or  Accidents  Connected  with  Birth. — Some  of  these 
are  distinctly  traumatic,  like  the  meningeal  haemorrhages.  A  very  large 
class  are  the  infectious  processes  in  the  newly  born.  Infection  usually 
takes  place  through  the  umbilical  wound,  more  rarely  through  the  skin 
or  mucous  membranes.  This  class  includes  pyaemia,  with  its  varied 
lesions  in  the  brain,  lungs,  and  serous  membranes,  erysipelas,  ophthalmia, 
and  tetanus.  In  tlie  class  of  infectious  diseases  may  also  be  included 
many  of  the  varieties  of  pulmonary  and  intestinal  diseases  in  the  newly 
born,  and  probably  also  some  of  the  haemorrhagic  affections. 

4.  Conditions  Interfering  with  Proper  Growth  and  Development. — 
These  are  among  the  largest  etiological  factors  in  the  diseases  of  infancy. 
They  are  improper  food  or  feeding,  unhygienic  surroundings,  and  neglect. 
These  may  cause  specific  diseases,  like  rickets  or  scurvy,  or  may  lead  to  a 
condition  of  general  malnutrition  or  marasmus.  In  this  way  they  become 
most  important  predisposing  factors,  in  infancy,  to  the  acute  diseases  of  the 
gastro-enteric  tract,  and  later  in  childhood,  to  functional  nervous  diseases. 

5.  Infection. — This  has  already  been  mentioned  as  an  important  fac- 
tor in  diseases  of  the  newly  born.  The  number  of  diseases  in  later  life 
directly  traceable  to  this  is  very  large.  Under  this  head  should  be  in- 
cluded not  only  the  well-known  classes  of  infectious  and  contagious  dis- 
eases, but  also  a  very  large  number  of  varieties  of  infection  which  as  yet 
have  not  been  differentiated,  and  the  nature  of  which  is  but  imperfectly 
understood. 

SYMPTOMATOLOGY  AND  DIAGNOSIS. 

In  older  children  the  symptoms  of  disease  are  very  much  the  same  as 
in  adults,  and  similar  methods  of  examination  may  be  employed.  What 
is  really  peculiar  to  children  belongs  especially  to  the  first  three  years  of 
life,  before  speech  has  developed.  During  this  period  the  chief  and 
almost  the  sole  reliance  of  the  physician  must  be  upon  the  objective 
signs  of  the  disease.  It  is  not  so  much  that  diseases  in  early  life  are 
peculiar,  as  that  the  patients  themselves  are  peculiar. 

Two  fundamental  facts  are  always  to  be  kept  in  mind :  First,  that  the 


SYMPTOMATOLOGY  AND   DIAGNOSIS.  31 

common  pathological  processes  are  comparatively  few,  being  chiefly  of 
the  gastro-enteric  tract,  the  lungs,  and  the  brain,  but  that  the  variations 
in  clinical  types  are  almost  endless;  the  second  is,  tliat  in  infaVits,  on 
account  of  the  susceptibility  of  the  nervous  system,  functional  derange- 
ments are  often  accompanied  by  very  grave  symptoms,  and  may  even 
prove  fatal  in  twelve  or  twenty-four  hours,  or  there  may  be  speedy  and 
complete  recovery  after  very  alarming  symptoms.  In  many  of  these 
cases  the  symptoms  are  so  indefinite  that  an  exact  diagnosis  is  impossible 
during  life,  and  even  the  autopsy  may  throw  but  little  light  upon  them. 

At  the  bedside  it  is  of  great  assistance  to  the  physician  if  he  can  keep 
in  mind  the  most  frequent  forms  of  acute--disease  that  are  likely  to  be 
met  with.  In  the  first  group,  including  those  which  are  very  common, 
may  be  placed  acute  indigestion  and  ileo-colitis,  bronchitis,  pneumonia, 
pharyngitis,  and  tonsillitis;  in  the  second  group,  including  those  which 
are  less  frequent,  may  be  placed  otitis  and  the  more  common  acute  infec- 
tious diseases;  in  the  third  group,  including  the  rarer  forms  of  acute 
disease — meningitis,  tuberculosis,  rheumatism,  and  diseases  of  the  kid- 
neys. Under  all  circumstances,  the  season,  and  the  nature  of  the  pre- 
vailing epidemic,  if  one  exists,  are  to  be  considered. 

In  the  examination  of  a  sick  infant  quite  a  difl'erent  method  is  to  be 
followed  from  that  pursued  with  adults.'  Much  information  is  to  be 
gained  from  a  history  carefully  taken  from  an  intelligent  mother  or 
nurse,  and  much  more  from  a  close  observation  of  the  child,  whether 
asleep  or  awake,  quiet  or  crying. 

The  History. — In  view  of  the  fact  that  but  little  information  can 
be  had  from  the  patient,  none  at  all  in  most  cases,  it  is  important  to 
obtain  from  the  mother  or  nurse  as  full  and  complete  information  as 
possible.  A  good  history  carefully  obtained,  puts  the  physician  in  pos- 
session of  a  fund  of  information  about  the  patient  which  is  not  only  of 
the  greatest  value  in  arriving  at  a  diagnosis  in  the  illness  for  which  he 
is  consulted,  but  is  exceedingly  helpful  in  the  future  management  of  the 
child.  He  may  thus  know  the  individual  peculiarities  and  special  path- 
ological tendencies.  The  laity  attach  great  importance,  and  justly  so, 
to  advice  from  the  physician  who  "  knows  the  child's  constitution."  Such 
a  history  should  be  taken  at  the  first  opportunity  after  the  physician  is 
placed  in  charge  of  a  child,  and  with  note  book  in  hand,  or  half  its  value 
will  be  lost. 

Family  History. — This  should  begin  with  the  parents,  going  farther 
back,  if  possible,  in  many  cases  of  hereditary  disease.  One  must  know 
regarding  tuberculosis,  syphilis,  rheumatism,  or  alcoholism,  the  general 
vigour  of  constitution  and  physical  condition  of  both  father  and  mother. 
Health  during  pregnancy  and  previous  miscarriages,  if  any,  are  im- 
portant facts  in  the  mother's  history.  One  should  know  the  number 
of  other  children  living  and  their  general  health,  the  number  dead  and 


32  PECULIARITIES  OF   DISEASE  IN   CHILDREN. 

from  what  causes.  A  knowledge  of  the  surroundings  in  which  the  child 
has  lived  may  be  necessary  to  appreciate  the  chances  of  exposure  to 
tuberculosis,  malaria,  and  many  other  forms  of  infection. 

Patient's  Previous  History. — This  should  begin  with  birth.  One 
should  inquire  whether  the  child  was  premature  or  born  at  term,  regard- 
ing the  character  of  the  labour,  whether  natural  or  instrumental,  tedious 
or  complicated,  the  condition  and  vigour  of  the  child  at  birth,  primary 
respirations,  early  convulsions,  and  the  nutrition  during  the  early  days. 
Next  the  methods  of  feeding  should  be  taken  up — how  long  entirely 
and  how  long  partly  breast  fed,  the  date  of  weaning  and  the  form  of 
artificial  feeding  then  employed.  If  the  patient  is  an  infant,  and  the 
problem  presented  is  one  of  its  nutrition,  all  the  reliable  data  relating 
to  the  feeding  should  be  obtained,  even  to  the  minutest  detail.  This 
may  be  wearisome  and  consume  time,  but  in  no  other  way  can  one  ap- 
preciate the  conditions  present.  The  best  idea  of  the  child's  growth  and 
development  may  be  obtained  from  a  weight  record  if  one  has  been 
kept.  If  not  available,  one  must  depend  upon  general  statements  as 
to  how  the  child  thrived  at  different  periods.  The  date  of  the  appear- 
ance of  the  first  teeth  and  the  time  and  the  order  in  which  the  teeth 
came,  are  significant.  The  general  muscular  development  may  be  best 
determined  by  learning  when  the  child  could  first  hold  the  head  erect, 
sit  alone  upon  the  floor,  bear  the  weight  upon  the  feet,  creep  or  walk 
alone;  the  mental  development,  by  learning  as  to  early  recognition  of 
mother  or  nurse,  knowing  the  bottle,  understanding  the  meaning  of 
words,  speaking  in  words  or  sentences.  The  muscular  and  mental  devel- 
opment of  a  normal  child  during  the  first  two  years  is  a  subject  with 
which  the  physician  should  be  familiar  if  he  would  detect  early  those 
differences,  often  slight  at  this  age,  in  children  whose  development  is 
backward  owing  to  cerebral  lesions. 

All  previous  attacks  of  acute  illness  of  whatever  character  should  be 
noted,  particularly  the  infectious  diseases — measles,  scarlet  fever,  diph- 
theria, pertussis,  and  influenza — with  dates  and  details  as  to  duration, 
severity,  and  complications.  One  should  learn  whether  the  child  is  espe- 
cially prone  to  disorders  of  digestion  or  those  of  the  respiratory  system. 
Under  the  former  head  are  included  early  difficulties  in  feeding,  acute 
attacks  of  indigestion,  diarrhoea,  or  dysentery,  also  chronic  disturbances 
of  the  stomach  or  bowels;  under  the  latter  head,  frequent  catarrhal 
colds,  earache  or  otitis,  catarrhal  croup,  bronchitis,  pneumonia,  or 
pleurisy.  Other  points  to  be  investigated  relate  to  attacks  of  tonsillitis, 
operations  for  the  removal  of  hypertrophied  tonsils  or  adenoids,  and 
previous  disorders  of  the  nervous  system.  In  infants,  particularly  im- 
portant are  extreme  restlessness,  insomnia,  convulsions,  or  attacks  of 
night  terrors ;  in  those  who  are  older,  hysterical  manifestations,  epilepsy, 
or  chorea.     Finally,  one  should  know  the  date  of  successful  vaccination. 


SYMPTOMATOLOGY  AND   DIAGNOSIS.  33 

Inquiry  should  also  be  made  concerning  any  recent  exposure  to  infection 
in  the  community,  school,  or  home. 

Present  Illness. — One  should  first  note  the  chief  complaints  as  stated 
by  mother  or  nurse.  It  is  important  to  obtain  as  definite  statements  as 
possible  as  to  the  time  when  the  child  was  quite  well,  and  whether  the 
onset  of  the  illness  was  abrupt  or  gradual,  and  with  what  particular 
symptoms.  In  all  digestive  disorders  one  should  know  exactly  concern- 
ing the  child's  food  at  the  time  of  the  onset,  its  quantity,  character,  and 
preparation;  also  any  recent  change  in  diet,  the  presence  or  absence  of 
vomiting,  and  the  condition  of  the  bowels,  whether  loose  or  constipated, 
the  frequency  and  character  of  the  stools.  General  questions  as  to 
whether  the  bowels  are  regular  or  the  stools  normal  are  of  no  value, 
since  the  informant  often  is  not  capable  of  judging  correctly. 

Nervous  symptoms,  like  the  others,  should  be  elicited  in  response  to 
direct  questions  regarding  sleep,  restlessness,  moaning,  crying  out,  or 
other  evidences  of  pain,  excitement,  delirium,  or  convulsions,  or  unnat- 
ural drowsiness.  In  any  acute  illness  other  important  symptoms  are 
fever,  sweating,  dyspnoea,  cough,  hoarseness,  nasal  discharge,  and  the 
amount  and  character  of  the  urine. 

The  Examination. — With  infants,  quite  a  different  method  should  be 
followed  from  that  pursued  with  adults.    It  may  well  begin  with : 

General  Inspection. — What  is  learned  in  this  way  will  depend  almost 
entirely  upon  the  acuteness  of  observation  of  the  physician,  but  much 
that  is  of  value  can  be  ascertained  before  the  clothing  is  removed  for  the 
physical  examination  by  simply  watching  the  patient,  whether  asleep  or 
awake,  for  several  minutes.  In  acute  disease,  the  following  points  should 
be  noted  especially: 

1.  Nutrition  and  general  development:  whether  the  child  is  well 
nourished  or  the  features  pinched  and  wasted. 

2.  The  facial  expression:  whether  it  is  bright  and  intelligent  or  dull 
and  stupid,  peaceful  or  anxious,  quiet  or  disturbed,  and  whether  the 
features  are  contracted  from  time  to  time,  as  if  from  pain. 

3.  The  character  of  the  respiration :  whether  it  is  rapid  or  slow,  easy 
or  difficult;  whether  there  is  nasal  obstruction,  as  indicated  by  snoring 
and  mouth-breathing,  suggesting  in  infants  acute  rhinitis,  syphilis,  or 
retro-pharyngeal  abscess;  in  older  children,  diphtheria,  scarlet  fever,  or 
adenoids.  Marked  dyspnoea  is  usually  accompanied  by  active  dilatation 
of  the  alae  nasi. 

4.  The  posture :  whether  the  child  lies  upon  the  back,  side,  or  face ; 
whether  the  head  is  drawn  back  with  general  flexion  of  the  extremities 
as  in  meningitis. 

5.  The  nervous  condition:  whether  the  child  is  restless,  excitable,  or 

drowsy  and  apathetic;  if  asleep,  the  nature   of  the  sleep   should  be 

observed. 

4 


34  PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

6.  The  colour  of  the  skin  of  the  face :  whether  pale  or  cyanotic ;  and 
the  lips,  whether  fissured  or  excoriated. 

7.  The  amount  of  prostration :  a  practised  eye  can  usually  tell  with 
older  children  whether  the  condition  is  grave  or  not,  but  infants  not 
infrequently  deceive  even  the  most  experienced  observer. 

8.  The  cry:  in  conditions  of  restlessness  or  irritability,  much  infor- 
mation may  be  obtained  from  its  character.  It  is  important,  but  not 
always  easy,  to  determine  whether  a  child  cries  from  fright,  as  at  the 
approach  of  a  stranger,  from  nervousness  or  bad  training,  from  general 
irritability  which  may  come  from  any  acute  disease,  or  from  actual 
pain.  The  cry  of  fright  is  usually  evident,  because  it  comes  with  the 
physician's  approach  and  ceases  when  he  goes  away.  Children  of  highly 
neurotic  parents  and  those  who  have  been  much  indulged  and  badly 
trained  will  often  cry  when  anything  out  of  the  usual  routine  occurs. 
The  cry  of  pain  may  be  very  distinctive ;  it  may  be  sharp  and  acute  and 
accompanied  by  some  attempt  at  localisation,  as  when  a  child  puts  hia 
hand  to  an  inflamed  part,  but  in  infancy  the  pain  of  acute  inflammation 
is  often  indicated  only  by  general  restlessness  and  irritability.  This  is 
frequently  true  of  acute  otitis.  The  cry  of  pain  is  usually  accompanied 
by  contraction  of  the  features  and  other  evidences  of  distress. 

The  cry  of  some  diseases  is  quite  characteristic,  as  the  short,  catchy 
cry  of  acute  pneumonia  or  bronchitis;  the  hoarse  cry  of  laryngitis, 
whether  catarrhal,  membranous,  or  syphilitic;  the  feeble  whine  of  ex- 
treme exhaustion  or  marasmus;  the  moaning  cry  of  intestinal  disease; 
and  the  sharp  cry  of  a  child  with  scurvy  whenever  its  bed  or  body  is 
touched. 

Measurements. — These,  though  of  greatest  value  in  chronic  diseases, 
particularly  disturbances  of  nutrition,  maj'  be  of  assistance  also  in  acute 
conditions.  The  important  measurements  are  the  circumference  of  the 
head,  chest,  and  body  length.  The.  circumference  of  the  abdomen  is  at 
times  important,  but  varies  so  much  with  the  degree  of  distention  that 
it  is  not  significant  as  to  the  general  development.  The  measurements 
and  weight  furnish  reliable  data  which  are  not  only  of  assistance  in  the 
diagnosis  of  existing  disease,  but  if  recorded  are  useful  for  future  com- 
parison. 

In  taking  the  circumference  of  the  head  the  largest  measurement 
(over  the  occipital  and  frontal  eminences)  is  preferable.  The  measure- 
ment of  the  chest  is  usually  taken  over  the  nipples.  The  body  length 
of  infants  is  best  taken  with  a  tape  as  the  child  lies  upon  his  back  upon 
a  table  or  a  firm  bed.  For  older  children  a  special  measuring  stick  is 
convenient. 

To  estimate  properly  the  significance  of  measurements  they  should 
be  compared  with  the  normal  averages  and  with  each  other.  It  should 
be  remembered  that  the  head  is  normally  larger  than  the  chest  until  near 


SYMPTOMATOLOGY   AND   DIAGNOSIS.  35 

the  end  of  the  second  year;  after  this  time,  with  a  normal  development, 
the  chest  should  be  larger.  Any  great  disproportion  between  the  size 
of  the  head  and  chest  is  suggestive  of  disease.  The  large  head  and  the 
small  chest  belong  especially  to  rickets.  The  measurements  form  impor- 
tant means  of  recognising  early  such  abnormalities  as  cretinism  and 
achondroplasia,  the  variations  often  being  marked  before  the  other  symp- 
toms are  prominent.  One  who  forms  the  habit  of  taking  regular  meas- 
urements soon  appreciates  the  variations  from  the  normal,  and  gains 
great  assistance  from  these  data.  Such  a  record  made  from  year  to 
year  in  children  whose  development  is  in  any  way  abnormal  is  of  great 
value  in  indicating  what  should  be  done  in  the  way  of  exercise  to  correct 
faulty  conditions. 

Vital  Signs. — Pulse,  Eespiration,  and  Temperature. — The  signifi- 
cance of  these  signs  is  not  to  be  measured  by  adult  standards,  since  the 
susceptible  nervous  system  of  infants  and  very  young  children  greatly 
exaggerates  their  reaction  to  all  forms  of  acute  infection. 

The  rate,  regularity,  quality,  and  tension  of  the  pulse  should  be  noted. 
In  young  children,  the  rate  of  the  pulse  is  of  less  importance  than  its 
force  and  quality.  A  slow,  irregular  pulse  is  always  significant,  and 
should  suggest  meningitis  or  brain  tumour;  an  irregular  pulse,  when 
rapid,  has  no  special  significance.  The  pulse  rate  is  much  increased 
from  slight  disturbances;  the  approach  of  the  stranger  or  the  examina- 
tion by  the  physician  may  cause  it  to  rise  20  or  30  beats.  In  acute 
disease,  a  pulse  rate  of  150  is  common,  and  170  or  180  is  often  seen 
where  other  symptoms  are  not  particularly  severe. 

The  rate,  depth,  and  rhythm  of  respiration  should  be  noted.  The 
last  often  cannot  be  determined  except  by  attentively  watching  the  child 
for  several  minutes.  In  premature  and  very  young  infants  a  rather 
marked  irregularity  may  be  seen,  often  approaching  the  Cheyne- Stokes 
type.  It  is  not  to  be  taken  as  indicating  a  cerebral  lesion,  but  seems 
rather  to  be  due  to  the  fact  that  the  respiratory  centre  is  not  yet  fully 
able  to  control  the  movements.  Eespiration  of  this  type  is  seen  only 
during  the  first  weeks  of  life.  Irregularity  of  rhythm  at  other  times 
should  suggest  cerebral  disease,  usually  meningitis.  The  respiration  rate 
is  proportionately  greater  in  infants  than  in  adults.  In  acute  diseases 
of  the  lungs  it  not  infrequently  rises  to  70  or  80,  and  occasionally  it  may 
be  over  100  a  minute.  The  rate  is  generally  in  proportion  to  the  extent 
of  the  pulmonary  lesion. 

The  temperature  of  infants  and  very  young  children  should  be  taken 
in  the  rectum,  since  groin  or  axillary  temperatures  are  untrustworthy 
and  those  in  the  mouth  difficult  to  obtain.  Immediately  after  birth  the 
temperature  of  the  child  is  about  the  same  as  that  of  the  mother,  or  a 
little  higher.  It  falls  from  1°  to  3°  F.  in  the  course  of  the  first  few 
hours.    Soon  it  again  rises  to  98.5°  or  99°  F. 


36  PECULIARITIES  OF   DISEASE   IN   CHILDREN. 

From  a  large  number  of  personal  observations  upon  healthy  infants, 
I  have  found  that  the  rectal  temperature  under  normal  conditions  varies 
between  98°  and  99.5°  F. ;  occasionally  the  range  may  be  as  wide  as 
97.5°  to  100.5°  F.  in  apparently  perfect  health.  The  heat-regulating 
centre  in  the  brain  acts  only  imperfectly  in  the  young  infant,  and  slight 
causes  are  enough  to  disturb  the  temperature. 

The  temperature  in  infants  is  always  higher  than  from  corresponding 
causes  in  adults.  Moreover,  very  high  temperatures  may  be  met  with  in 
cases  not  serious,  and  not  infrequently  when  no  explanation  can  be 
found  even  after  thorough  examination.  In  such  cases  the  temperature 
seldom  remains  at  a  high  point  for  more  than  a  few  hours.  It  is  a 
continuous  high  temperature  rather  than  a  single  rise  which  is  significant 
of  disease  in  infancy.  Nothing  is  more  perplexing  to  the  young  practi- 
tioner than  the  frequency  with  which  a  high  temperature  is  seen  in 
infants  in  cases  of  comparatively  mild  illness. 

It  is  common  in  chronic  wasting  diseases,  in  delicate  infants  and  in 
those  prematurely  born,  to  find  the  temperature  one  or  two  degrees  below 
the  normal;  95°  and  96°  F.  are  of  almost  daily  occurrence  in  hospitals, 
and  much  lower  ones  are  not  rare.  Daily  observations  should  be  made 
with  the  thermometer  in  such  conditions,  just  as  in  fever. 

Puzzling  and  apparently  alarming  temperatures  are  seen  in  infants 
as  a  result  of  the  application  of  artificial  heat.  In  one  of  my  patients, 
an  infant  two  days  old,  a  temperature  of  107°  F.  was  caused  by  the 
close  proximity  of  two  large  hot-water  bags  placed  in  the  baby's  basket. 
The  younger  and  feebler  the  child  the  more  readily  are  such  tempera- 
tures produced. 

Muscular  and  Mental  Development. — The  general  muscular  develop- 
ment is  determined  by  seeing  how  well  the  child  can  hold  up  his  head, 
sit  alone,  stand,  or  walk;  the  mental  development  in  young  infants  by 
the  intelligence  of  expression,  the  manner  in  which  they  respond  to 
stimuli,  the  recognition  of  objects,  fright  at  strangers,  etc. ;  later  in  the 
first  year,  by  the  use  of  their  hands,  their  understanding  of  speech,  and 
their  ability  to  pronounce  words. 

Local  Examination. — For  the  purpose  of  making  a  complete  routine 
examination  of  an  infant  the  entire  clothing,  with  the  exception  of  the 
napkin,  should  be  removed,  and  the  infant  placed  preferably  upon  the 
nurse's  lap  upon  a  blanket.  With  older  children  the  clothing  may  be 
removed  and  the  body  examined,  one  part  at  a  time,  but  with  all  children 
it  is  essential  that  the  examination  be  complete.  A  warm  room  is  indis- 
pensable, and  a  table  covered  with  a  blanket  in  many  respects  better 
than  the  nurse's  lap,  although  tlie  latter  has  usually  to  be  employed. 
The  local  examination  should  be  deliberate,  the  physician  should  pro- 
ceed cautiously,  winning  the  child  by  gradual  approaches,  and  avoiding 
excitement,  force,  or  anything  which  may  cause  pain. 


SYMPTOMATOLOGY   AND   DIAGNOSIS.  37 

Skin. — The  skin  should  first  be  inspected  for  eruptions,  and  it  is 
important  that  the  entire  eruption  be  examined  in  order  that  the  distri- 
bution as  well  as  the  character  of  the  lesion  may  be  seen.  It  should 
be  noted  also  whether  the  skin  is  dry  or  moist.  Marked  wrinkling  or 
loss  of  elasticity  of  the  skin  is  one  of  the  best  indications  of  loss  in 
weight.  Bedsores  are  more  frequently  seen  over  the  occiput  than  over 
the  sacrum,  and  any  large  veins  should  be  noted. 

External  glands  should  now  be  examined,  especially  the  cervical, 
axillary,  inguinal,  and  epitrochlear.  The  cause  of  a  marked  enlarge- 
ment of  any  of  these  groups  should  be  sought  in  the  skin  or  mucous 
membranes  with  which  they  are  connected.  Marked  swelling  of  the 
cervical  glands  may  indicate  diphtheria,  scarlet  fever,  or  a  simple  acute 
inflammation  dependent  upon  a  rhino-pharyngitis.  Enlargement  of  the 
epitrochlear  glands  is  especially  significant  of  syphilis.  General  enlarge- 
ment of  all  the  glands  to  a  slight  degree  is  seen  in  most  cases  of  mal- 
nutrition and  in  many  acute  infectious  diseases. 

Head. — One  should  first  note  whether  the  sutures  are  ossified,  un- 
naturally open  or  separated;  also  whether  the  fontanel  is  closed  or,  if 
open,  whether  it  is  depressed  or  bulging.  Prominences  of  the  frontal 
or  parietal  regions  when  symmetrical  are  indicative  of  rickets.  Irregular 
prominences  of  a  smaller  size,  when  present,  are  usually  syphilitic.  In 
the  newly  born,  a  tumour  on  the  head,  if  in  the  median  line,  may  indicate 
an  encephalocele ;  if  limited  to  either  the  parietal  or  occipital  bone  it  is 
usually  a  cephalhaematoma. 

Eyes. — The  condition  of  the  conjunctiva  and  lids  should  be  noted, 
also  the  presence  of  ptosis,  strabismus,  or  other  paralysis,  but  particularly 
the  condition  of  the  pupils,  whether  contracted  or  dilated,  and  the  nature 
of  their  response  to  light.  One  should  look  also  for  the  presence  of 
corneal  ulcers  or  the  interstitial  keratitis  so  frequent  in  late  hereditary 
syphilis. 

Ears. — The  presence  of  a  discharge  may  be  recognised  by  sight  or 
by  the  odour.  In  any  acute  febrile  condition  one  should  look  for  tender- 
ness or  swelling  over  the  ear  or  mastoid. 

Nose. — The  presence  of  any  nasal  discharge  should  be  noted  and  its 
character  determined.  An  abundant  discharge  tinged  with  blood,  in 
young  infants,  should  suggest  syphilis;  in  older  children,  diphtheria;  a 
chronic  discharge,  adenoid  growths;  a  purulent  discharge  of  one  side, 
a  foreign  body. 

Mouth. — The  appearance  of  the  mucous  membrane  of  the  mouth 
and  gums  as  well  as  the  teeth  may  often  be  ascertaino/i  by  watching 
the  child  while  he  is  crying.  It  should  be  noted  whether  the  tongue  is 
dry  or  moist,  clean  or  coated;  whether  thrush  is  present  or  any  other 
form  of  stomatitis.  If  the  gums  are  congested,  swollen,  or  haemorrhagic, 
they  should  suggest  scurvy.     The  number,  position,  and  character  of 


38  PECULIARITIES  OF  DISEASE  IN   CHILDREN. 

the  teeth  are  important.  The  general  colour  of  the  mucous  membrane 
may  be  significant  in  cases  of  cyanosis  in  congenital  cardiac  difeease,  and 
extreme  pallor  of  the  mucous  membrane  in  anaemia.  On  the  mucous 
membrane  of  the  hard  palate  may  often  be  found  the  first  local  evidence 
of  scarlet  fever  in  the  form  of  a  minute  punctate  eruption,  and  on  that 
portion  of  the  cheeks  opposite  the  molar  teeth  should  be  sought  Koplik's 
sign,  the  earliest  reliable  symptom  of  measles. 

Throat. — A  careful  examination  of  the  pharynx  and  tonsils  should 
never  be  omitted  in  any  acute  illness,  no  matter  what  other  symptoms 
may  l)e  present.  Not  only  tonsillitis,  but  often  diphtheria,  is  overlooked 
from  a  failure  to  observe  this  as  an  invariable  rule.  A  good  light  is 
essential,  and  one  must  train  himself  to  take  in  all  the  appearances  at 
a  single  glance.  Marked  general  redness  of  the  pharynx  may  be  asso- 
ciated with  scarlet  fever,  influenza,  or  simple  acute  pharyngitis.  If  other 
symptoms  are  present  pointing  to  chronic  nasal  obstruction  or  to  a 
catarrhal  process  of  the  rhino-pharynx,  a  digital  examination  should  be 
made- to  determine  the  presence  of  adenoids.  Dyspnoea  with  mouth- 
breathing  when  associated  with  diflBculty  in  swallowing  should,  in  an 
infant,  always  suggest  retropharyngeal  abscess.  The  examination  of  the 
mouth  and  throat  may  wisely  be  made  the  last  step,  since  it  usually 
disturbs  a  child  so  as  to  embarrass  further  investigation. 

Ned'. — One  should  consider  the  position  in  which  the  head  is  held 
and  the  amount  of  rigidity  of  the  cervical  muscles.  Opisthotonus  may  be 
associated  with  meningitis  or  old  cerebral  palsy.  A  marked  rigidity  may 
indicate  cervical  Pott's  disease  or,  if  accompanied  by  torticollis,  may 
be  of  rheumatic  origin. 

Chest. — In  young  children  particular  importance  should  be  attached 
to  the  shape  of  the  chest.  Symmetrical  deformities  are  usually  due  to 
rickets.  Contraction  of  one  side  only  is  most  frequently  the  result  of 
an  old  empyema  or  an  extensive  interstitial  pneumonia.  Bulging  of  the 
precordial  region  is  frequent  in  cardiac  disease.  One  should  notice  also 
the  recession  of  the  soft  parts — intercostal  spaces,  the  suprasternal  notch, 
or  the  epigastrium;  the  amount  of  this  is  usually  the  best  means  of 
judging  the  severity  of  obstructive  dyspnoea.  Details  regarding  the 
physical  examination  of  the  lungs  are  discussed  in  the  introductory  chap- 
ter to  pulmonary  diseases. 

Heart. — It  should  be  remembered  that  under  two  years  old  loud 
murmurs  are  almost  invariably  of  congenital  origin,  that  soft  murmurs 
at  the  base  are  very  frequently  functional,  and  that  acquired  cardiac  dis- 
ease is  rare  un^l  after  three  years.  For  further  details  in  the  examina- 
tion the  reader  is  referred  to  the  chapters  upon  diseases  of  the  heart. 

Abdomen. — There  should  be  noted  the  presence  or  absence  of  tym- 
panites or  abdominal  tenderness,  whether  general  or  localised,  and  the 
existence  of  retraction  of  the  abdominal  walls  as  in  meningitis.     The 


SYMPl'OMATOLOGY  AND  DIAGNOSIS.  39 

size  and  position  of  the  liver  and  spleen  are  best  determined  by  palpa- 
tion. The  lower  border  of  the  liver  is  usually  slightly  below  the  free 
border  of  the  ribs.  If  the  spleen  can  be  easily  felt  below  the  ribs,  it  is, 
as  a  rule,  enlarged.  If  it  can  not  be  felt  in  a  satisfactory  examination, 
it  is  not  sufficiently  enlarged  to  be  of  any  diagnostic  importance.  In 
acute  disease  a  large  spleen  suggests  malaria,  typhoid,  or  tuberculosis; 
in  chronic  disease,  malaria,  syphilis,  leukaemia,  or  anaemia. 

Spine. — The  most  frequent  spinal  curves  seen  in  infancy  are  those 
due  to  muscular  weakness.  These  disappear  by  placing  the  child  in  a 
prone  position.  Rachitic  curvatures  are  of  the  same  general  character, 
but  as  they  have  usually  lasted  a  longer  time  the  spine  is  less  flexible 
and  the  curvatures  may  not  entirely  disappear  by  change  of  posture.  An 
angular  deformity  or  even  marked  rigidity  of  the  spine  should  suggest 
Pott's  disease. 

Extremities. — The  colour  of  the  skin  and  the  character  of  the  periph- 
eral circulation  should  be  noted  especially  in  pneumonia,  diphtheria,  and 
other  diseases  attended  by  weakened  heart.  Clubbing  of  the  fingers  or 
toes  may  be  due  to  congenital  heart  disease  or  to  chronic  disease  of  the 
lungs.  Desquamation  of  the  palms  or  soles  may  indicate  hereditary 
syphilis  or  scarlet  fever,  even  though  no  other  evidence  may  be  pres- 
ent. The  fuiger-nails  may  give  valuable  information  in  hereditary 
syphilis.  In  examining  the  extremities  one  should  note  especially  the 
presence  of  tenderness,  flaccidity,  or  rigidity  of  muscles,  whether  the 
limbs  are  wasted  or  plump,  and  the  degree  of  muscular  power;  also  any 
abnormal  swelling  on  the  shaft  or  near  the  extremities  of  the  bones,  and, 
finally,  the  function  of  the  joints.  A  general  relaxation  of  the  liga- 
ments is  common  in  rickets  and  paralytic  conditions.  Flabbiness  of  the 
muscles  belongs  to  malnutrition  and  rickets;  rigidity,  if  chronic,  is 
usually  indicative  of  cerebral  palsy.  Weakness  of  special  groups,  with 
atrophy  and  flaccid  muscles,  suggests  poliomyelitis.  Acute  tenderness  of 
the  legs  in  infants  should  suggest  scurvy.  Rachitic  deformities  are  al- 
most invariably  bilateral.  Tuberculous  bone  disease  affects  the  epiphyses, 
while  syphilis  usually  involves  the  shafts,  the  only  exception  to  this 
being  the  epiphyseal  separation  which  may  occur  in  the  first  months 
of  life. 

The  reflexes  may  be  somewhat  difl&cult  to  obtain  in  infants  and  when 
exaggerated  may  indicate  cerebral  palsy,  meningitis,  or,  as  in  tetany,  only 
an  extreme  irritability  of  the  nervous  centres  without  organic  disease. 
The  plantar  reflex  of  Babinski  has  little  significance  in  infants,  and  in 
older  children  it  is  present  in  many  conditions.  Kernig's  sign  is  a  form 
of  muscular  spasm  almost  invariably  present  in  cerebro-spinal  menin- 
gitis, but  often  seen  in  other  diseases. 

Genital  Organs. — Male  children  should  be  examined  to  determine  the 
presence  of  phimosis  or  of  undescended  testicles.    Hydrocele  of  the  cord 


40  PECULIARITIES  OF   DISEASE   IN   CHILDREN. 

is  a  frequent  condition,  and  may  be  mistaken  for  hernia.  Both  inguinal 
and  umbilical  hernias  are  very  common.  In  female  children  it  should  be 
remembered  that  preputial  adhesions  may  be  considered  normal,  and  are 
seldom  the  cause  of  the  nervous  symptoms  attributed  to  them.  Every 
vaginal  discharge  is  significant,  and  if  purulent  should  be  examined 
bacteriologically.  Tile  great  frequency  of  gonococcus  infections  is  not 
appreciated,  and  they  may  be  found  w^hen  least  expected. 

The  examination  is  not  complete  without  the  inspection  of  the  stools, 
the  chemical  and  microscopical  examination  of  the  urine,  and  an  exam- 
ination of  the  blood.    All  are  more  fully  considered  in  special  chapters. 

PATHOLOGY. 

The  pathological  processes  which  result  from  intra-uterine  disease 
and  those  which  are  connected  with  delivery  are  peculiar  to  early  life. 
They  have  already  been  referred  to  in  the  section  on  etiology.  Of  the 
processes  of  early  life  which  begin  after  birth,  the  first  in  frequency 
are  those  of  the  mucous  membranes  resulting  from  the  various  forms  of 
irritation  and  infection.  In  summer,  it  is  the  stomach  and  intestines 
which  suffer  chiefly;  in  winter,  the  respiratory  tract. 

The  serous  membranes  are  rarely  the  seat  of  primary  inflammation. 
The  pleura  is  seldom  the  seat  of  primary  disease,  but  is  very  often  in- 
volved secondarily  to  disease  of  the  lung  itself.  Affections  of  the  peri- 
cardium and  peritonaeum  are  quite  rare.  Meningitis  is  fairly  common, 
especially  the  tuberculous  form. 

Diseases  of  the  lymph  nodes  (lymphatic  glands)  play  an  important 
part  in  connection  with  the  acute  diseases  of  the  mucous  membranes, 
with  many  affections  of  the  skin,  and  even  of  the  viscera.  Acute  infec- 
tion tends  to  excite  suppurative  inflammation,  particularly  in  infants;  a 
less  active  process  leads  to  chronic  hyperplasia  in  the  mesenteric,  medias- 
tinal, and  cervical  glands,  in  the  tonsils,  adenoid  tissue  of  the  pharynx, 
etc.  The  lymph  nodes  in  the  neck  and  thorax  are  frequently  the  earliest 
seat  of  tuberculous  deposits,  and  in  very  many  cases  they  are  the  foci 
from  which  secondary  infection  of  the  lungs,  brain,  or  joints  may  occur. 

Of  the  visceral  inflammations  ^  those  of  the  lungs  are  the  most  com- 
mon, it  being  rare  to  find  the  lungs  normal  at  autopsy  after  any  acute 
infectious  disease  which  has  lasted  a  week.  Up  to  the  third  or  fourth 
year  of  life  the  heart  usually  escapes.  In  older  children  it  may  be 
involved,  as  in  adults,  in  the  rheumatic  diseases.  The  liver  and  spleen 
are  not  often  the  seat  of  organic  disease  in  early  life,  nor  is  serious  disease 

*  The  following  table  gives  in  a  general  way  a  verj-  good  idea  of  the  relative  fre- 
quency of  diseases  of  the  different  organs  in  infancy.  It  is  based  upon  seven  hundred 
and  twenty-six  consecutive  autopsies  in  the  New  York  Infant  Asylum,  extending  over 
a  period  of  eight  years  during  my  connection  with  that  institution.  More  than  one 
half  of  the  autopsies  I  made  f)ersonally.     Of  these  children  seventy-two  per  cent  were 


PATHOLOGY.  41 

of  the  kidney  likely  to  be  met  with  excepting  in  connection  with  scarlet 
fever.  Organic  disease  of  the  brain  itself  is  rare,  as  is  also  organic  dis- 
ease of  the  spinal  cord,  with  the  exception  of  poliomyelitis.     Chronic 

under  one  year,  twenty-five  per  cent  between  one  and  two  years,  and  only  three  per 
cent  were  over  two  years.  The  institution  did  not  receive  infants  under  one  month, 
hence  the  absence  of  lesions  peculiar  to  the  newly  bom: 

Table  showing  principal  lesions  in  seven  hundred  and  twenty-six  con- 
secutive autopsies  in  the  New  York  Infant  Asylum. 
Lungs: 

Pneumonia — Primary 139 

Complicating  other  acute  infectious  diseases 112 

Complicating  other  conditions 71 

Noted  to  be  present  in 322 

Pleurisy —      No  case  uncomplicated  with  disease  of  lungs. 

Empyema 5 

Serous  pleurisy 1 

Dry  pleurisy  in  nearly  all  the  severe  cases  of  pneu- 
monia. 

Atelectasis  (congenital) 6 

Pulmonary  abscess  (always  with  pneiimonia) 7 

Pulmonary  gangrene  (always  with  pneumonia) 2 

Pulmonary  tuberculosis 56 

Mouth: 

Noma 1 

PeritoruBum: 

Acute  peritonitis  (localised  2,  with  acute  pneumonia  and  pleurisy  2)      4 
Kidneys: 

Acute  nephritis  (complicating  scarlet  fever  4,  diphtheria  1,  pneu- 
monia 4,  measles  1,  pertussis  1,  ileo-colitis  2,  pyonephrosis  1, 

apparently  primary  5) 19 

Malformations  of  the  kidney 7 

Stomach  and  Intestines: 

Acute  ileo-colitis,  with  or  without  gastritis 116 

Acute  gastritis  (without  intestinal  lesions) None 

Acute  diarrhceal  disease  (without  gross  lesions) 72 

Intussusception 1 

Heart: 

Pericarditis  (all  with  acute  pneumonia) 3 

Congenital  malformations 3 

Acute  or  chronic  endocarditis None 

Brain: 

Acute  meningitis  (7  with  pneumonia,  2  cerebro-spinal) .  14 

Tuberculous  meningitis 11 

Acute  encephalitis 1 

Chronic  pachymeningitis 5 

Chronic  simple  meningitis 1 

Chronic  hydrocephalus 3 

There  were  twenty-six  deaths  from  marasmus  without  gross  lesions. 


42 


PECULIARITIES  OF  DISEASE  IN  CHILDREN. 


diseases  of  the  dififerent  viscera  are  decidedly  rare,  except  when  resulting 
from  acute  processes.  Diseases  of  the  bones  and  joints  are  common,  and 
of  extreme  importance.  They  are  usually  of  tuberculous,  less  frequently 
of  syphilitic,  origin.  Diseases  of  the  blood  are  quite  common,  but  as 
yet  but  little  understood.  New  growths  are  rare.  The  parts  most  fre- 
quently affected  are  the  kidney  and  the  bones.  Disorders  of  nutrition 
are  extremely  common  and  of  great  importance,  particularly  rickets  and 
scurvy. 

PROGNOSIS  AND  INFANT  MORTALITY. 

The  younger  the  patient  the  worse  the  prognosis  in  all  the  diseases  of 
childhood.  This  is  in  consequence  of  the  feeble  resistance  of  the  infan- 
tile organism  to  all  diseases,  particularly  those  which  are  of  an  acute 
nature.  On  the  other  hand,  the  rapid  metabolism  of  childhood  makes 
it  possible  for  many  conditions  of  an  organic  nature  to  disappear  with 
time,  or,  as  the  phrase  is,  to  be  "  outgrown,'"'  provided  the  patient  can 
be  so  placed  that  the  general  nutrition  can  be  carried  to  the  highest 
point. 

The  accompanying  chart  (Plate  I)  shows  the  mortality  of  New  York 
City  by  months  during  three  consecutive  years,  representing  a  total  mor- 
tality of  128,136. 

The  following  table  gives  comparative  figures  for  three  periods  of 
three  years  each,  and  shows  the  reduction  in  infant  and  child  mortality 
which  has  taken  place  in  the  last  twenty  years: 

Deaths — New  York  City  (Manfiattan  and  Bronx). 


1890-1892. 


Under  1  year 32,916  =  26% 

1  to    2  years 10,.'>47  -    8% 

2  "     5      "    9,794  =    7% 

5  "  15      "    5,470  =    5% 

Over  15  years 69,409  =  54% 

Total 128,136 


1898-19C0. 


29,326  =  24% 
9,012  =7% 
7,292  =:  6% 
6,922  =    5% 

71,024  =  58% 


123,576 


1907-1909. 


30,626  =  22.5% 

8,298  =    6.0% 

6,579  =    5.0% 

4,902  =    3.5% 

85,741  =  63.0% 


136,146 


The  deaths  per  1,000  of  population  show  the  same  reduction.  The 
curves  for  the  different  age  periods  are  indicated  in  the  accompanying 
chart  (Fig.  6). 

The  reduction  in  mortality  in  New  York  has  been  chiefly  in  acute 
gastro-intestinal  diseases,  marasmus  and  debility  in  infants  over  three 
months  old,  and  acute  infectious  diseases,  especially  diphtheria.  The 
mortality  from  certain  other  causes  is  increasing,  notably,  acute  respi- 
ratory diseases,  prematurity  and  diseases  of  the  newly  born. 

The  only  age  in  which  the  mortality  is  increased  during  the  summer 


PLATE  I. 


CHILDREN  UNDER  1  YEAR 
I       "     1  TO  2  YEARS 
n        '•'     2  TO  5  YEARS. 

i  "       5  to  15  years 

Over  15  years. 


JAN. 


Feb. 


Mar, 


Apr. 


May 


June  July  Aug.  Sept  Oct.   Nov.    Dec 


Chart  showing  by  months  the  mortality  of  New  York  city  for  the  different  ages 
for  three  consecutive  years,     (Scale,  1  in.  =  2,200  deaths.) 


PROGNOSIS  AND   INFANT   MORTALITY. 


43 


months  is  tlie  first  year.    In  Fig.  7  are  given  the  curves  indicating  for  five 
years,  by  months,  the  deaths  under  one  year  and  from  one  to  five  years. 


1887   1890  1893   1896  1899  1902   1905   1908 

27 

24 

V 

t^ 

/ 

V 

V 

> 

\ 

A 

LI 

_  / 

\G 

ES 

s 

— 

N 

/ 

s 

j 

V 

S 

/ 

\ 

\ 

s 

\. 

\ 

^ 

— ' 

— 

\j 

p^ 

/£R 

Fl 

V 

" 

[TEARS 

...12  ■ 

s 

/ 

\ 

s 

X 

~~ 

— 

k 

., 

<-) 

v^ 

\ 

U 

h^DE 

? 

Fl 

VI 

Q 

... 

•- 

, 

— 

•^ 

V 

'■ 

., 

••• 

S 



_ 

s 

'V 

|X 

s 



■»« 

u 

NC 

)E 

\ 

0 

^^ 

_9 

0 

Fig.  6. — Deaths — New  York  City  per  1,000  of  Population. 

The  sharp  rise  in  the  summer  mortality  during  the  first  year  is 
chiefly  due  to  diarrhoeal  diseases.  It  will  be  noted  that  the  curve  for 
children  from  one  to  five  years  of  age  touches  the  highest  point  in  the 
late  winter  and  early  spring  months,  the  time  when  pneumonia  and  the 


DEATHS  BY   MONTHS,   NEW  YORK  CITY   (MANHATTAN  AND  BRONX.)                 | 

1                    1904                   1 
|j.  FM.A. M.J.J.  A.S.O.N.oJ 

1005                                        1906                                        1907 
J  F.M  AM  J  J.ASOND  J.F.M  AM  J  J.A  SON.D  J.F.M  AM  J.J 

1908 
A  S.O  NJ>  J  F.M  A  M.J  J  A.8.O.N.D. 

1600 



1600 

1500 

1500 

1400 

J 

1                                               1400 

1300 

t_._. 

. 

1                 \\         '^"^ 

1200 

t\. 

I                    \         '^'"' 

ilOO 

L \:t\::":\ 

1                               \              1100 

1000 

1 

--  k- 

] . \ 

I                               '              1000 

900 

y 

I                                \            900 

800 

"jx:.".'" 

*'^    ■                   i'''^             \      6    ^s    J 

\         r^        \        8"" 

700 

.^_aL__\__ 

,/    \\        \         f      \^         \        ^    \^ 

._L=/-L_-V-  "0 

600 

^    ^  t 

^      ^             _.._^^ 

\i            /\                 1/600 

500 

-^T~\~  '  0' 

z      .      ^      ^  S                        r 

5 l\ !.   600 

400 

::::::^r"^ 

A__,^L.-,, 400 

300 

\-! 

\/               ^\         L   300 

200 

.^_^ v^_. 

-^      200 

100 

L  PPER  CUR 

vk  -LNDER  (JnE  YEAR, 

100 

,0 

LOWER  Cp 

i^/E==ONETO    ^iJeIy^/^R^. 

0 

Fig.  7. 


44 


PECULIARITIES  OF  DISEASE  IN  CHILDREN. 


common  contagious  diseases  are  most  prevalent.  The  curve  for  both 
groups  is  lowest  in  the  months  of  October  and  November,  which  may 
therefore  be  considered  the  healthiest  "months  in  New  York.  The  highest 
mortality  is  in  the  first  month  of  age.  During  this  time  twenty-five  per 
cent  of  the  deaths  of  the  first  year  occur.  Eross,  writing  in  1894,  states 
that  from  the  records  of  sixteen  large  cities  of  Continental  Europe  nearly 
ten  per  cent  of  all  the  infants  born  died  during  the  first  month.  These 
figures  have  been  considerably  reduced  since  that  time.  The  first  weeks 
of  life  are  the  period  of  highest  mortality,  because  in  them  takes  place 
the  adaptation  of  the  organism  to  its  environment.  After  this  period 
each  month  shows  a  steadily  declining  death  rate  to  the  end  of  the  first 
year. 

Causes  of  Death  at  Different  Periods. — The  most  frequent  causes  of 
infant  mortality,  according  to  the  combined  reports  from  the  records  of 


CHIEF  CAUSES  OF  DEATH   FIRST  YEAR. 

ACUTE  GASTRO  INTESTINAL                  28.0  PER  CENT. 

MARASMUS,  PREMATURITY,  ETC.         25.5      " 

ACUTE  RESPIRATORY                                  18.5       " 

CONGENITAL  MALFORMATION,  ETC.       5.8      •• 

ACUTE  INFECTIOUS                                       5.4      - 

^CONVULSIONS                                                 3.4      " 

TUBERCULOSIS                                                2.0      " 

SYPHILIS                                                            1.2      " 

ALL  OTHERS                                                     10.2      •• 

FiQ.  8. 


the  cities  of  New  York,  Philadelphia,  Boston,  and  Chicago,  making  a 
total  of  44,226  deaths  in  the  first  year,  are  shown  in  the  accompanying 
chart  (Fig.  8). 

The  group,  acute  gastro-intestinal,  includes  chiefly  diarrhceal  dis- 
eases in  summer.  The  acute  respiratory  diseases  are  pneumonia  and 
bronchitis.  Marasmus,  prematurity,  etc.,  include  also  congenital  de- 
bility, inanition,  and  other  conditions  in  which  the  cause  of  death  re- 
corded is  disorder  of  nutrition  rather  than  some  general  or  local  disease. 
The  group,  congenital  malformations,  includes  also  deaths  from  acci- 
dents during  birth.    Whooping  cough  is  the  most  important  member  of 


PROGNOSIS  AND   INFANT   MORTALITY.  45 

the  group  of  acute  infectious  diseases,  diphtheria  coming  next.  Tuber- 
culosis should,  I  believe,  be  rated  higher  than  is  shown  in  these  figures. 
The  mortality  records  of  the  Babies'  Hospital  show  that  the  deaths  from 
tuberculosis  constitute  5.6  per  cent  of  the  first-year  mortality  of  that 
institution. 

The  figures  and  charts  above  given  indicate  that  a  very  marked  re- 
duction in  infant  and  child  mortality  has  taken  place  especially  within 
the  last  twenty  years.  Many  causes  have  united  to  bring  about  this 
result.  Among  those  which  have  affected  infants  may  be  mentioned: 
A  wider  diffusion  of  knowledge  of  infant-feeding  and  hygiene;  a  great 
improvement  in  the  general  milk  supply;  the  furnishing  of  pure,  whole 
milk  and  of  modified  milk  gratis,  or  at  small  cost,  from  milk  depots;  a 
general  adoption  during  hot  weather  of  some  form  of  milk  sterilisation ; 
the  sending  of  a  large  number  of  infants  into  the  country  in  summer; 
the  closer  supervision  of  infants  in  cities  during  the  summer  by  visiting 
physicians  and  nurses,  and  the  operation  of  many  other  agencies  to  im- 
prove sanitary  conditions.  Besides  these  important  factors  in  preventing 
disease  there  must  be  considered  the  recent  advances  in  paediatrics  and 
the  more  rational  treatment  of  the  sick  infant  by  the  average  physician. 

During  the  second  year  the  diseases  of  the  gastro-intestinal  tract  are 
still  a  large  factor  in  the  death  rate,  also  the  acute  diseases  of  the  lungs 
and  the  acute  infectious  diseases,  especially  measles,  diphtheria,  and  per- 
tussis. Deaths  from  scarlet  fever  are  much  less  numerous.  General 
tuberculosis  and  tuberculous  meningitis  are  frequent. 

From  the  second  to  the  fifth  year  the  deaths  are  mainly  from  acute 
infectious  diseases — chiefly  diphtheria  and  scarlet  fever — much  less  fre- 
quently from  measles  or  pertussis.  In  the  next  group  come  the  acute 
diseases  of  the  lungs,  general  tuberculosis,  and  tuberculous  meningitis. 

From  the*  fifth  to  the  fifteenth  year  the  mortality  in  childhood  is 
remarkably  small,  diphtheria  and  scarlet  fever  being  still  in  the  front 
rank  in  point  of  frequency.  Next  come  the  acute  diseases  of  the  lungs, 
meningitis,  diseases  of  the  bones,  appendicitis,  rheumatism,  and  cardiac 
disease. 

By  far  the  largest  single  factor  in  reducing  mortality  after  the  first 
year  is  without  doubt  the  use  of  diphtheria  antitoxin.  The  serum  treat- 
ment of  cerebro-spinal  meningitis  is  important,  but  not  influential  in 
vital  statistics,  as  cases  are  relatively  infrequent. 

Sudden  Death. — This  is  not  a  very  uncommon  occurrence  in  infants 
who  are  apparently  healthy.  They  are  sometimes  found  dead  in  bed 
under  circumstances  in  which  grave  suspicion  may  unjustly  rest  upon 
the  attendants.  This  usually  happens  with  those  who  are  delicate  or 
suffering  from  malnutrition,  especially  in  institutions  where  sudden 
death  is  by  no  means  rare.  The  most  frequent  causes  in  infants  are  the 
following : 


46  PECULIARITIES  OF  DISEASE   IN   CHILDREN. 

1.  Malformations. — "While  in  most  cases  malformations  of  a  serious 
nature  give  rise  to  symptoms,  they  may  be  absent,  or  may  be  so  slight 
as  to  be  overlooked.  Infants  may  succumb  during  the  first  few  days  of 
life  from  malformations  of  the  heart,  lungs,  kidneys,  stomach  or  in- 
testines, and  sometimes  from  diaphragmatic  or  umbilical  hernia. 

2.  Internal  Hcemorrhage. — This  is  chiefly  limited  to  the  first  two 
weeks  of  life.  In  the  cases  that  have  come  to  my  notice  the  cause  has 
been  rupture  of  some  subperitoneal  haemorrhage  into  the  general  abdomi- 
nal cavity,  or  meningeal  luemorrhage.  Such  cases  are  reported  in  the 
chapter  upon  Visceral  Haemorrhages  in  the  Newly  Born.  Under  these 
circumstances  no  symptoms  may  exist  until  the  occurrence  of  collapse, 
with  death  in  a  few  hours. 

3.  Asphyxia  from  Overlying. — This  is  not  very  common,  excepting 
among  the  lower  classes,  and  is  most  frequently  due  to  intoxication  on 
the  part  of  the  mother.  Such  infants  after  death  present  the  usual 
lesions  of  death  from  asphyxia,  but  without  any  evidence  of  violence. 
A  recent  writer  in  the  British  Medical  Journal  states  that  one  thousand 
infants  die  every  year  from  this  cause  in  the  city  of  London  alone. 

4.  Asphyxia  from  Aspiration  of  Food  into  the  Larynx  or  Trachea. 
-—This  may  be  due  to  vomiting  or  to  the  regurgitation  of  food  during 
sleep;  in  a  very  weak  infant  it  may  occur  while  awake.  This  is  usually 
seen  in  infants  who  are  less  than  a  year  old,  and  most  of  the  reported 
cases  have  been  under  six  months.  Such  children  are  usually  delicate. 
There  seems  to  be  vomiting  with  an  attempt  at  crying,  during  which  the 
food  is  drawn  into  the  air  passages.  In  some  cases,  as  that  reported  by 
Demme,  a  single  large  curd  of  milk  has  been  found  in  the  larynx.  In 
others,  food  is  found  in  the  larynx,  trachea,  and  large  bronchi.  Cases 
have  also  been  reported  by  Partridge  and  Parrot,  and  I  have  myself  met 
with  at  least  three.  The  infants  have  generally  been  found  dead  in  bed 
within  a  few  hours  after  feeding.  This  accident  is  more  likely  to  happen 
when  an  infant  lies  upon  his  back. 

5.  Enlargement  of  the  Thymus. — Although  these  cases  are  very  im- 
perfectly understood,  they  are  not  rare.  I  see  two  or  three  each  year. 
The  condition  is  most  frequent  in  infancy,  but  is  not  confined  to  this 
period.  When  a  child  is  suffering  from  som.e  minor  illness,  often  bron- 
chitis, severe  attacks  of  asphyxia  may  develop  and  sometimes  convulsions 
may  unexpectedly  occur  and  death  soon  follow.  Or  the  first  attack  may 
not  be  fatal.  Sometimes  sudden  death  follows  the  administration  of  an 
anaesthetic,  particularly  chloroform.  In  most  cases  there  is  found  besides  an 
enlarged  thymus,  a  general  hyperplasia  of  the  lymphatic  tissues  through- 
out the  body  known  as  status  lymphaticns,  more  fully  discussed  elsewhere. 

6.  Atelectasis. — In  very  young  infants  there  may  be  no  symptoms 
excepting  malnutrition  until  sudden  death  occurs,  sometimes  with  con- 
vulsions and  sometimes  without  any  such  symptoms.     (See  Atelectasis.) 


PROPHYLAXIS.  47 

7.  Marasmus. — In  this  class  of  cases  sudden  death  is  of  very  common 
occurrence.  These  children  are  often  as  well  two  or  three  hours  before 
death  as  for  several  weeks.  Death  frequently  occurs  at  niglit,  the  chil- 
dren being  found  dead  in  bed  in  the  morning.  In  some  of  the  cases  the 
exciting  cause  seems  to  be  the  lowering  of  the  temperature,  while  in 
many  no  exciting  cause  can  be  found;  the  vital  spark  simply  goes  out 
after  burning  for  some  time  with  a  feeble  intensity.  In  some  of  these 
cases  the  autopsy  reveals  atelectasis,  but  in  many  cases  nothing  abnormal 
is  found,  death  apparently  resulting  from  heart  failure. 

8.  Convulsions  in  Children  Previously  Showing  no  Special  Signs  of 
Disease. — Many  of  these  cases  are  seen  in  children  who  were  previously 
rachitic;  some  are  associated  with  the  status  lymphaticus,  and  many  are 
manifestations  of  tetany.  The  autopsy  may  show  no  lesion  except  cere- 
bral hyperaemia.  It  is  extremely  rare  for  cerebral  haemorrhage  to  produce 
death  in  this  way.  In  some  rachitic  cases  death  is  due  to  spasm  of  the 
glottis. 

9.  Asphyxia  in  Older  Infants  and  Young  Children. — This  may  result 
from  the  pressure  of  a  retropharyngeal  abscess  upon  the  larynx  or 
trachea,  or  from  the  rupture  of  such  an  abscess  into  the  air  passages. 
Previous  symptoms  may  have  been  wanting.  Pressure  upon  the  pneu- 
mogastric  nerve  leading  to  fatal  asphyxia  may  be  caused  by  tuberculous 
bronchial  nodes,  or  by  abscesses  in  the  posterior  mediastinum  connected 
with  caries  of  the  spine.  Sudden  death  may  occur  with  spinal  caries 
from  dislocation  of  the  upper  cervical  vertebrae. 

Sudden  asphyxia  may  follow  the  ulceration  of  tuberculous  lymph 
nodes  and  the  escape  of  cheesy  masses  into  the  trachea  or  primary 
bronchi.    This  usually  occurs  in  children  from  two  to  five  years  old. 

10.  Death  after  a  Few  Hours'  Illness,  in  which  the  Chief  Symptom 
is  High  Temperature. — This  is  not  an  uncommon  occurrence.  Infants 
apparently  well  may  be  taken  with  great  prostration  and  a  high  tem- 
perature, which  may  rise  rapidly  to  106°  or  even  107°  F.,  and  death 
follow  in  from  six  to  twelve  hours,  sometimes  preceded  by  convulsions. 
These  are  often  examples  of  acute  septicaemia,  most  frequently  from  the 
pneumococcus,  sometimes  from  the  streptococcus,  or  other  organisms.  In 
older  children  death  may  be  due  to  malignant  scarlet  fever  or  epidemic 
meningitis;  however,  unless  these  diseases  are  prevailing  epidemically, 
it  is  somewhat  hazardous  to  make  such  a  diagnosis. 

It  does  not  fall  within  the  scope  of  this  chapter  to  consider  cases  of 
sudden  death  from  heart  failure  after  diphtheria,  with  pleurisy  with 
effusion,  or  with  myocarditis.    These  will  be  discussed  elsewhere, 

PROPHYLAXIS. 

There  is  no  more  promising  field  in  medicine  than  the  prevention  of 
disease  in  childhood.    The  majority  of  the  ailments  from  which  children 


48  PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

die  it  is  within  the  power  of  man  in  great  measure  to  prevent.  Prophy- 
laxis should  aim  at  the  solution  of  two  distinct  problems:  (1)  The  re- 
moval of  the  causes  which  interfere  with  the  proper  growth  and  devel- 
opment of  children;  (2)  the  prevention  of  infection.  The  former  can 
come  only  through  the  education  first  of  the  profession  and  then  of  the 
general  public,  in  the  fundamental  principles  of  infant  feeding  and 
hygiene.  This  is  a  department  which  has  received  altogether  too  small 
a  place  in  medical  education.  The  latter  must  come  through  the  pro- 
fession, and  through  legislation,  the  purpose  of  which  shall  be  more 
rigid  quarantine,  more  thorough  disinfection,  and  improved  sanitation 
in  all  its  departments.  The  subject  of  prophylaxis  will  be  discussed  in 
connection  with  the  different  diseases  treated  elsewhere. 


THERAPEUTICS. 

Tlierapeutics  in  infancy  consists  in  something  more  than  a  graduated 
dosage  of  drugs.  Many  therapeutic  means  which  are  valuable  in  adults 
are  useless  in  children,  and  many  others  which  are  of  little  value  in 
adults  are  extremely  useful  in  children.  Children  in  the  past  have 
suffered  much  from  overzealous  treatment,  particularly  from  drug- 
giving.  In  early  life  more  than  at  any  other  period  the  old  dictum 
non  nocire  should  be  heeded.  It  should  be  a  fundamental  principle 
never  to  give  a  dose  of  medicine  without  a  clear  and  definite  indication. 
If  this  rule  is  followed,  it  is  surprising  to  find  how  often  medication 
can  be  dispensed  with.  A  second  rule  is  equally  important :  never  to 
give  a  nauseous  dose  when  one,  that  is  palatable,  will  answer  the  purpose 
equally  well.  The  simpler  prescriptions  are  made,  the  better.  As  a 
rule,  infants  revolt  against  most  of  the  highly  seasoned  sirups  and 
elixirs  which  are  used  to  disguise  the  taste  of  unpleasant  doses.  Bitter 
medicines  when  mixed  with  water,  are  frequently  administered  without 
difficulty. 

It  is  a  common  mistake  to  underestimate  the  importance  of  the 
hygienic  surroundings  of  the  patient,  the  value  of  good  nursing,  careful 
feeding,  and  judicious  stimulation,  just  as  it  is  to  overestimate  the 
beneficial  effects  of  drugs.  In  the  great  majority  of  acute  ailments  not 
serious  in  character,  for  which  a  physician  is  called,  the  patient  recovers 
quite  as  promptly  without  drugs  as  with  them.  This  does  not  mean  that 
such  children  require  no  treatment,  but  that  the  least  important  part  of 
the  treatment  is  drug-giving.  In  cases  of  severe  illness,  in  infants 
especially,  we  must  avoid  all  unnecessary  medication,  in  order  that  the 
stomach  may  not  be  disturbed.  Hence  the  importance  of  relying  as  far 
as  possible  upon  local  measures.  The  strong  tendency  to  recovery  from 
all  acute  processes,  while  seen  in  adult  life,  is  even  more  striking  in 
childhood,  where,  if  we  can  but  remove  that  which  hampers  the  bodily 


THERAPEUTICS.  49 

functions,  Nature  will  usually  conduct  the  case  to  a  satisfactory  termi- 
nation. Thus,  after  an  attack  of  bronchitis,  it  is  often  seen  that  the 
disturbance  of  the  stomach  and  intestines  can  be  directly  traced  to  the 
drugs  employed,  and  continues  long  after  the  original  disease  has  sub- 
sided. In  diseases  of  the  stomach  and  intestines  especially  there  is  a 
great  amount  of  unnecessary  medication.  In  all  chronic  disturbances 
of  nutrition — chronic  indigestion,  malnutrition,  and  anaemia — no  tonic 
is  so  good  as  a  change  of  air  and  surroundings. 

Antipyretics. — The  indications  for  the  employment  of  antipyretics  in 
children  are  somewhat  different  from  those  in  adults.  It  is  to  be  borne 
in  mind  that,  where  the  cause  is  similar,  all  temperatures  in  children  are 
higher  than  in  adults.  Thus  conditions,  which  in  an  adult  would  pro- 
duce a  rise  of  temperature  of  only  100°  or  101°  F.,  in  a  child  are  not 
infrequently  accompanied  by  a  temperature  of  10-1°,  or  even  105°  F.  The 
height  of  the  temperature,  as  measured  by  the  thermometer,  is  not  to 
be  taken  as  the  only  or  even  the  best  guide  for  the  employment  of  anti- 
pyretics. The  nervous  disturbance  which  accompanies  such  a  tempera- 
ture is  much  more  important.  The  temperature  may  be  104°,  or  even 
105°  F.,  and  yet  the  child  exhibit  no  signs  of  unusual  discomfort.  Such 
a  temperature  manifestly  does  not  call  for  interference.  High  tem- 
perature from  apparently  trivial  causes,  is  very  common.  It  is  only  a 
continuously  high  temperature  or  a  recurring  high  temperature  which 
indicates  serious  illness.  Whenever  the  temperature  is  found  to  be  much 
above  the  normal  it  should  be  carefully  watched,  but  not  interfered  with 
until  a  diagnosis  has  been  made,  unless  the  symptoms  urgently  demand 
it;  otherwise  the  physician  may  lose  one  of  the  most  valuable  aids  to 
diagnosis,  since  it  is  not  the  height  of  the  temperature  but  its  course 
which  is  significant.  In  many  cases  it  is  very  important  to  know  whether 
the  temperature  uninfluenced  by  drugs  is  remittent,  intermittent,  or 
steadily  high,  and  hence  the  advantage  of  waiting  until  a  diagnosis 
has  been  made  before  disturbing  the  temperature  curve.  This  is,  of 
course,  not  admissible  when  the  temperature  is  itself  a  source  of  real 
danger,  which  after  all  is  seldom  the  case.  Since  the  cause  of  a  great 
many  obscure  temperatures  is  found  in  the  stomach  and  intestines,  it 
very  often  happens  that  a  purgative,  stomach-washing,  or  intestinal 
irrigation  may  be  the  most  efficient  antipyretic.  In  cases  of  moderate 
elevation  of  temperature  we  need  go  no  further  than  cold  sponging. 

The  most  reliable  antipyretic  measure  for  children  is  the  use  of  cold. 
This  may  be  employed — 

(1)  As  an  Ice  Cap  to  the  Head. — In  many  cases  of  quite  high  tem- 
perature and  restlessness  in  infants  this  alone  will  reduce  the  tem- 
perature one  or  two  degrees  and  allay  the  nervous  symptoms. 

(2)  Cold  Sponging. — For  this  purpose  water  at  about  80°  to  85°  F., 
equal  parts  of  alcohol  and  water,  or  equal  parts  of  vinegar  and  water  may 

5 


50  PECULIARITIES  OF   DISEASE   IN   CHILDREN. 

be  employed.  In  the  ease  of  infants,  all  the  clothing  except  the  diaper 
should  be  removed  and  the  child  laid  upon  a  blanket.  The  body  should 
be  sponged  for  from  ten  to  twenty  minutes,  and  then  wrapped  in  a 
blanket  without  further  dressing.  Cold  sponging  must  be  very  frequently 
employed  in  order  to  be  efficient  in  reducing  high  temperature.  Its 
great  value  in  allaying  nervous  symptoms,  even  when  the  temperature  is 
not  very  high,  is  not  sufficiently  appreciated.  Its  effect  is  often  more 
satisfactory  than  that  of  an  anodyne. 

(3)  Cold  Pack. — This  is  one  of  the  most  efficient  means  of  reducing 
temperature  which  can  be  employed.  The  child  should  be  stripped  and 
laid  upon  a  blanket.  The  entire  trunk  should  then  be  enveloped  in  a 
small  sheet  wrung  from  water  at  a  temperature  of  100°  F.  Upon  the 
outside  of  this,  ice  ma}'  now  be  rubbed  over  the  entire  trunk,  first  in 
front  and  then  behind.  By  this  method  there  is  no  shock  and  no  fright, 
and  any  ordinary  temperature  can  usually  be  readily  reduced. 

The  rubbing  with  ice  should  be  repeated  in  from  five  to  thirty  min- 
utes, according  to  circumstances,  after  which  the  child  may  be  rolled  in 
the  blanket  upon  which  he  is  lying  without  the  removal  of  the  wet  pack. 
The  head  should  be  sponged  with  cold  water  while  this  is  being  carried 
on,  and  artificial  heat,  if  necessary,  should  be  applied  to  the  feet.  The 
pack  is  continued  from  one  to  twenty-four  hours,  according  to  circum- 
stances. 

(4)  The  Cold  Bath. — The  child  is  put  into  a  bath  at  a  temperature 
of  100°  F.,  the  temperature  being  gradually  lowered  by  the  addition  of 
ice  or  cold  water  to  85°  or  80°  F.  The  body  should  be  well  rubbed  while 
the  child  is  in  the  bath  and  water  should  also  be  applied  to  the  head. 
On  removal  from  the  bath,  the  body  should  be  quickly  dried  and  rolled  in 
a  warm  blanket.    The  bath  is  usually  continued  from  five  to  ten  minutes. 

(5)  Evaporation  Baths. — The  trunk  is  closely  enveloped  in  two 
layers  of  surgeon's  gauze,  or  some  loosely  woven  equivalent,  which  is 
moistened  from  time  to  time  with  water  at  a  temperature  of  115°  F., 
continuous  evaporation  being  kept  up  by  means  of  a  hand,  or  better 
electric,  fan.  The  evaporation  bath  would  seem  to  possess  some  impor- 
tant advantages  in  the  case  of  infants  and  young  children,  in  that  it  is 
more  efficient  than  sponging,  involves  little  disturbance  of  the  patient, 
and  causes  no  shock  or  fright.  Hot  applications  should  constantly  be 
made  to  the  extremities. 

(6)  Rectal  Irrigations. — These  are  easily  given,  disturb  the  patient 
very  little,  and  are  effective  in  reducing  the  temperature.  A  double  tube 
or  two  catheters  may  be  employed.  It  is  best  to  use  at  first  water  at  a 
temperature  of  90°  F.,  and  gradually  reduce  this  to  70°  F.  The  irriga- 
tion should  be  continued  for  ten  or  fifteen  minutes,  or  even  longer  if  the 
desired  fall  in  temperature  is  not  obtained,  and  may  be  repeated  as  often 
as  every  three  hours. 


THERAPEUTICS.  51 

Antipyretic  Drugs. — Except  in  cases  of  malaria,  quinine  should  not 
be  employed  for  the  reduction  of  temperature  in  children. 

Of  the  many  coal-tar  derivatives  employed,  phenacetine  has  the  ad- 
vantage for  children  of  being  tasteless  and  causing  little  depression,  but 
the  slight  disadvantage  of  practical  insolubility.  None  of  the  drugs  of 
this  group  is,  however,  to  be  employed  in  large  doses  with  the  sole  pur- 
pose of  reducing  the  temperature.  Their  great  value  in  paediatrics  con- 
sists rather  in  allaying  the  nervous  symptoms  which  accompany  fever, 
and  this  purpose  can  be  accomplished  by  the  use  of  comparatively  small 
doses.  To  an  infant  of  one  year,  phenacetine  or  antipyrine  can  be  given 
in  one-grain  doses  every  hour  or  two  hours  until  the  desired  effect  is 
produced.  For  a  child  of  five  years  a  dose  of  two  grains  may  be  given 
in  the  same  manner.  When  used  as  indicated,  these  drugs  are  of  very 
great  value  in  making  the  patient  more  comfortable,  in  promoting  sleep, 
and  in  allaying  headache  and  general  pains.  In  cases  of  hyperpyrexia 
they  are,  however,  much  less  certain  and  less  safe  than  the  use  of  cold. 

Stimulants. — In  spite  of  the  many  statements  to  the  contrary,  alco- 
holic stimulants  are  well  tolerated  even  by  very  young  infants.  All 
stimulants,  and  alcohol  in  particular,  are  very  greatly  abused  in  the 
hands  of  practitioners,  and  their  indiscriminate  and  protracted  use  can 
not  be  too  strongly  condemned. 

The  indications  for  the  employment  of  stimulants  are  much  the  same 
in  young  children  as  in  adults.  In  most  of  the  acute  fevers  they  are 
not  to  be  given  early  in  the  disease,  and  in  many  cases  they  are  not  re- 
quired at  all.  They  must  often  be  used  very  sparingly  while  the  tem- 
perature is  high,  but  may  be  necessary  as  soon  as  it  falls.  In  many  acute 
febrile  diseases  stimulants  are  not  called  for  at  any  period. 

The  method  of  administering  alcohol  is  of  no  little  importance. 
Brandy  and  whisky  are  in  most  cases  to  be  preferred  to  the  wines,  but 
not  always.  For  infants  under  one  year  old,  brandy  should  be  diluted 
with  at  least  eight  parts  of  water.  Altogether  the  best  method  of  admin- 
istration is  to  determine  the  amount  to  be  given  in  every  twenty-four 
hours,  have  it  diluted  sufficiently,  and  then  administer  it  in  small  doses 
at  short  intervals. 

An  infant  one  year  old,  for  whom  alcohol  is  indicated,  should  not  be 
given  to  begin  with  more  than  one-fourth  of  an  ounce  of  brandy  or  whisky 
during  the  twenty-four  hours,  and  even  in  bad  conditions  it  is  rarely 
advisable  to  give  more  than  twice  this  quantity,  except  for  a  very  short 
period.  In  children  four  years  old  double  the  amount  may  be  employed 
in  the  corresponding  conditions.  Little  good  and  much  harm  is  likely 
to  follow  such  amounts  as  six  or  eight  ounces  daily  of  brandy  or  whisky 
for  children  of  two  or  three  years.  There  certainly  is  a  strong  tendency 
at  the  present  time  to  use  less  and  less  alcohol  in  therapeutics,  and  many 
would  abandon  it  altogether. 


52 


PECULIARITIES  OF  DISEASE   IN   CHILDREN. 


Other  stimulants,  caft'eiiie,  camphor,  strychnine,  digitalis,  stro- 
phanthus,  etc.,  are  used  in  children  with  much  the  same  indications  as 
in  adults.  Their  application  is  more  fully  discussed  in  the  different 
diseases  in  which  they  are  employed.  They  may  be  used  in  the  follow- 
ing doses  at  the  different  ages  indicated : 


3  months. 


Digitalis,  tincture TT^  i 

Strophanthus,  tincture TT^^  i 

Caffeine  citrated Gr.  i 

Strychnine  sulphate Or.  to  o 

Camphor  (10  per  cent  solution  in  oil) !  711^  iii 

Adrenalin  (1-1000  Sol.) I  TTt  1 


1  year. 


TTl  iii 
Tfl  .i 
Gr 
Gr 
"R  vi 
TTLiii 


7 
2  oT) 


S  years. 


HI  V 
Tfl  V 

Gr.  i 

Gr.  bV 

m  vi 


Note. — Camphor  and  adrenaUn  are  for  hypodermic  use  only.     The  dosage  of  all 
these  stimulants  is  calculated  for  administration  at  intervals  of  four  hours. 

Tonics. — Cod-liver  oil  is  particularly  useful  in  the  convalescence 
after  acute  diseases  of  the  respiratory  tract,  in  anaemia,  and  in  a  large 
number  of  children  who  are  extremely  delicate.  In  these  patients  it 
may  be  advantageously  administered  throughout  the  greater  part  of 
nearly  every  winter  season.  In  convalescence  after  attacks  of  gastro- 
enteric disease  it  should  'be  withheld  for  a  long  time.  When  the  tongue 
is  coated,  the  digestion  poor,  and  the  stomach  easily  disturbed  it  should 
not  be  given  at  all.  In  the  case  of  infants,  as  a  rule,  the  pure  oil  is  to 
be  preferred  to  the  emulsion.  The  administration  of  small  doses — i.  e., 
ten  or  twenty  drops  of  the  oil  three  times  a  day  continued  for  a  long 
period — is  much  better  than  the  use  of  larger  doses  for  a  shorter  time. 

Preparations  of  malt  are  sometimes  of  even  greater  value  than  cod- 
liver  oil,  for  they  can  be  used  in  many  conditions  when  the  oil  is  contra- 
indicated.  The  two  may  often  be  advantageously  combined.  The  best 
preparations  of  iron  for  very  young  children  are  the  bitter  wine,  sweet 
wine,  saccharated  carbonate,  and  the  wine  of  the  citrate.  These  are  only 
slightly  constipating,  and  many  of  them  can  be  given  with  milk.  Most 
of  the  organic  preparations  of  the  market  are  less  reliable  than  those 
mentioned.  For  older  children  nothing  is  better  than  reduced  iron  or 
Blaud's  pills. 

Arsenic  is  second  only  to  iron  in  the  treatment  of  the  anaemia  of  chil- 
dren, and  in  very  many  cases  it  is  to  be  preferred  to  iron.  The  tablet 
triturates  of  arsenious  acid,  one  one-hundredth  of  a  grain,  may  be  given 
immediately  after  meals  three  times  a  day,  or  one  or  two  drops  of 
Fowler's  solution  largely  diluted  with  water. 

Alcohol  is  useful  in  combination  with  some  of  the  bitters,  either 
small  doses  of  quinine,  nux  vomica,  or  the  bitter  wine  of  iron.  Usually 
wines,  especially  sherry,  are  to  be  preferred  to  spirits,  although  some 
children  take  spirits  better.    When  combined  with  a  bitter  there  is  little 


THERAPEUTICS. 


53 


danger  of  the  formation  of  the  alcoholic  habit,  even  though  its  use  may 
be  long  continued. 

Of  the  bitter  tonics,  nux  vomica  is  easily  superior  to  all  others. 

Opiates. — Strong  objections  have  been  urged  by  many. against  the 
employment  of  opium  in  the  diseases  of  infancy.  While  opiates  have 
no  doubt  been  abused,  the  fact  remains  that  opium  is  almost  as  valu- 
able a  remedy  in  the  treatment  of  disease  during  the  first  five  years 
as  at  any  other  period  of  life.  For  infants  relatively  smaller  doses 
are  required  than  of  most  drugs.  If  the  physician  will  accustom  him- 
self to  the  use  of  very  small  doses,  he  will  be  surprised  to  see  how  satis- 
factory are  the  effects  produced. 

The  most  useful  preparations  for  young  children  are  paregoric, 
Dover's  powder,  the  deodorised  tincture,  morphine,  and  codeine.  The 
following  table  gives  what  may  be  considered  safe  initial  doses  at  the 
different  ages: 


Paregoric 

Deodorised  tincture 
Dover's  powder  . . ... 

Morphine 

Codeine 


1  month. 


-nii 

Gr.  5-\t 

Gr.  TTMiTJ 

Gr.  .hi 


3  months. 


ITL  ii 

Gr.  A- 
Gr.  ^^,0 
Gr.  rirs 


1  year. 


Tfl.  V  to  X 
TTl  1  to  ^ 
Gr.  i  to  i 
Gr.  ^ha 
Gr.  ,h, 


5  years. 


ni  XXX  to  xl 

TT[  ii  to  iii 
Gr.  ii  to  iii 
Gr.  -aV  to  -k 
Gr.  -Aj  to  i 


Ordinarily  doses  like  the  above  should  not  be  repeated  oftener  than 
every  two  hours.  In  exceptional  circumstances,  as  when  very  great  pain 
is  present,  the  dose  may  be  given  more  frequently.  In  the  hypodermic 
use  of  morphine  it  should  be  remembered  that  its  effects  are  always  more 
uniform  and  striking  than  when  the  drug  is  administered  by  the  mouth, 
and  the  dose  should  therefore  be  smaller.  In  every  instance  where  a  full 
dose  of  opium  has  been  given  the  physician  should  wait  until  the  effects 
have  subsided  before  the  dose  is  repeated. 

Sedatives. — For  most  of  the  milder  conditions  where  sedatives  are 
required  bromides  are  to  be  preferred.  A  preference  should  be  given  to 
the  sodium  salt.  Young  children  require  relatively  large  doses :  e.  g.,  in 
convulsive  conditions  three  grains  every  two  hours  are  often  necessary 
at  three  months.  Chloral  is  usually  well  borne  even  by  quite  young 
infants.  Since  it  is  often  irritating  to  the  stomach  it  may  be  advan- 
tageously given  by  the  rectum.  After  rectal  administration  its  effects 
are  usually  manifest  in  half  an  hour,  and  sometimes  sooner.  The  rectal 
dose  for  an  infant  of  one  month  is  one  grain ;  three  months,  two  grains ; 
one  year,  three  to  five  grains.  It  may  be  repeated  every  two  to  four 
hours,  according  to  indications.  Doses  by  mouth  should  be  about  half 
as  large.  Other  drugs  may  replace  this  in  most  diseases,  but  in  the  case 
of  infantile  convulsions  nothing  is  so  reliable  as  chloral. 


54  PECULIARITIES  OF  DISEASE   IN   CHILDREN. 

Belladonna  is  well  borne  by  cbildren,  and  in  relatively  larger  doses 
than  most  drugs.  A  tolerance  is  quite  readily  established.  The  eruption 
is  more  readily  produced  than  the  other  physiological  effects,  and  even 
quite  small  doses  may  be  sufficient  to  bring  out  a  very  abundant  blush. 
The  parents  should  be  advised  of  this  fact,  lest  undue  alarm  be  felt. 

The  drugs  classed  as  antipyretics — phenacetine  and  antipyrine — are 
exceedingly  valuable  in  the  treatment  of  many  diseases  of  infancy  where 
irritative  nervous  symptoms  are  prominent.  In  many  cases  they  may 
advantageously  take  the  place  of  opium,  except  where  pain  is  the  prin- 
cipal symptom,  as  in  otitis  or  pleurisy.  In  all  conditions  where  spasm 
is  a  prominent  symptom,  whether  of  the  larynx  or  bronchi,  or  local 
or  general  convulsions,  antipyrine  is  especially  valuable. 

Drugs  Well  Borne  by  Children. — In  this  list  might  be  mentioned 
belladonna,  the  bromides,  the  iodides,  chloral,  quinine,  calomel — in  fact, 
all  mercurials — aiid  alcohol. 

The  drugs  not  well  borne  include  particularly  cocaine  and  heroin. 
In  the  case  of  many  others,  while  the  constitutional  effects  are  well  tol- 
erated, they  must  be  given  carefully  to  young  infants,  since  they  are 
irritants  to  the  stomach.  In  this  class  may  be  mentioned  the  salicylates, 
salol,  the  astringent  preparations  of  iron,  and  the  acids. 

Vaccines. — These  are  suspensions  of  dead  bacteria  in  a  normal  salt 
solution.  Their  application  in  pediatrics  is  confined  to  therapeutics; 
as  a  prophylactic  measure  they  are  seldom  called  for.  Vaccine  therapy 
has  been  employed  in  almost  every  form  of  bacterial  infection.  In  the 
great  majority  of  these  the  results  have  been  disappointing.  They  are 
of  unquestioned  value  in  localised  staphylococcus  infections,  particularly 
those  of  the  skin,  e.  g.,  general  furunculosis  and  larger  multiple  ab- 
scesses. In  other  staphylococcus  infections  they  are  sometimes  useful, 
but  results  are  very  uncertain.  In  streptococcus  infections  whether 
localised  or  general  their  effect  is  doubtful ;  although  in  rare  cases  they 
have  seemed  to  be  of  benefit.  Pneumo'coccus  infections  are  apparently 
not  at  all  influenced  by  their  use.  Regarding  the  effect  of  vaccines  on 
gonococcus  infections  of  mucous  membranes,  one  must  speak  very  guard- 
edly. The  great  majority  of  patients  with  gonococcus  vaginitis  so  treated 
have  received  but  temporary  benefit,  although  a  few  striking  cures  have 
been  obtained.  Colon  infections  of  the  urinary  tract  (pyelitis)  some- 
times appear  to  be  decidedly  improved  by  vaccines.  With  respect  to  most 
other  conditions  experience  thus  far  does  not  warrant  one  in  forming  a 
sanguine  opinion  of  their  value.  For  the  technique  of  vaccine  treatment 
special  works  should  be  consulted. 

Counter-irritants. — These  are  of  great  value  in  a  large  variety  of 
diseases. 

The  mustard  paste  is  probably  the  most  satisfactory  means  of  pro- 
ducing quick  counter-irritation  over  a  large  surface.    To  make  a  mustard 


THERAPEUTICS.  55 

paste :  Take  one  part  powdered  mustard  and  six  parts  of  wheat  flour,  mix 
with  lukewarm  water,  and  spread  between  two  layers  of  muslin.  This 
should  be  removed  as  soon  as  a  thorough  redness  of  the  skin  has  been 
produced — in  most  cases  from  five  to  eight  minutes,  according  to  the 
strength  of  the  mustard  employed.  This  may  be  repeated  as  often  as 
every  three  hours,  and  continued  for  a  week  if  necessary,  without  pro- 
ducing excoriations  of  the  skin.  For  older  children  the  paste  may 
be  made  one  part  mustard  to  four  parts  flour.  In  pulmonary  diseases 
it  should  be  large  enough  to  surround  the  chest.  When  it  is  used 
to  produce  general  reaction  in  heart  failure  it  should  cover  the  entire 
trunk. 

The  Mustard  Pack. — The  child  is  stripped  and  laid  upon  a  blanket, 
and  the  trunk  is  surrounded  by  a  large  towel  or  sheet  saturated  with 
mustard  water.  This  is  made  as  follows :  One  tal)lespoonful  of  mustard 
to  one  quart  of  tepid  water.  In  this  a  towel  is  dipped,  and  while  drip- 
ping wound  around  the  entire  body.  The  patient  should  then  be  rolled 
in  the  blanket.  This  pack  may  be  continued  for  ten  or  fifteen  minutes, 
at  the  end  of  which  time  there  will  usually  be  a  very  decided  redness  of 
the  whole  body.  It  may  be  repeated  according  to  indications.  Where  it 
is  desired  to  produce  a  general  counter-irritation,  the  mustard  pack  is  not 
quite  as  efficient  as  the  mustard  bath,  but  it  has  the  advantage  in  causing 
much  less  disturbance  to  the  patient.  The  mustard  pack  is  useful  in  the 
condition  of  collapse  or  of  great  prostration  from  any  cause  whatever,  in 
convulsions,  and  in  cerebral  or  pulmonary  congestion. 

The  turpentine  stupe  is  made  by  wringing  a  piece  of  flannel  out  of 
water  as  hot  as  can  be  borne  by  the  hand.  Upon  this  is  sprinkled  ten  or 
fifteen  drops  of  the  spirits  of  turpentine.  The  stupe  is  then  applied  to 
the  body  and  covered  with  oiled  silk  or  dry  flannel.  It  is  useful  chiefly 
in  abdominal  pains  or  inflammations,  but  in  infancy  must  be  carefully 
watched  or  vesication  will  be  produced.  For  continuous  use  it  is  not  so 
valuable  as  the  mustard  paste. 

Stimulating  liniments  containing  turpentine  and  other  irritants  are 
useful  in  inflammations  of  the  chest,  although  less  reliable  than  the  mus- 
tard paste.  One  of  the  mildest  and  most  useful  preparations  is  camphor- 
ated oil.  Another  is  olive  oil  four  parts  and  turpentine  one  part.  These 
may  either  be  rubbed  upon  the  surface,  or  a  piece  of  flannel  may  be  satu- 
rated with  them  and  then  applied  to  the  skin. 

Local  Blood-letting. — Leeches  are  sometimes  useful  in  the  early 
stages  of  acute  inflammations  of  the  mastoid  or  middle  ear.  They  may 
also  be  applied  to  the  praecordium  in  acute  pneumonia  with  signs  of  fail- 
ure of  the  right  heart,  viz.,  great  dyspnoea  and  cyanosis. 

Dry  cups  may  be  used  even  in  young  infants,  to  relieve  acute  conges- 
tion in  pneumonia  or  bronchitis,  and  for  pulmonary  oedema.  Wet  cups 
should  never  be  used  for  young  children. 


56  PECULIARITIES  OF   DISEASE   IN   CHILDREN. 

Poultices  are  much  too  frequently  emplo3'ed  and  may  with  advantage 
be  omitted  in  the  treatment  of  most  local  inflammations.  They  have 
been  largely  replaced  by  wet  dressings,  especially  those  of  aluminum 
acetate.     In  acute  pulmonary  inflammations  their  use  is  very  limited. 

Cold. — Cold  is  useful  in  almost  all  forms  of  local  inflammation.  In 
inflammation  of  the  cervical  lymph  glands  and  of  the  joints  it  is  of 
undoubted  value,  but  its  advantage  over  heat  is  questionable.  The  effi- 
ciency of  both  cold  and  heat  in  these  cases  depends  largely  upon  the 
method  of  use.  The  difficulties  in  the  way  of  their  proper  application 
are  great  in  young  children.  Sometimes  in  pleurisy  much  greater  relief 
is  obtained  from  the  use  of  an  ice  bag  to  the  chest  than  from  hot  appli- 
cations, but  this  is  not  the  general  experience.  The  treatment  of 
pneumonia  by  the  application  of  the  ice  bag  to  the  chest  has  many  advo- 
cates, although  in  my  own  hands  it  has  not  yielded  the  results  claimed 
for  it.  It  is  admissible  only  in  lobar  pneumonia,  and  here  chiefly  in  older 
and  stronger  children.  The  application  of  cold  in  young  or  very  deli- 
cate children  should  be  made  with  caution  in  all  inflammations  of  the 
respiratory  tract. 

Cold  is  best  applied  to  the  head  by  an  ice  cap  made  like  a  helmet ;  an 
ordinary  rubber  or  flannel  bag  filled  with  ice  may  answer  the  purpose. 
The  rubber  coil  filled  with  ice  water  is  also  an  excellent  method.  For 
inflamed  glands  or  joints  the  ice  bag  or  the  coil  should  be  used;  for  the 
eyes,  cold  compresses,  changed  every  minute. 

The  Hot  Pack. — All  clothing  is  to  be  removed  and  the  child's  body 
covered  with  towels  wTung  from  water  at  a  temperature  of  from  100°  to 
108°  F.,  after  which  the  body  should  be  rolled  in  a  thick  blanket.  These 
hot  applications  may  be  changed  every  twenty  or  thirty  minutes  until  free 
perspiration  is  produced,  which  may  be  continued  as  long  as  necessary. 
This  is  mainly  useful  in  uraemia. 

The  hot  bath,  like  the  mustard  pack  or  the  mustard  bath,  may  be 
used  to  promote  reaction  in  cases  of  shock  or  collapse.  The  patient  should 
lie  put  into  the  bath  at  a  temperature  of  100°  F.,  the  water  being  gradu- 
ally raised  to  103°,  or  even  to  106°,  but  rarely  above  this  point.  The  body 
should  be  well  rubbed  while  the  patient  is  in  the  bath.  A  thermometer 
should  be  kept  in  the  water  to  see  that  the  temperature  does  not  go  too 
high.  Unless  this  precaution  is  taken  the  danger  of  burning  the  child  is 
great.  During  the  bath,  in  most  cases,  cold  should  be  applied  to  the 
head. 

The  Hot-Air  or  Vapour  Bath. — All  the  clothing  should  be  removed 
and  the  patient  laid  upon  the  bed  with  the  bedclothing  raised  above  the 
body  ten  or  twelve  inches,  and  sustained  by  means  of  a  wicker  support. 
The  bedclothing  should  be  pinned  tightly  about  the  neck,  so  that  only 
the  head  is  outside.  Beneath  the  bedclothing  hot  vapour  is  introduced 
from  a  croup  kettle  or  a  vapouriser.    This  will  usually  induce  free  per- 


THERAPEUTICS.  57 

spiration  in  fifteen  or  twenty  minutes.  It  may  be  continued  from  twenty 
to  thirty  minutes  at  a  time.  Instead  of  vapour,  hot  air  may  be  intro- 
duced in  the  same  way.  The  air  space  about  the  body  is  indispensable. 
The  vapour  bath  is  applicable  chiefly  to  cases  of  uraemia. 

The  Mustard  Bath. — Four  or  five  tablespoonfuls  of  powdered  mustard 
should  be  mixed  for  a  few  minutes  with  one  gallon  of  tepid  water.  To 
this  should  be  added  four  or  five  gallons  of  plain  water  at  a  temperature 
of  100°  F.  The  temperature  of  the  bath  may  be  raised  by  the  addition  of 
hot  water  to  103°  or  106°  F.,  if  desired.  Nothing  is  more  efficient  than 
the  hot  mustard  bath  for  a  general  derivative  effect  in  bringing  the  blood 
to  the  surface  in  cases  of  shock,  collapse,  heart  failure  from  any  cause,  or 
in  sudden  congestion  of  the  lungs  or  brain.  The  bath  should  not  usually 
be  continued  for  more  than  ten  minutes.  If  necessary,  it  may  be  re- 
peated in  an  hour. 

The  Bran  Bath. — Put  one  quart  of  ordinary  wheat  liran  in  a  l)ag  made 
of  coarse  muslin  or  cheese  cloth  and  place  this  in  four  or  five  gallons  of 
water.  The  bran  bag  should  be  frequently  squeezed  and  moved  about 
until  the  bath  water  resembles  a  thin  porridge.  It  may  be  of  any  tem- 
perature desired,  but  usually  about  90°  to  95°  F.  is  best.  A  bran  bath  is 
of  great  value  in  cases  of  eczema,  excoriations  about  the  buttocks,  or  in 
other  cases  where'  the  skin  is  very  delicate,  and  plain  water  seems  to  irri- 
tate it. 

The  tepid  bath  may  be  given  at  a  temperature  of  95°  to  100°  F.  It 
is  very  useful  in  many  conditions  of  excitement  or  extreme  nervous 
irritability.     To  induce  sleep  it  is  often  more  efficient  than  drugs. 

The  cold  sponge  or  the  shower  bath  should  be  given  in  the  morning 
before  breakfast,  and  in  a  warm  room.  The  child  should  stand  in  a 
foot  tub  containing  warm  water  enough  to  cover  the  feet,  then  a  large 
sponge  holding  about  a  pint  of  water  at  a  temperature  of  from  40°  to  60° 
F.  should  be  squeezed  three  or  four  times  over  the  chest,  shoulders,  and 
spine  of  the  child,  the  skin  being  rubbed  meanwhile.  The  bath  should 
not  last  more  than  half  a  minute.  It  should  be  followed  by  a  brisk  rub- 
bing until  a  thorough  reaction  is  established.  This  is  very  useful  at  all 
ages,  but  it  is  a  particularly  valuable  tonic  in  delicate  children.  It  may 
be  used  in  those  only  eighteen  months  old.  Not  the  least  of  the  bene- 
ficial results  is  the  full  expansion  of  the  lungs  from  the  strong  cry 
which  the  bath  usually  excites.  In  younger  infants  a  cold  plunge  may  be 
substituted.  This  should  be  merely  a  single  dip  of  the  entire  body  in 
water  at  a  temperature  of  50°  to  60°  F.  In  order  that  beneficial  effects 
shall  follow  the  cold  plunge  or  cold  sponging,  a  good  reaction  must 
be  established.  If  children  lack  sufficient  vitality  to  secure  this,  and 
if  they  remain  pale,  pinched,  and  blue  for  some  time  after  the  bath, 
it  must  be  discontinued  altogether,  or  water  of  a  higher  temperature 
used. 


58  PECULIARITIES  OF   DISEASE   IN   CHILDREN. 

Nasal  Spray. — This  may  be  either  of  an  aqueous  or  oily  solution.  For 
the  oil  spray  an  atomiser  should  be  employed.  It  is  valuable  in  cases 
of  dry  catarrh,  where  there  is  a  formation  of  crusts  in  the  nose.  A 
variety  of  oils  may  be  used,  benzoinol  being  perhaps  as  satisfactory 
as  any. 

There  are  many  forms  of  hand  atomisers  to  be  found  in  tlie  market 
for  the  production  of  aqueous  or  oil  sprays.  For  a  cleansing  nasal  spray, 
Dobell's  solution,  Seller's  solution,  or  a  two-per-cent  solution  of  boric 
acid  may  be  used. 

Nasal  Irrigation. — In  cases  of  considerable  nasal  obstruction  and  in 
the  more  serious  aifections  of  the  rhino-pharynx,  only  the  syringe  can  be 
considered  an  efficient  means  of  cleansing  the  cavity. 

The  fountain  syringe  has  the  advantage  of  being  easily  regulated 
as  to  the  force  employed,  this  being  determined  by  the  height  at  which 
the  bag  is  suspended  above  the  bed.  For  ordinary  purposes  an  eleva- 
tion of  one  or  two  feet  is  sufficient,  and  rarely  is  a  greater  pressure 
than  three  feet  advisable.    The  last  is  desirable  when  a  thorough  flushing 


Fig.  9. — Nasal  Syringe. 

of  the  rhino-pharynx  is  required.  The  position  of  the  patient  is  the 
same  as  that  shown  in  Fig.  10.  The  danger  of  forcing  fluid  into  the 
middle  ear  is  greatly  lessened  if  the  patient  keeps  the  moutli  wide 
open. 

Where  a  smaller  amount  of  fluid  is  sufficient  a  piston  syringe  may 
be  employed.  This  should  be  small  enough  to  be  easily  worked  with 
one  hand.  It  should  have  a  soft  rubber  tip,  to  prevent  injuring  the 
nasal  mucous  membrane,  and  the  tip  should  be  large  enough  to  fill  the 
nostril.  The  best  piston  syringe  for  nasal  use  is  shown  in  Fig.  9.  This 
is  made  either  of  glass  or  hard  rubber,  and  fulfils  all  the  conditions 
mentioned.  It  is  easy  of  action,  can  be  readily  cleansed,  and  holds 
about  half  an  ounce.  The  same  syringe  should  not  be  used  for  more 
than  one  patient,  unless  it  has  been  very  thorouglily  disinfected.  In  hos- 
pitals, and  even  in  private  practice,  nasal  syringes  are  frequent  carriers 
of  infection. 

Either  of  two  positions  may  be  used  in  nasal  syringing.  In  dipli- 
theria,  scarlet  fever,  or  any  constitutional  disease  attended  by  great  de- 
pression, the  child  should  not  be  removed  from  the  bed.  Tiie  syringing 
may  be  done  by  a  single  nurse,  who  stands  at  the  head  of  the  bed,  alter- 
nately syringing  the  right  and  left  nostril,  turning  the  head  from  side 


THERAPEUTICS. 


59 


to  side  (see  Fig.  10).  The  other  method  is  to  hold  tlie  chihl  erect 
on  the  lai>,  with  tlie  head  inclined  somewhat  forward,  the  syringing 
being  done  by  a  second  person  standing  behind.  In  either  position  the 
child's  arms  and   hands  should   be  securely  pinioned   to   the   sides   by 


Fig.  10. — Method  of  Stringing  the  Nose. 


a  sheet.  To  make  sure  that  the  rhino-pharynx  has  been  reached  the 
water  should  return  through  the  opposite  nostril  or  the  mouth.  When 
properly  done,  no  prostration  and  very  little  irritation  are  caused.  The 
bulb  (Davison)  syringe  should  not  be  employed  for  nasal  irrigation;  as 
the  pressure  can  not  be  satisfactorily  regulated,  fluids  are  likely  to  be 
forced  into  the  Eustachian  tubes. 

Syringing  the  mouth  and  pharynx  is  useful  in  many  pathological 
conditions  of  these  parts,  particularly  in  children  too  young  to  gargle. 
Either  the  fountain,  piston,  or  bulb  syringe  may  be  used.  If  the  pharynx 
is  to  be  reached,  the  nozzle  is  used  as  a  tongue  depressor.  This  should 
be  placed  at  the  angle  of  the  mouth  between  the  back  teeth.  The  child 
should  lie  upon  the  side  or  be  held  in  the  sitting  posture,  with  the  head 
inclined  forward.     Only  bland  solutions  should  be  employed. 

Inhalations. — These  are  of  very  great  utility  in  all  affections  of  the 
respiratory  tract.  To  be  efficient,  the  patient  should  be  put  under  a 
tent.  A  satisfactory  tent  may  be  made  by  erecting  a  T-shaped  piece  of 
wood  at  the  head  and  foot  of  the  crib  arid  throwing  over  this  a  large 
sheet  folded  and  pinned  at  the  corners.  Another  method  is,  to  stretch 
a  cord  around  the  top  of  each  of  the  four  posts  of  the  crib,  or  simply 
from  the  centre  of  the  head  piece  to  the  centre  of  the  foot  piece ;  the  sheet 


60 


PECULIARITIES  OF  DISEASE  IN  CHILDREN. 


should  be  used  as  in  the  first  instance.  A  very  good  tent  may  be  im- 
provised by  throwing  a  large  sheet  over  an  open  imibrella.  Instead  of 
an  ordinary  cotton  sheet  one  of  rubber  cloth  may  be  used.  For  hospital 
use  I  have  found  it  convenient  to  have  a  rubber  cover  made  to  fit  closely 
over  the  top  of  the  crib  to  be  used  for  inhalations.  The  better  the  tent 
the  more  satisfactory  are  the  results  from  inhalations. 

Inhalations  may  be  in  the  form  of  vapour  or  spray.  The  apparatus 
employed  may  be  the  croup  kettle,  the  vapouriser,  or  the  steam  atomiser. 
As  all  of  these  are  used  with  alcohol  lamps,  innumerable  accidents  from 
fire  have  occurred  with  them.  Patients  and  nurses  should  always  be 
cautioned  regarding  this.  Whenever  possible,  the  electric  heater  should 
be  substituted.  The  ordinary  croup  kettle  is  a  clumsy  affair  and  es- 
pecially likely  to  be  the  cause  of  accidents.  In  Fig.  11  is  shown  one 
of  an  improved  pattern,^  which  possesses  the  advantages  both  of  the  ordi- 
nary croup  kettle  and  of  the 
vapouriser.  The  base  has  been 
weighted,  to  prevent  the  ap- 
paratus being  easily  upset.  The 
pail  is  low,  which  fact  also  con- 
tributes to  its  stability.  It  is 
provided  with  a  safety  alcohol  lamp,  the 
flame  of  which  can  be  regulated  by  a  screw. 
The  lamp  holds  enough  alcohol  to  burn 
from  five  to  six  hours.  This  kettle  may  be 
used  to  produce  simple  vapour,  or  vapour 
from  lime  water,  or  a  medicated  vapour 
may  be  employed.  If  the  latter  is  de- 
sired, the  substance  to  be  vapourised  is 
placed  on  a  sponge  held  in  the  expansion 
of  the  spout.  The  kettle  should  be  filled 
with  hot  water  before  using.  It  should  be 
placed  upon  the  floor  or  a  low  box  beside 
the  crib,  standing  in  a  large  tin  basin  to 
avoid  accident,  at  such  a  height  that  the  end  of  the  spout  is  just  inside 
the  tent  at  a  level  with  the  surface  of  the  bed. 

There  are  various  other  forms  of  apparatus  for  the  purpose  of  ob- 
taining medicated  inhalations. 

Stomach-washing  consists  in  the  introduction  of  water  into  the  stom- 
ach through  a  flexible  catheter  or  stomach  tube  and  then  siphoning  it 
out.  It  was  introduced  into  general  practice  among  infants  by  Epstein, 
of  Prague.  It  is  one  of  the  most  valuable  therapeutic  measures  we  pos- 
sess.   The  procedure  is  very  simple,  and  may  be  considered  entirely  free 


Fio.   11.- 


-The  Author's  Croup 
Kettle. 


'  Made  by  Lewis  &  Conger,  130  W.  42d  St.,  New  York. 


THERAPEUTICS.  61 


A 


from  danger;  in  fact,  it  is  difficult  to  pass  the  tu!)e  anywhere  else  than 
into  the  oesophagus.     The  amount  of  prostration  produced  by  stomach 
washing  may  be  compared  to  that  of  an  ordinary  attack 
of  vomiting. 

The  apparatus  for  stomach-washing   (Fig.  12)  con- 
sists of  a  soft-rubber  catheter,  size  16,  American  scale  (24 
French) — one  with  a  large   eye  is  preferred ;   a   glass 
funnel,  holding  four  to  six  ounces;  two  feet  of  rubber 
tubing,  and  a  few  inches  of  glass  tubing  to  join  tliis 
to  the  catlieter.     The  child  should  be  held  in  a  siiting 
or  recumbent  posture  (Fig.  13),  the  body  well  protected 
by  a   rubber  sheet,   with   a   large   l)asin 
conveniently  near.     The  catheter  should 
be  moistened.     While  the  tongue  is  de- 
pressed with  the  forefinger   of  the   left 
hand,  the  catheter  is  passed  rapidly  back 
into  the  pharynx  and  down  the  oesoph- 
agus.     It    is    important    that    the    first 
part   of   the   introduction   should   be   as 
rapid  as  possible,  for  if  the  child  begins 
to  gag  from  the  pharvngeal  irritation  the 
introduction  of  the ''tube   may   be   quite     ri«- 12--Apparatus  for  Stomach- 

•'  ^      .  WASHING. 

difficult.  No  resistance  is  ordinarily  en- 
countered after  the  tube  reaches  the  oesophagus.  About  ten  inches  of 
the  catheter  should  be  passed  beyond  the  lips.  When  it  has  reached  the 
stomach  the  funnel  should  be  raised  as  high  as  possible,  to  allow  the 
escape  of  gases  almost  invariably  present.  It  should  then  be  lowered,  in 
order  to  siphon  out  the  fluid  contents.  If  nothing  escapes,  the  funnel 
is  then  to  be  raised  and  from  two  to  six  ounces  of  water  poured  into  it 
from  a  pitcher;  the  funnel  is  then  lowered  and  the  water  siphoned  out. 
This  procedure  is  repeated  from  four  to  ten  times,  or  until  the  fluid 
comes  back  clear.  About  a  quart  of  water  is  ordinarily  used.  Various 
solutions  have  been  advised  for  stomach-washing,  but  nothing  is  better 
than  boiled  water,  used  at  the  temperature  of  from  100°  to  110°  F. — the 
higher  temperature  being  employed  when  the  gastric  irritation  is  very 
great.  If  much  tenacious  mucus  is  present  in  the  stomach  an  alkaline 
solution  (bicarbonate  of  soda,  5j  to  Oj)  is  preferable.  Through  the  tube 
are  easily  discharged  mucus  and  small  curds;  larger  ones  are  gradually 
broken  down  by  repeated  washing.  Vomiting  may  be  induced  by  over- 
distending  the  stomach  with  water.  If  there  is  great  thirst  there  is  often 
an  advantage  in  leaving  one  or  two  ounces  of  water  in  the  stomach.  To 
this  water  it  is  at  times  beneficial  to  add  lime  water. 

Stomach-washing  in  its  application  is  practically  limited  to  children 
under  two  and  a  half  years.    It  is  easiest  in  those  under  eighteen  months. 


62 


PECULIARITIES  OF  DISEASE   IN   CHILDREN. 


Children  of  three  years  and  over  are  usually  so  much  alarmed  and  strug- 
gle so  violently  as  to  make  it  difficult  and  undesirable. 

The  indications  for  stomach- washing  are :  ( 1 )  Acute  gastric  indiges- 
tion, either  with  or  without  persistent  vomiting.     Here  the  purpose  is 


Fig.  13. — Position  roR  SxoaiACH-wASHmo. 


simply  to  clear  the  stomach  of  its  irritating  contents,  and  a  single  wash- 
ing may  be  sufficient.  (2)  Chronic  indigestion  attended  by  the  pro- 
duction of  gastric  mucus.  (3)  Dilatation  of  the  stomach.  (4)  Hyper- 
trophic stenosis  of  the  pylorus.     (5)  Poisoning. 

Gavage. — Gavage  consists  in  the  introduction  of  food  into  the 
stomach  by  a  tube  passed  through  the  mouth.  The  same  apparatus  is 
employed  as  in  stomach-washing,  and  the  method  is  similar,  with  the 
exception  that  for  gavage  the  child  should  be  placed  upon  the  back,  the 
head  being  steadied  by  an  assistant.     With  older  children  a  mouth-gag 


THERAPEUTICS.  63 

is  often  necessary.  After  the  tube  has  entered  the  stomach  the  funnel 
should  be  raised  to  allow  the  gas  to  escape.  The  food  is  then  poured 
into  the  funnel ;  as  soon  as  it  has  disappeared  the  tube  is  tightly  pinched 
and  quickly  withdrawn,  to  prevent  food  from  trickling  into  the  pharynx, 
since  this  is  often  a  cause  of  vomiting.  If  the  food  is  regurgitated  this 
usually  happens  at  once.  It  may  then  be  introduced  a  second  time. 
After  feeding,  the  child  should  be  kept  absolutely  quiet  upon  the  back. 

In  cases  v.iiere  all  the  food  is  given  by  gavagc  the  interval  between 
feedings  must  be  considerably  longer  tlian  under  other  circumstances. 
Often  the  food  given  should  be  partially  predigested,  since  digestion  in 
these  cases  is  usually  feeble.  The  stomach  should  be  washed  before  each 
feeding,  in  order  to  remove  mucus  and  to  be  sure  that  it  is  empty  be- 
fore the  meal  is  given. 

Gavage  is  valuable  in  the  feeding  of  premature  infants  and  after 
certain  operations  upon  the  mouth  and  neck.  It  is  also  useful,  first,  in 
the  case  of  very  young  infants,  who,  suffering  from  severe  malnutrition, 
can  not  be  induced  to  take  food  enough  to  sustain  life;  secondly,  in 
many  acute  diseases,  particularly  in  septic  cases  where  the  child  will 
not  readily  take  the  necessary  food,  as  in  diphtheria,  scarlet  fever, 
typhoid,  pneumonia,  etc. ;  thirdly,  in  many  cases  of  cerebral  disease 
where  food  is  refused  on  account  of  delirium  or  coma;  and,  fourthly, 
in  some  cases  of  persistent  vomiting,  as  first  suggested  by  Kerley. 

Gavage  is  a  very  simple  procedure  and  one  which  a  nurse  can  easily 
be  taught.  Not  only  may  food  be  given,  but  also  medicines  and  stimu- 
lants as  may  be  required,  with  little  or  no  trouble.  The  advantage  of 
gavage  over  the  continued  coaxing  or  holding  the  nose  and  forcing  the 
patient  to  swallow,  will  be  at  once  apparent  to  one  using  it. 

Nasal  Feeding. — The  method  is  similar  to  gavage,  the  only  difference 
being  that  the  tube  is  passed  through  the  nose,  and  consequently  a  much 
smaller  one  is  used.  No.  10  American  or  No.  16  French  scale  is  a  proper 
size.  Nasal  feeding  is  applicable  to  children  over  two  years  old,  in  whom 
the  tube  can  seldom  be  passed  through  the  mouth  without  the  use  of  a 
gag,  and  then  only  after  much  struggling.  It  is  of  value  after  intuba- 
tion, tracheotomy,  and  other  operations  about  the  throat,  also  in  some 
cases  of  throat  paralysis,  especially  after  diphtheria. 

Irrigation  of  the  Colon. — By  irrigation  of  the  colon  is  meant  the 
flushing  of  the  entire  large  intestine  by  fluids  injected  high  up  through 
a  catheter  or  rectal  tube. 

The  apparatus  required  for  irrigating  the  colon  is  a  fountain  syringe, 
five  or  six  feet  of  rubber  tubing,  and  a  flexible  rectal  tube  or  soft-rubber 
catheter — No.  26  or  27,  French  scale,  being  preferred.  Kemp's  double- 
current  tube  of  hard  or  flexible  rubber  is  useful.  The  same  result  can 
be  obtained  by  using  two  catheters,  the  larger  for  outflow,  the  smaller 
for  inflow.     The  child  is  placed  upon  the  back,  with  the  thighs  flexed 


64 


PECULIARITIES  OF   DISEASE   IN   CHILDREN. 


and  the  buttocks  brought  to  the  edge  of  the  bed  or  table.  He  should  lie 
upon  a  Kelly  pad  or  a  rubber  sheet  so  arranged  as  to  form  a  trough 
emptying  into  a  large  basin  or  tub.  The  bag  containing  the  water  is 
hung  two  or  three  feet  above  the  bed.  If  a  catheter  is  used  it  is  inserted 
just  within  the  sphincter  before  the  water  is  turned  on.     As  it  flows 


Fig.  14. — Colon  of  a«  Child  Six  Months  Old,  in  Position.     (From  a  photograph.) 

the  catheter  is  gradually  pushed  upward  to  a  distance  of  twelve  or  four- 
teen inches.  The  water  distending  the  intestine  in  advance  of  the  cathe- 
ter usually  makes  its  introduction  quite  easy.  In  Fig.  14  is  shown  the 
colon  of  an  infant  of  six  months  in  position.  It  is  the  peculiar  curve 
and  the  great  length  of  the  sigmoid  flexure  that  make  the  introduction 
of  water  difficult,  unless  the  tube  is  inserted  for  some  distance. 

Usually  a  pint,  and  often  a  quart,  will  be  introduced  before  any  water 
returns.  At  least  a  gallon  of  water  should  be  used  for  a  single  irrigation. 
The  washing  should  be  continued  until  the  water  returns  quite  clean. 
Change  of  posture  and  gentle  kneading  of  the  abdomen  should  be  em- 
ployed during  the  irrigation,  particularly  the  early  part  of  it,  to  facili- 
tate the  introduction  of  the  water  into  the  upper  part  of  the  colon.  At 
the  end  of  the  irrigation  the  rubber  tube  is  detached  and  the  water  al- 


THERAPEUTICS.  65 

lowed  to  escape  through  the  catheter,  whieli  remains  in  situ.  Sometimes 
as  much  as  a  pint  of  water  remains  in  the  intestine.  This  is  usually 
passed  within  half  an  hour.  As  tlie  irrigation  of  tlie  coh)n  almost  in- 
variably excites  active  peristalsis  of  the  lower  ileum,  this  ])art  of  the 
intestine  is  emptied  as  well.  It  is  to  be  remembered  tbat  the  colon  of  an 
infant  six  months  old  will  hold  about  one  pint  without  distention,  and 
at  the  age  of  two  years  from  two  to  three  pints. 

Irrigation  of  the  colon  is  useful  to  clear  this  part  of  the  intestine  of 
mucus,  faecal  matter,  undigested  food,  and  tlie  products  of  decomposi- 
tion. It  may  also  be  employed  as  a  means  of  local  medication  in  ileo- 
colitis. Where  the  object  is  simply  to  cleanse  the  intestine,  a  saline 
solution  —  a  teaspoonful  of  common  salt  to  a  pint  of  water  —  is  pre- 
ferred. 

The  temperature  of  the  water  used  for  irrigation  may  be  varied 
according  to  the  special  indications.  For  ordinary  purposes,  where 
cleansing  only  is  aimed  at,  a  temperature  of  from  95°  to  100°  F.  seems  to 
be  best.  When  the  body  temperature  is  high,  or  wlien  there  is  much 
pain,  tenesmus  and  straining,  cold  water  has  important  advantages. 

Irrigation  under  most  circumstances  is  required  only  once  in  twenty- 
four  hours.  It  is  important  to  use  a  large  quantity  of  water.  It  must 
be  done  thoroughly  to  be  of  value,  and  either  by  the  physician  himself 
or  an  experienced  nurse. 

In  collapse  or  great  prostration  hot  saline  injections  may  be  em- 
ployed for  purposes  of  stimulation;  the  temperature  of  these  should  be 
from  105°  to  110°  F. 

Enemata. — Simple  enemata  are  useful  in  infants  and  older  children 
for  constipation.  Where  an  immediate  effect  is  desired  the  most  eflftcient 
is  one  containing  glycerine — e.  g.,  for  an  infant,  one  teaspoonful  to  one 
ounce  of  water.  Oil  enemata  (one  half  to  one  ounce)  are  useful  where 
the  faecal  mass  is  hard  and  dry  and  expelled  with  difficulty.  Enemata 
should  always  be  given  with  care,  and  preferably  a  rubber  catheter  should 
be  attached  to  the  nozzle  of  the  syringe. 

Nutrient  enemata  have  a  limited  application  in  infancy,  as  the  rec- 
tum soon  becomes  intolerant.  The  quantity  injected  should  be  small, 
rarely  more  than  one  or  two  ounces,  and  the  interval  between  injections 
should  be  at  least  four  hours.  In  older  children  they  may  be  used  as  in 
adults.  For  this  purpose  either  completely  peptonised  milk  or  glucose 
may  be  employed. 

The  administration  of  drugs  per  rectum  is  useful  in  certain  cases 
where,  on  account  of  the  unpleasant  taste  or  vomiting,  the  administration 
by  mouth  is  difficult — e.  g.,  quinine  and  chloral.  As  a  diluent,  gruel  is 
preferable  to  water.  If  quinine  is  used,  the  bisulphate  is  the  best  prepa- 
ration, but  this  must  be  well  diluted.  The  temperature  of  enemata  which 
are  to  be  retained  should  be  about  100°  F.  It  is  necessary  in  infancy  to 
6 


66  PECULIARITIES  OF  DISEASE   IN  CHILDREN. 

press  the  buttocks  together  for  half  an  hour  afterward  to  prevent  t"he 
expulsion  of  the  injection. 

Hypodermic  Medication. — This  is  not  so  often  used  in  young  children 
as  it  should  be,  and  is  of  the  greatest  service  even  in  infancy.  The  use 
of  morphine  hypodermically  in  convulsions,  of  morphine  and  atropine 
in  cholera  infantum,  of  strychnine,  adrenalin,  caffeine,  or  digitalis  in 
heart  failure,  may  be  cited  as  examples. 

Hypodermoclysis. — This  is  a  therapeutic  measure  of  considerable 
value  in  a  few  conditions,  chiefly  when  the  system  is  suffering  from  a 
rapid  loss  of  fluid  as  in  some  forms  of  acute  diarrhoea,  less  frequently 
after  severe  haemorrhage  from  whatever  cause.  A  sterile  normal  salt 
solution  is  employed  at  body  temperature  and  may  be  injected  into 
any  of  the  areolar  planes  of  the  body.  With  young  infants  the  prefer- 
able location  is  between  the  scapula;  next,  the  abdomen  or  the  lateral 
thoracic  region.  For  very  small  patients  injections  should  be  made  at 
several  points.  The  amount  injected  at  one  time  may  vary  from  one 
to  four  ounces  for  an  infant,  and  from  four  to  sixteen  ounces  for  an 
older  child.  The  apparatus  should  be  carefully  sterilised.  One  may 
employ  a  piston  syringe  with  a  connecting  rubber  tube  and  a  hypodermic 
or  fine  exploring  needle,  or  a  funnel  may  be  substituted  for  the  syringe. 

Massage. — In  older  children  massage  is  useful  for  the  same  condi- 
tions as  those  for  which  it  is  employed  in  adults;  the  most  important 
are  anaemia,  general  malnutrition,  chorea,  and  chronic  constipation.  It 
is  necessary  that  in  the  beginning  only  the  mildest  movements  of  massage 
should  be  employed,  and  these  but  for  a  short  time. 

In  infancy  massage  has  a  limited  application,  and  it  is  doubtful 
whether  it  really  does  more  than  can  be  accomplished  by  the  general 
friction  of  the  body.  This  rubbing,  either  with  the  bare  hand  or  with 
cocoa  butter,  or  with  some  form  of  fat,  is  useful  in  malnutrition,  in 
rickets,  and  in  wasting  diseases  where  the  circulation  is  feeble  and  the 
muscular  tone  low.  Cocoa  butter  is  cleanly  and  has  a  pleasant  odour,  and 
is,  I  think,  quite  as  valuable  as  the  more  commonly  employed  cod-liver 
oil,  which  is  exceedingly  disagreeable.  The  inunctions  should  be  given 
daily  after  the  morning  bath,  before  an  open  fire.  The  rubbing  should 
be  continued  for  fifteen  to  twenty  minutes. 

Ansesthetics. — As  a  general  anaesthetic  for  routine  use,  ether  is  to  be 
recommended  for  children.  Its  disadvantages  can  largely  be  overcome 
by  proper  administration ;  in  point  of  safety  it  is  immeasurably  superior 
to  chloroform  for  the  very  young.  The  administration  of  ether  to  young 
children  may  be  advantageously  preceded  by  a  few  whiffs  of  nitrous 
oxide  or  ethyl  chloride;  both,  however,  are  to  be  used  with  caution  in 
infants.  Ether  should  be  given  slowly,  well  diluted  with  air,  and  if  used 
in  this  way  its  unpleasant  features  may  be  obviated.  This  can  best  be 
accomplished  by  the  use  of  some  special  form  of  inhaler.     Ether  should 


p 


THERAPEUTICS.  67 


not  be  selected  as  the  anaesthetic  for  patients  suffering  from  nephritis, 
bronchitis,  pneumonia,  pleurisy,  or  any  other  disease  attended  by  ob- 
structed respiration.     For  all  these  conditions  chloroform  is  much  safer. 

The  dangers  from  chloroform  are  greatest  when  it  is  given  too 
rapidly  or  in  too  concentrated  a  form.  Both  are  exceedingly  likely  to 
occur  where  it  is  administered  to  a  struggling  child.  The  greatest  care 
and  judgment  should  be  exercised  at  such  times,  or  disastrous  con- 
sequences may  follow.  To  produce  and  maintain  the  effect  desired  with 
the  minimum  amount  of  chloroform  should  always  be  the  aim.  All 
anaesthetics,  but  especially  chloroform,  are  dangerous  in  children  with 
the  so-called  lymphatic  diathesis.  For  the  removal  of  tonsils  or  adenoids, 
chloroform  should  not  be  employed. 

Nitrous  oxide,  while  very  useful  in  older  children,  as  in  adults,  for 
momentary  operations,  is  not  well  borne  by  infants.  It  produces  so  early 
and  so  deep  asphyxia  that  its  prolonged  use  may  be  fraught  with  serious 
danger. 


PART  II. 

SECTION   I. 
DISEASES   OF  THE  NEWLY  BORN. 

CHAPTER    I. 
ASPHYXIA. 

The  lungs  in  the  full-term  foetus  arc  of  uniform  dark  red  colour, 
and  show  very  distinctly  upon  their  surface  the  lobular  divisions.  They 
are  firm  and  solid  and  readily  sink  in  water.  The  connective  tissue  is 
very  abundant,  and  forms  distinct  fibrous  septa,  which  stretch  through 
the  lungs  in  every  direction. 

Inflation  of  the  lungs  begins  with  the  first  cry  uttered  by  the  in- 
fant as  it  is  born  into  the  world.  The  parts  first  expanded  are  the 
anterior  borders  of  the  lungs,  then  the  upper  lobes,  and  finally  the  lower 
lobes  posteriorly.  The  superficial  lobules  are  nearly  always  expanded 
before  those  in  the  interior  of  the  lung.  The  inflation  is  sometimes 
irregular,  because  of  the  accumulation  of  mucus  in  some  of  the  bronchial 
tubes.  The  right  lung  is  frequently  stated  to  be  expanded  earlier  than 
the  left.  Although  this  is  often  the  case,  there  is  no  uniformity  in  this 
respect.  The  important  point  to  be  remembered  is,  that  the  parts  last 
inflated  are  the  posterior  portions  of  the  lower  lobes.  The  expansion  of 
the  lungs  is  a  gradual  process,  and  in  healthy  infants  it  is  probably  not 
complete  much  before  the  end  of  the  second  day.  In  delicate  children 
it  may  be  postponed  for  several  days,  or  even  weeks.  The  above  state- 
ments are  based  upon  post-mortem  observations  upon  infants  dying  from 
various  causes  during  the  first  weeks.  It*  has  often  been  a  matter  of 
great  surprise  to  find  at  autopsy  on  an  infant  two  or  three  days  old,  that 
less  than  one-half  of  the  lung  tissue  was  expanded,  although  the  child 
had  breathed  well  and  shown  no  signs  of  atelectasis.  Under  normal 
conditions  at  full  term  inflation  of  tlie  lungs  takes  place  very  readily,  but 
not  so  readily  in  premature  or  delicate  infants,  on  account  of  the  feeble- 
ness of  the  respiratory  muscles.  The  longer  it  js  postponed  after  birth 
the  more  difficult  does  it  become,  on  account  of  the  changes  which  occur 
in  the  collapsed  air  vesicles.  The  condition  of  the  child  in  utero  may 
be  described  as  one  of  fcetal  apnoea,  its  oxygen  being  received  and  its 
68 


ASPHYXIA.  69 

carbon  dioxide  discharged  tliroiigh  the  placenta,  whicli  is  essentially 
the  organ  of  respiration  at  this  period.  This  condition  is  interrupted 
by  cutting  off  the  supply  of  oxygen  and  the  accumulation  of  carbon 
dioxide  in  the  blood.  Which  of  these  is  the  important  factor  in  induc- 
ing pulmonary  respiration  has  been  much  debated ;  but  the  best  exj^eri- 
mental  evidence  seems  to  show  that  it  is  the  want  of  oxygen  which 
stimulates  the  respiratory  centres. 

Under  the  term  "  asphyxia "  may  be  included  all  cases  in  which 
primary  respiration  is  not  spontaneously  established  with  sufficient  force 
to  maintain  life.  Usually  there  is  no  attempt  at  pulmonary  respiration 
until  after  the  birth  of  the  child,  but  it  may  occiir  in  utero  or  at  any 
stage  of  parturition.  Asphyxia  may  be  of  intra-uterine  or  extra-uterine 
origin. 

Etiology. — 1.  Intra-uterine  Asphyxia. — The  maternal  causes  include 
any  disturbance  of  the  placental  circulation  during  labour — anything 
which  prolongs  the  second  stage  of  labour,  convulsions,  hsemorrhage, 
the  use  of  ergot  in  the  second  stage,  or,  final h',  the  death  of  the  mother. 
The  causes  relating  to  the  child  are  pressure  upon  the  cord,  nmltiple 
winding  of  the  cord  about  the  neck,  early  separation  of  the  placenta, 
and  pressure  upon  the  brain.  If  the  respiratory  stimulus  comes  before 
the  birth  of  the  child,  the  effort  at  respiration  may  cause  the  entrance 
into  the  mouth  and  air  passages  of  amniotic  fluid,  mucus,  blood,  me- 
conium, etc. 

2.  Extra-uterine  Asphyxia. — This  condition  is  a  much  less  common 
one.  It  arises  from  causes  quite  apart  from  those  above  mentioned,  and 
depends  upon  malformations  or  intra-uterine  disease  of  the  organs  of 
respiration,  circulation,  or  of  the  brain.  It  may  be  secondary  to  an 
injury  of  any  of  these  organs  received  during  parturition.  It  is  also 
seen  in  premature  infants,  where  it  depends  upon  the  feeble  development 
of  the  nerve  centres  and  respiratory  muscles  and  upon  the  soft,  yielding 
chest  walls. 

Lesions. — In  infants  dying  of  intra-uterine  asphyxia  there  are  seen 
the  usual  changes  found  in  death  from  suffocation,  together  with  the 
effects  of  attempts  at  breathing  in  utero.  There  is  general  congestion  of 
all  the  viscera,  particularly  of  the  brain  and  its  meninges,  the  liver,  and 
the  lungs.  They  may  show  small,  punctate  haemorrhages,  and  occa- 
sionally large  extravasations.  Blood  or  bloody  serum  may  be  found  in 
any  of  the  serous  cavities.  The  right  heart  is  overdistended  with  dark, 
soft  clots,  and  the  blood  generally  is  more  fluid  than  normal.  The 
lungs  may  contain  no  air,  but  more  frequently  there  are  small,  scattered 
areas  in  which  lobular  inflation  has  taken  place.  If  the  child  has  lived 
several  hours  there  are  larger  areas  of  expanded  lung,  especially  in  the 
upper  lobes,  and  these  may  even  be  emphysematous,  if  artificial  inflation 
has  been  employed.    In  the  mouth,  nose,  larynx,  and  even  as  far  as  the 


70  DISEASES  OF  THE   NEWLY   BORN. 

finest  bronchi,  there  may  be  found  aspirated  materials — amniotic  fluid, 
blood,  mucus,  or  meconium.  In  extra-uterine  asphyxia  there  are  organic 
changes  in  the  viscera — malformations  of  the  lungs  or  the  heart,  intra- 
uterine pneumonia  or  pleuritic  effusion,  malformation  of  the  diaphragm 
and  sometimes  of  the  brain. 

Symptoms. — Under  normal  conditions  the  newly-born  infant  begins 
at  once  to  scream  and  to  use  his  limbs,  the  purplish  colour  of  the  skin 
giving  place  in  a  few  moments  to  a  rosy  pink.  In  the  first  degree  of 
asphyxia — asphyxia  livida — the  child  is  deeply  cyanosed.  Either  no 
attempt  whatever  is  made  at  respiration,  or  it  is  superficial  and  repeated 
only  at  long  intervals.  The  pulse  is  slow,  full,  and  strong.  The  vessels 
of  the  cord  are  distended.  Muscular  tone  is  preserved,  and  also  cutaneous 
irritability,  so  that  with  the  application  of  almost  any  kind  of  external 
stimulus,  respiration  is  excited  and  the  symptoms  disappear. 

In  the  second  degree — asphyxia  pallida — the  picture  is  quite  a  dif- 
ferent one.  The  face  is  pale  and  deathlike,  though  the  lips  may  still  be 
blue.  The  heart's  action  is  weak,  and  by  palpation  can  rarely  be  felt 
at  all.  By  auscultation  the  sounds  are  feeble,  irregular,  and  usually  slow. 
The  cord  is  soft,  pale,  and  flaccid,  and  its  vessels  nearly  empty.  The 
sphincters  are  relaxed,  and  meconium  oozes  from  the  anus.  There  is 
entire  loss  of  tone  in  the  voluntary  muscles,  so  that  the  extremities  and 
entire  body  seem  perfectly  limp.  Cutaneous  sensibility  is  abolished. 
The  extremities  are  often  cold.  There  may  occur  a  few  short,  convulsive 
contractions  of  the  respiratory  muscles,  but  these  are  without  effect  and 
soon  cease.  Unless  such  cases  receive  the  most  prompt  and  efficient  treat- 
ment, the  heart's  action  becomes  more  and  more  feeble  until  it  ceases 
and  death  occurs.  Other  cases  are  partly  resuscitated  and  may  survive 
for  a  few  hours  or  days,  when  they  gradually  sink,  respiration  becoming 
more  and  more  feeble  in  spite  of  all  efforts  to  maintain  it.  Between 
these  two  extremes  all  degrees  of  severity  are  seen. 

In  extra-uterine  asphyxia  there  may  be  some  attempts  at  voluntary 
respiration  continuing  for  several  hours,  sometimes  for  a  day  or  two, 
but  this  may  be  inadequate  to  sustain  life. 

Diagnosis. — Almost  the  only  condition  with  which  asphyxia  is  likely 
to  be  confounded  is  cerebral  compression  from  a  meningeal  haemorrhage. 
The  difficulties  in  the  case  are  much  increased  by  the  fact  that  the  two 
conditions  are  not  infrequently  associated.  It  may  then  be  impossible  to 
tell  that  in  addition  to  asphyxia,  intracranial  haemorrhage  is  present. 
If  the  haemorrhage  is  extensive  and  the  asphyxia  only  moderate,  a  diag- 
nosis is  possible  in  most  of  the  cases.  In  haemorrhage  there  is  often  a 
history  of  undue  compression  during  delivery — sometimes  the  use  of 
forceps.  The  fontanel  is  bulging;  there  is  coma,  and  there  may  be 
paralysis.  The  respiratory  murmur  may  be  quite  strong  for  several 
hours,  but  it  gradually  fails  as  the  child  becomes  completely  comatose. 


ASPHYXIA.  71 

Anaemia  resulting  from  a  large  haemorrhage,  like  that  due  to  rupture  of 
the  cord,  may  simulate  the  severe  form  of  asphyxia. 

Prognosis. — This  depends  upon  the  grade  of  asphyxia  and  the  treat- 
ment employed.  There  is  but  little  tendency  to  spontaneous  recovery  in 
any  form.  In  the  milder  cases  recovery  is  almost  invariable  with  any 
intelligent  treatment.  In  the  severest  cases  the  outcome  is  always  doubt- 
ful, although  by  persistent  effort  many  infants  that  are  apparently 
hopeless  may  be  saved.  In  a  prognosis  as  to  the  ultimate  result,  the 
frequent  complication  of  asphyxia  with  meningeal  haemorrhage  should 
always  be  kept  in  mind.  Apart  from  this  complication  it  is  doubtful 
whether  asphyxia  has  anything  to  do  with  the  production  of  idiocy. 

Treatment. — In  every  case  the  first  step  is  to  clear  the  mouth  and 
pharynx  of  mucus  by  means  of  the  finger  covered  with  absorbent  cotton. 
In  the  milder  forms  respiration  is  usually  excited  either  by  spanking  the 
child  or  the  alternate  use  of  hot  and  cold  baths.  If  the  hot  bath  is 
employed,  the  water  should  be  from  104°  to  108°  F.  and  always  tested 
by  a  thermometer.  After  a  moment  the  child  should  be  dipped  into  very 
cold  water,  or  the  body  may  be  douched  with  it.  In  the  livid  cases  relief 
is  often  afforded  by  allowing  the  cord  to  bleed  for  a  few  moments  before 
ligation.  The  loss  of  half  an  ounce  of  blood  is  ordinarily  sufficient. 
Simply  swinging  the  child  in  the  air  is  a  powerful  stimulus  to  respira- 
tion. The  above  means  will  suffice  in  the  great  majority  of  cases.  In 
the  more  severe  forms,  however,  these  are  inadequate.  There  is  no 
response  whatever  to  external  stimulation,  either  by  heat  or  mechanical 
irritation.  In  these  cases  two  methods  of  resuscitation  may  be  employed : 
artificial  respiration  and  direct  inflation  of  the  lungs. 

One  of  the  most  widely  employed  methods  of  inducing  artificial 
respiration  is  that  of  Sclmltze.  The  infant  is  grasped  by  both  axillae  in 
such  a  way  that  the  thumbs  of  the  physician  rest  upon  the  anterior  surface 
of  the  chest,  the  index  fingers  in  the  axillae,  and  the  remaining  fingers 
extending  across  the  back.  The  child  is  thus  suspended  at  arm's  length 
between  the  knees  of  the  physician,  the  feet  downward  and  the  face 
anterior.  The  body  is  now  swung  forward  and  upward,  until  the  physi- 
cian's arms  are  nearly  horizontal.  This  produces  the  inspiratory  effort. 
When  this  point  is  reached,  an  arrest  in  the  swinging  causes  flexion  of 
the  trunk,  the  head  now  being  directed  downward,  the  lower  extremities 
fall  toward  the  physician  until  the  whole  weight  of  the  body  rests  upon 
the  thumbs.  In  this  way  expiration  is  produced.  Lusk  cautions  against 
the  employment  of  this  method  if  the  heart's  action  is  very  feeble,  as  it 
may  cause  the  heart  to  stop  altogether.  This  method  should  be  used 
with  care  and  skill;  clumsy  and  too  forcible  manipulation  has  resulted 
in  many  serious  injuries  to  the  viscera  and  fractures  of  ribs  or  clavicles. 

A  method  introduced  by  Dew  has  been  extensively  employed  in  New 
York.    The  infant  is  grasped  in  such  a  way  that  the  neck  rests  between 


72  DISEASES  OF  THE   NEWLY  BORN. 

the  thumb  and  forefinger  of  the  left  hand,  the  head  being  allowed  to 
fall  far  backward,  the  upper  portion  of  the  back  resting  upon  the  palm 
of  the  hand;  with  the  right  hand  the  knees  are  grasped  between  the 
thumb  and  fingers,  the  thighs  resting  against  the  palm  of  the  hand. 
Inspiration  is  produced  by  depressing  the  pelvis  and  lower  extremities, 
thus  causing  the  abdominal  organs  to  drag  upon  the  diaphragm,  and  at 
the  same  time  gently  bending  the  dorsal  region  of  the  spine  backward. 
In  expiration  the  movement  is  reversed,  the  head  being  brought  forward 
and  flexed  upon  the  thorax,  while  at  the  same  time  the  thighs  are  flexed 
80  as  to  bring  them  against  the  abdomen.  The  body  is  thus  alternately 
folded  upon  itself  and  unfolded  as  the  movements  are  carried  on.  If  there 
is  much  mucus  in  tlie  moutli,  the  movement  of  expiration  should  first  be 
made  with  the  body  completely  inverted.  This  method  is  simple,  efficient, 
and  much  less  fatiguing  than  that  of  Schultze  when  it  is  to  be  main- 
tained for  a  long  time.  It  is  also  of  great  advantage  in  that  it  can  be  car- 
ried on  while  the  child  is  in  the  hot  bath,  one  of  the  greatest  objections  to 
the  method  of  Schultze  being  the  loss  of  animal  heat  incident  to  its  use. 

In  all  cases  where  artificial  respiration  is  used  the  first  movement 
should  be  that  of  expiration,  to  expel,  so  far  as  possible,  mucus  or  other 
foreign  substances  from  the  air  passages.  The  movements  should  be 
made  from  eight  to  twelve  times  a  minute,  and  not  too  forcibly,  the 
child  being  kept  in  the  hot  bath  between  the  movements,  and  as  much 
as  possible  during  them.  As  long  as  the  heart  beats  resuscitation  is 
possible,  and  the  case  should  not  be  abandoned. 

Direct  inflation  of  the  lungs  by  the  mouth-to-mouth  method  should 
not  be  employed. 

An  ingenious  apparatus  for  artificial  inflation  of  the  lungs  has  been 
devised  by  Carrel  of  the  Eockefeller  Institute,  making  use  of  Meltzer's 
method  of  the  continuous  insufflation  of  air.  A  flexible  catheter  con- 
taining a  wire  stylet  is  introduced  into  the  larjux.  To  the  catheter  is 
then  attached  the  apparatus  shown  in  Fig.  15.  By  means  of  the  double 
bulb  a  continuous  flow  of  air  is  maintained.  The  manometer  shown  at  A 
measures  the  pressure  employed  and  is  a  guide  by  which  one  is  prevented 
from  using  an  excessive  amount  of  force.  When  the  pressure  employed  is 
normal  the  mercury  in  the  descending  and  ascending  arms  of  the  curved 
tube  stands  at  about  the  same  level;  if  an  excessive  amount  of  pressure 
is  used,  the  mercury  will  be  forced  up  into  the  bulb.  Although  this  has 
been  as  yet  very  little  employed  in  infants  it  has  been  extensively  used 
in  resuscitating  animals  and  seems  to  fulfill  all  the  indications  better 
than  any  apparatus  hitherto  suggested.  It  is  so  simple  of  construction 
that  it  can  easily  be  put  together  by  any  instrument  maker. 

The  method  introduced  by  Laborde,  of  making  rhythmical  traction 
upon  the  tongue  ten  or  twelve  times  a  minute  as  a  means  of  exciting  res- 
piration, is  sometimes  very  useful  in  conjunction  with  other  methods. 


CONGENITAL  ATELECTASIS. 


73 


Faradisation  of  the  phrenic  is  of  undoubted  value,  but  somewhat  difficult 
of  application. 

In  cases  of  asphyxia  it  is  not  enough  to  make  the  child  cry.     The 
deep  respirations  should  be  made  to  continue,  for  very  often  it  happens 


Fig.  15. — Carrel's  Apparatus  for  Infl.\ting  the  Lungs. 

that  resuscitation  is  only  partial,  and  that  the  child  after  six  or  eight 
hours  lapses  into  its  previous  condition.  All  severe  cases  require  close 
watching  for  the  first  twenty-four  or  thirty-six  hours,  as  a  repetition  of 
the  treatment  is  often  necessary. 


CHAPTER    II. 
CONGENITAL  ATELECTASIS. 

This  condition  is  one  in  which  there  is  a  persistence  of  the  foetal  state 
in  the  whole  or  in  any  part  of  the  lung. 

Atelectasis  is  the  pathological  condition  with  which  asphyxia  of  the 
newly  born  is  usually  associated.  In  most  of  the  cases  the  condition  of 
atelectasis  is  completely  overcome  by  the  means  employed  in  resuscita- 
tion ;  in  some,  however,  these  means  are  only  partially  successful,  so  that 
a  portion  of  lung  of  variable  extent  remains  in  the  foetal  condition. 
These  are  the  circumstances  in  which  most  of  the  cases  of  atelectasis 
arise.  But  there  are  others  in  which  there  is  no  history  of  early  asphyxia, 
where  the  primary  respirations,  although  taking  place  spontaneously, 
have  not  been  of  sufficient  force  and  depth  to  produce  full  pulmonary  ex- 
pansion. This  usually  occurs  in  feeble  infants,  or  in  those  who  are  prema- 
ture. The  causes  of  congenital  atelectasis  are  therefore,  in  the  main, 
those  mentioned  as  producing  asphyxia. 

Lesions. — In  cases  where  the  child  dies  during  the  first  few  days  the 
amount  of  expanded  lung  is  often  small,  frequently  not  more  than  one 


74  DISEASES  OF  THE   NEWLY   BORN. 

fourth  of  the  pulmonary  area.  The  expanded  portion  is  usually  the  ante- 
rior borders  of  the  upper  lobes.  This  is  often  the  seat  of  acute  emphy- 
sema. The  rest  of  the  lung  is  still  in  the  foetal  state;  it  is  of  a  brown- 
ish-red colour,  very  vascular,  does  not  crepitate,  and  shows  the  lobular 
outlines  both  on  the  surface  and  on  section.  With  a  little  force  the  atelec- 
tatic lung  may  be  completely  inflated. 

If  children  have  lived  a  longer  time,  nearly  the  whole  of  the  upper 
lobes  and  the  anterior  portion  of  the  lower  lobes  are  usually  well  inflated. 
These  portions  are  either  normal  or  slightly  emphysematous.  The  pos- 
terior portion  of  the  upper  lobes  and  the  lower  lobes  are  almost  invariably 
the  seat  of  the  atelectasis.  On  the  surface  even  these  portions  may  pre- 
sent quite  a  large  area  of  expanded  vesicles,  but  the  underlying  portion 
may  be  solid  to  the  touch,  and  crepitates  but  slightly.  On  section  it  is 
seen  that  only  the  most  superficial  part  of  the  lung  is  inflated,  while  the 
interior  of  the  lobe  is  unexpanded.  Small  haemorrhages  are  frequently 
seen  beneath  the  pleura. 

It  is  usual  for  both  lungs  to  be  affected,  and  often,  but  by  no  means 
uniformly,  to  about  the  same  degree.  It  is  frequently  a  great  surprise  to 
discover  that  a  child  has  lived  for  some  weeks  without  presenting  any 
signs  of  cyanosis,  although  using  not  more  than  one-third  of  its  pulmo- 
nary area.  This  variety  of  atelectasis  closely  resembles  the  hypostatic 
pneumonia  of  delicate  infants,  and  very  often  the  two  conditions  are 
associated.  It  may  require  the  microscope  to  decide  between  them.  If  con- 
genital atelectasis  has  existed  for  a  considerable  time,  there  are  usually 
found  evidences  of  pneumonia.  Inflation  is  not  so  easy  as  in  recent  cases, 
but  with  force  the  greater  part  of  the  lung  can  usually  be  expanded.  The 
heart  commonly  shows  the  right  auricle  and  ventricle  to  be  distended  with 
dark  clots,  and  there  is  occasionally  found  a  patent  foramen  ovale  or 
some  other  form  of  congenital  lesion.  The  liver  and  spleen  are  in  most 
cases  congested,  and  the  spleen  may  be  considerably  enlarged.  The  mucous 
membrane  of  the  stomach  and  intestines  is  sometimes  deeply  congested. 

Symptoms. — In  one  group  of  cases  the  children  are  asphyxiated  at 
birth,  but  the  attempts  at  resuscitation  have  been  only  partially  success- 
ful. Although  the  patients  may  live  for  a  few  days,  there  is  cyanosis, 
which  gradually  deepens,  and  death  takes  place  from  asphyxia,  exhaus- 
tion, or  convulsions. 

In  a  second  group  of  cases  the  infants  have  been  asphyxiated  at  birth, 
and  resuscitated  perhaps  with  difficulty,  but  to  all  appearance  completely. 
They  do  not  thrive,  however,  remaining  small  and  delicate,  gaining  very 
little  or  not  at  all  in  weight,  and  showing  poor  circulation,  cold  extremi- 
ties, and  occasionally  subnormal  temperature.  It  is  characteristic  of  these 
cases  that  the  cry  is  never  loud,  strong,  and  lusty.  Some  of  them  will  not 
cry  at  all.  Such  children  may  live  several  weeks.  There  may  develop 
at  any  time,  often  quite  suddenly  and  without  assignable  cause,  attacks 


CONGENITAL  ATELECTASIS.  75 

of  cyanosis  with  prostration.  Children  may  have  several  such  attacks, 
which  do  not  excite  suspicion  since  they  pass  away  spontaneously.  In 
other  cases  the  symptoms  are  so  severe  that  they  may  result  fatally  in  a 
few  hours,  death  being  frequently  preceded  by  convulsions.  If  energet- 
ically treated  the  symptoms  may  pass  away  but,  reappearing  in  a  few 
hours,  or  again  after  a  week  or  more,  they  gradually  deepen  in  intensity 
until  death  occurs. 

Two  cases  that  came  under  my  observation  in  the  New  York  Infant 
Asylum  illustrate  this  point.  The  infants  were  twins,  ten  weeks  old 
and  delicate.  Suddenly  at  night  one  child  was  taken  with  convulsions, 
became  deeply  cyanosed,  and  died  in  two  and  a  half  hours.  It  had  been 
suffering  from  a  slight  attack  of  indigestion  for  a  week  previous.  The 
other  twin  had  been  apparently  well  on  the  previous  day.  Two  hours 
after  the  death  of  the  first  child  the  second  was  taken  with  similar  symp- 
toms, dying  in  a  few  hours.  At  autopsy  I  found  very  extensive  atelec- 
tasis involving  the  posterior  part  of  the  upper  and  the  greater  part  of 
both  lower  lobes.  The  lesions  were  almost  identical  in  the  two  cases. 
In  both,  the  stomach  was  greatly  distended  with  food  and  gas.  I  have 
repeatedly  seen  the  effect  of  overdistention  of  the  stomach  in  producing 
cyanosis  in  young  children,  and  in  this  instance  I  believe  it  to  have  been 
the  exciting  cause  of  the  final  symptoms.  It  was  subsequently  learned 
that  during  the  six  weeks  of  observation  the  nurse  had  witnessed  several 
slight  attacks  of  cyanosis  in  one  of  the  infants.  It  is  of  course  possible 
that  the  atelectasis  in  these  cases  may  have  been  in  part  at  least  acquired. 

I  have  seen  a  number  of  cases,  in  which  there  was  nothing  whatever 
to  attract  attention  to  the  lungs  until  the  final  attack  of  cyanosis  oc- 
curred. In  not  all  of  these  cases  is  there  a  history  of  asphyxia  at  birth. 
Some  are  only  puny,  delicate  or  premature,  exhibiting  during  the  early 
weeks  of  life  all  the  signs  of  feeble  vitality.  The  subsequent  course  is 
the  same  as  in  those  in  which  there  is  early  asphyxia.  The  duration  of 
life  in  these  cases  depends  chiefly  upon  the  extent  of  the  atelectasis. 

It  is  not  to  be  supposed  that  all  cases  of  congenital  atelectasis  ter- 
minate fatally.  Infants  in  whom  there  is  every  reason  to  believe  that 
atelectasis  exists,  from  the  occasional  attacks  during  the  first  few  weeks 
of  cyanosis,  feeble  cry,  poor  circulation,  etc.,  may  under  favourable  con- 
ditions with  improved  nutrition  recover  completely,  even  though  no 
special  treatment  is  directed  to  the  lungs. 

Diagnosis. — The  physical  signs  are  of  much  less  value  than  the  symp- 
toms. It  should  be  remembered  that  the  principal  seat  of  the  disease 
is  the  lower  lobes  posteriorly.  Percussion  usually  gives  resonance  over 
the  entire  chest,  although  this  may  be  somewhat  diminished  posteriorly. 
There  is  not,  however,  so  much  change  as  one  would  expect  to  find,  for 
the  collapsed  areas  are  surrounded  by  others  which  are  overdistended,  and 
there  are  in  the  midst  of  the  collapsed  parts,  especially  upon  the  surface. 


76  DISEASES   OF   THE   NEWLY   BORN. 

lobules  which  are  inflated.  If  the  two  sides  are  involved  to  about  the 
same  degree,  as  is  often  the  case,  we  can  get  no  diiference  in  the  percus- 
sion note  over  the  two  lungs,  and  the  change  from  the  normal  may  be  so 
slight  as  not  to  be  appreciable.  Where  only  one  lung  is  affected  a  differ- 
ence can  usually  be  made  out.  The  respiratory  murmur  is  rarely  bron- 
chial, but  generally  only  feeble  in  its  intensity,  and  rather  ruder  in 
quality  than  normal.  The  cardiac  sounds  may  be  transmitted  with  ab- 
normal intensity.  As  in  the  case  of  percussion,  if  only  one  lung  is 
affected  this  is  of  some  value  in  diagnosis,  but  it  is  not  sufficiently 
marked  to  be  readily  recognised  wlien  both  sides  are  involved.  Occa- 
sionally rales  are  present. 

Treatment.— In  the  newly-born  child,  whether  asphyxiated  or  not, 
the  physician  should  see  to  it  that  the  infant  not  only  cries,  but  does  so 
loudly  and  strongly,  and  that  this  cry  is  repeated  every  day.    If  children 
do  not  cry  naturally  they  must  be  made  to  do  so  by  the  alternate  use  of 
the  hot  and  cold  bath,  as  in  cases  of  asphyxia,  or  by  mechanical  means, 
like  spanking.     This  should  be  repeated  at  least  twice  a  day,  and  con- 
tinued for  from  fifteen  to  thirty  minutes.    It  may  seem  cruel,  but  it  is 
often  the  only  means  of  saving  life.     Expansion  of  the  lungs  is  much 
.  more  easily  induced  during  the  first  few  days  of  life,  becoming  more  and 
more  difficult  tlie  longer  it  is  delayed.    Provided  the  condition  is  recog- 
nised, treatment  is  fairly  successful.     In  institutions  where  delicate  in- 
fants spend  most  of  the  time  in  their  cribs,  atelectasis  is  likely  to  be 
found.    An  infant  needs  exercise,  and  this  is  often  only  to  be  obtained  by 
taking  the  child  from  its  crib  several  times  a  day,  by  general  friction, 
massage,  the  stimulus  of  fresh  air,  etc.     Nothing  is  more  certain  to  per- 
petuate atelectasis  than  to  allow  the  infant  a  life  of  feeble  vegetative 
existence.     Food  and  feeding  must  be  carefully  attended  to,  but  even 
these  are  of  less  importance  than  the  maintenance  of  the  animal  heat. 
The  temperature  is  often  subnormal,  and  should  be  closely  watched.     If 
there  is  difficulty  in  keeping  the  child  warm  it  should  be  rolled  in  cotton 
and  surrounded  by  hot  bottles,  or  kept  in  an  incubator  during  the  first 
few  weeks.     During  attacks  of  cyanosis  the  same  means  are  to  be  em- 
ployed as  in  cases  of  asphyxia  of  the  newly  born — cutaneous  stimulation 
and  artificial  respiration — the  administration  of  drugs  being  of  little  or 
no  value,  but  oxygen  may  be  of  assistance. 


CHAPTER    III. 
ICTERUS. 


Several  varieties  of  icterus  are  met  with  in  the  newly  born. 
1.  It  is  often  seen  in  the  various  forms  of  pyogenic  infection.     In 
such  cases  the  icterus  is  usually  mild. 


ICTERUS.  77 

2.  It  may  be  due  to  congenital  uiairoriuations  ol  Uu;  bile-clucts. 

3.  It  may  depend  upon  interstitial  hepatitis. 

4.  The  most  frequent  of  all  varieties  is  the  so-called  idiopathic 
icterus,  sometimes  spoken  of  as  "  physiological "'  icterus. 

In  the  cases  included  under  the  first  and  second  heads  icterus  is  a 
minor  symptom.  The  other  varieties  are  sufficiently  important  to  re(juire 
separate  consideration. 

Malformations  of  the  Bile-ducts. — The  coumion  Inle-duct  is  tlie  most 
frequently  affected.  There  may  be  atresia  at  the  point  where  it  opens 
into  the  intestine,  the  duct  may  be  represented  by  a  fibrous  cord,  or  it 
may  be  absent  altogether.  In  many  cases  this  is  the  only  lesion;  in 
others  it  is  associated  with  an  impervious  hepatic  or  cystic  duct;  in  still 
others  the  common  duct  is  normal,  but  the  cystic  or  hepatic  ducts  are 
impervious. 

At  autopsy  all  the  organs  are  usually  found  intensely  jaundiced,  par- 
ticularly the  liver.  In  recent  cases  this  is  very  much  swollen,  but  pre- 
sents no  marked  organic  changes.  In  cases  which  have  lasted  several 
months  there  is  commonly  found  chronic  interstitial  hepatitis,  sometimes 
to  a  very  marked  degree.  This  was  present  in  nine  of  the  fifty  cases  col- 
lected by  Thomson.  The  gall-bladder  is  usually  small,  and  often  rudi- 
mentary. In  cases  of  atresia  of  the  common  duct  it  may  be  greatly  dis- 
tended. 

The  condition  of  the  bile-ducts  is  ascribed  to  an  error  in  development 
and  subsequent  catarrhal  inflammation.  There  does  not  seem  to  be  suf- 
ficient evidence  to  prove  that  hereditary  syphilis  is  an  etiological  factor 
of  much  importance.  This  was  present  in  but  five  of  Thomson's 
cases. 

Symptoms. — The  most  striking  symptom  is  jaundice,  which  is  usu- 
ally noticed  a  day  or  two  after  birth,  and  steadily  increases  until  it 
becomes  intense.  The  other  symptoms  of  obstructive  jaundice  are  pres- 
ent. The  urine  is  coloured  a  dark  brown  or  bronze  by  bile  pigment,  the 
stools  are  white,  and  tests  show  bile  pigment  to  be  absent,  except  in  cases 
where  malformation  is  limited  to  the  cystic  duct.  The  liver  as  a  rule 
is  much  enlarged.  The  spleen  is  often  swollen.  Haemorrhages  beneath 
the  skin  or  from  any  of  the  mucous  membranes  are  quite  common.  Vom- 
iting is  usually  absent.  In  most  cases  there  is  progressive  wasting,  and 
death  from  inanition  within  the  first  few  weeks.  Of  Thomson's  fifty 
cases,  nine  lived  less  than  a  month,  and  only  eighteen  over  four  months. 
Lotze  has  reported  a  case  of  a  child  living  eight  months  with  an  imper- 
vious hepatic  duct.  A  frequent  cause  of  death  in  the  more  rapid  cases 
is  convulsions. 

These  malformations  cannot  be  influenced  by  any  treatment. 

Interstitial  Hepatitis. — There  is  seen  in  newly-born  children  a  form 
of  icterus  which  resembles  the  foregoing  in  many  particulars,  but  which 


78  DISEASES  OF  THE   NEWLY   BORN. 

may  end  in  recovery.  In  three  such  cases  which  have  terminated  fatally 
I  have  found  the  lesions  of  a  general  interstitial  hepatitis,  presumably 
of  syphilitic  origin.  It  is  not  certain  that  syphilis  is  always  the  cause  of 
this  condition,  for  the  clinical  history  in  some  of  them  gives  no  evidence 
of  this  disease.  While  not  a  common  condition  I  believe  it  to  be  more 
frequent  than  congenital  malformations  of  the  bile-ducts  with  which  it  is 
often  confounded. 

The  symptoms  and  course  may  be  illustrated  by  the  following  cases: 
A  full-term,  well-developed  child  of  eight  pounds'  weight  became  jaun- 
diced on  the  second  day.  By  the  fifth  day  the  jaundice  was  intense; 
stools,  pale  yellow,  and  urine  deeply  bile-stained.  Examination  at  three 
weeks  showed  both  liver  and  spleen  much  enlarged.  The  jaundice  was 
very  marked  for  over  a  month ;  it  was  nearly  two  months  before  it  faded 
entirely.  The  nutrition  of  the  child  was  a  matter  of  much  difficulty  for 
several  weeks.  The  enlargement  of  the  spleen  and  liver  like  the  jaundice 
disappeared  very  gradually.  There  was  no  other  evidence  of  syphilis  in 
this  patient  nor  in  the  two  other  children  of  the  family,  and  no  history 
of  this  disease  could  be  obtained  in  the  parents.  Yet  the  improvement 
which  began  with  the  use  of  mercurial  inunctions  strongly  suggested  a 
syphilitic  lesion. 

In  another  case,  the  symptoms  and  course  of  which  were  almost 
identical,  the  stools,  though  nearly  white,  never  failed  to  give  the  reac- 
tion for  bile.  A  previous  child  in  this  family  had  died  three  years  before 
at  the  age  of  six  weeks  with  persistent  jaundice,  which  had  been  diag- 
nosticated congenital  malformation  of  the  bile-duct.  There  was  no  his- 
tory of  syphilis;  but  the  mercurial  inunctions  seemed  equally  efficacious 
as  in  the  first  case  cited. 

Not  much  need  be  added  to  the  symptoms  described.  Both  in  those 
recovering  and  in  the  fatal  cases  there  was  no  fever  and  no  ascites ;  but 
there  was  much  tympanites.  The  application  of  the  Wassermann  test 
will  no  doubt  aid  in  clearing  up  the  etiolog}'  of  these  cases.  Other  evi- 
dences of  syphilis  should  always  be  carefully  sought,  but  in  all  the  cases 
I  have  seen,  even  those  ending  fatally  and  with  syphUitic  lesions  at 
autopsy,  clinical  evidence  of  syphilis  during  life  was  wanting.  A  care- 
ful trial  of  antisyphilitic  treatment  should,  therefore,  be  made  in  every 
case  of  protracted  jaundice  in  a  newly-born  child.  One  should  not  be 
too  ready  to  make  the  diagnosis  of  malformation  of  the  bile-ducts  and 
regard  the  case  as  hopeless.  Nor  does  the  fact  that  the  child  recovers 
without  antisyphilitic  treatment  exclude  syphilis  as  the  eause,  for  one  of 
StUPs  cases  recovered  from  the  jaundice  and  died  at  the  age  of  nineteen 
months,  the  autopsy  showing  lesions  evidently  syphilitic. 

Physiological  or  Idiopathic  Icterus.— In  900  consecutive  births  at  the 
Sloane  Maternity  Hospital  icterus  was  noted  in  300  eases  In  88  it  was 
intense,  in  212  it  was  mild.    According  to  the  statistics  of  various  lying- 


ICTERUS.  79 

in  hospitals  of  Germany,  it  was  found  in  from  40  to  80  per  cent,  of  all 
infants.  In  the  300  cases  just  referred  to,  icterus  was  noticed  on  the 
first  day  in  4,  on  the  second  day  in  19,  on  the  third  day  in  72,  on  the 
fourth  day  in  -86,  on  the  fifth  day  in  67,  and  on  or  after  the  sixth  day 
in  44.  From  the  second  to  the  fifth  day  is  therefore  the  usual  period  for 
its  appearance. 

It  usually  increases  in  severity  for  one  or  two  days  and  then  slowly 
disappears.  The  average  duration  in  the  mild  cases  is  three  or  four  days ; 
in  those  of  moderate  severity  about  a  week ;  in  the  most  severe  cases  it 
may  last  for  two  weeks.  The  icterus  is  first  noticed  in  the  skin  of  the 
face  and  chest,  then  in  the  conjunctive^,  then  in  the  extremities.  The 
skin  varies  in  colour  from  a  pale  to  an  intense  yellow.  The  urine  in  most 
cases  is  normal.  It  sometimes  is  of  a  light-brown  colour,  and  only  in  the 
most  severe  cases  does  it  contain  bile  pigment.  According  to  Eunge,  both 
urea  and  uric  acid  are  produced  in  larger  amounts  than  in  children  not 
icteric.  The  stools  are  unchanged,  the  normal  yellow  evacuations  occur- 
ring in  the  icteric  as  early  as  in  those  not  affected. 

According  to  some  observers,  in  infants  who  are  icteric  the  initial  loss 
in  weight  is  greater  and  the  subsequent  gain  slower  than  in  other  chil- 
dren. This  is  not  borne  out  by  the  Sloane  statistics.  Of  the  300  icteric 
children,  155  made  satisfactory  progress  in  every  respect  and  gained  rap- 
idly. The  progress  in  106  cases  was  said  to  be  "  fair  " — i.  e.,  at  the  time 
of  discharge,  usually  on  the  tenth  day,  a  slight  gain  in  weight  was  noted. 
The  remaining  39  did  badly,  not  gaining  in  weight  and  showing  other 
symptoms  of  malnutrition.  The  proportion  of  icteric  infants  who  did 
well,  moderately,  and  badly,  was  practically  the  same  as  of  the  other 
children  in  the  institution  not  suffering  from  icterus.  Icterus  occurs  with 
equal  frequency  in  both  sexes.  According  to  Kehrer,  it  is  more  frequent 
in  first  children  than  in  later  ones,  and  considerably  more  frequent  in 
premature  children  than  in  those  born  at  term.  The  presentation,  the 
duration  of  labour  and  its  character — whether  natural  or  artificial — have 
no  influence  upon  the  production  of  icterus.  As  a  rule  icteric  children 
appear  in  other  respects  healthy,  but  in  those  below  the  average  size  the 
icterus  is  apt  to  be  more  intense. 

Few  subjects  have  given  rise  to  wider  speculation  than  this  form  of 
icterus.  Its  exact  pathology  is  at  present  unknown.  It  is  generally 
held  that  the  icterus  is  due  to  resorption,  and  is  hepatogenous  in  origin. 
The  most  recent  and  reasonable  theory  advanced  is  that  of  Abramow,^ 
who  considers  it  to  be  an  anomaly  of  secretion  of  the  liver  cells;  it  is 
due  to  an  active  secretion  of  bile  which  occurs  soon  after  birth  and  which 
is  poured  out  into  capillary  ducts  obstructed  by  thick  bile  which  is  pres- 
ent at  birth :  from  these  conditions  there  results  an  overflow  of  bile  into 


Knopfelmacher,  Jahrbuch  fur  Kinderheilkunde,  Vol.  17;   1908. 


80  DISEASES  OF  THE  NEWLY  BORN. 

the  lymph  and  blood  vessels,  producing  jaundice.  Usually  the  more 
feeble  the  child  the  more  intense  is  the  icterus. 

In  jaundiced  infants  who  have  died  from  accident  or  other  causes  the 
skin  and  almost  all  the  internal  organs  are  found  icteric.  There  is  also 
staining  of  the  internal  coat  of  the  arteries,  the  endocardium,  the  peri- 
cardium, and  the  pericardial  fluid.  Sometimes  the  subcutaneous  connect- 
ive tissue  is  yellow,  also  the  brain  and  cord ;  the  spleen  and  kidneys  only 
in  the  most  severe  cases.  The  liver  is  rarely  discoloured.  The  bile- 
duets  are  normal. 

This  jaundice  is  never  fatal,  and  in  itself  is  not  serious.  Other 
conditions,  such  as  atelectasis,  may  co-exist,  which  may  make  the  case 
grave. 

Diagnosis  of  the  Different  Varieties  of  Ictenis, — The  diagnosis  of 
physiological  icterus  is  to  be  made  from  sepsis,  malformations  of  the 
bile-ducts,  and  interstitial  hepatitis.  In  sepsis  the  symptoms  usually 
appear  at  a  later  date;  there  is  fever,  rapid  wasting,  and  often  a  dis- 
charge from  the  umbilicus  and  local  symptoms  indicating  peritonitis, 
arthritis,  pneumonia,  or  meningitis.  In  malformations  of  the  bile-ducts 
the  icterus  is  usually  more  intense  and  appears  almost  immediately  after 
birth;  bile  is  absent  from  the  stools;  the  icterus  is  persistent,  and  the 
8}-mptom8  go  progressively  from  bad  to  worse,  always  ending  fatally. 
In  interstitial  hepatitis  the  icterus  develops  at  about  the  same  time  as, 
but  is  generally  more  marked  than,  in  the  pliysiological  variety.  Both 
liver  and  spleen  are  usually  enlarged.  The  stools  may  be  white,  but 
still  give  a  faint  bile  reaction. 

Physiological  icterus  requires  no  treatment. 


CHAPTER    IV. 

THE  ACUTE  INFECTIONS  OF  THE  NEWLY  BORN. 

It  is  possible  for  the  newly-born  infant  to  sutfer  from  almost  all  of 
the  common  infectious  diseases.  Smallpox  probably  has  been  most  fre- 
quently observed.  In  rare  instances,  influenza,  typhoid  fever,  malaria, 
and  pneumonia  have  occurred  in  the  first  days  of  life.  As  the  mothers 
in  many  instances  were  suffering  from  the  diseases  during  or  just  prior 
to  delivery,  the  infants  appear  to  have  been  infected  before  birth  through 
the  circulation  of  the  mother.  In  other  cases,  especially  in  pneumonia, 
influenza,  and  gastro-enteritis,  infection  may  take  place  soon  after  birth. 
The  symptoms  of  these  diseases  in  the  newly  born  differ  very  little  from 
those  occurring  in  any  other  young  infant.  In  addition  to  the  diseases 
mentioned,  there  are  other  forms  of  infection  which  belong  especially 
— some  of  them  exclusively—  to  the  newly  born. 


THE  ACUTE  PYOGENIC   DISEASES.  81 

THE  ACUTE  PYOGENIC  DISEASES. 

Under  this  head  are  grouped  various  infections  of  the  newly  born, 
due  to  the  entrance  of  the  common  pyogenic  bacteria.  They  have  been 
designated  as  puerperal  fever  of  the  child,  also  as  pycemia  or  septicemia, 
or  simply  as  sepsis  of  the  newly  horn.  A  variety  of  pathological  and 
clinical  conditions  are  met  with.  In  some  cases  there  is  only  a  localised 
external  inflammation,  often  terminating  in  abscess  formation;  some- 
times one  or  more  of  the  internal  organs  is  affected ;  occasionally  a 
general  blood  infection — a  true  septicaemia — is  seen  without  any  note- 
worthy local  lesion;  finally,  there  are  the  cases  attended  by  the  pro- 
duction of  multiple  abscesses  in  the  viscera,  joints,  or  cellular  tissue 
— a  true  pyaemia.  Formerly  infections  of  this  class  were  very  com- 
mon, especially  in  large  lying-in  hospitals;  but,  owing  to  the  general 
adoption  of  the  metliods  of  aseptic  midwifery,  tliey  have  steadily  dimin- 
ished. 

Etiology. — The  source  of  infection  of  the  child  may  be  the  vaginal 
secretion  of  the  mother  or,  in  rare  cases,  the  mother's  milk.  Although 
it  has  been  shown  that  in  a  great  proportion  of  the  cases  the  milk  of  a 
woman  suffering  from  mastitis  or  from  septictemia  contains  pyogenic 
germs,  still  the  taking  of  these  into  the  stomach  is  not  likely  to  infect 
the  infant.  More  frequently  the  child  is  infected  by  the  nurse  in  the 
process  of  dressing  the  cord,  bathing,  or  cleansing  the  mouth  or  eyes, 
possibly  after  having  attended  to  the  needs  of  a  septic  mother  or  another 
child.  Infection  may  be  carried  by  the  physician,  by  instruments,  or  by 
the  dressings  of  the  cord.  Infection  may  occur  through  any  wound  or 
abrasion  of  the  skin. 

Infection  through  the  umbilicus  may  take  place  either  before  or  after 
the  separation  of  the  cord.  The  infection  may  take  place  through  the 
umbilicus,  yet  this  may  give  no  external  evidence  of  disease,  although 
the  umbilical  vessels  inside  the  body  may  contain  pus.  From  this  focus 
of  infection  may  arise  peritonitis,  meningitis,  or  other  inflammations. 
Entering  through  the  mouth,  bacteria  may  lead  to  infectious  processes 
in  the  throat,  the  stomach  or  intestines,  and  rapidly  produce  death;  or 
the  alimentary  tract  may  be  the  focus  from  which  infection  of  distant 
parts  may  arise. 

The  micro-organisms  chiefly  concerned  in  these  infections  are  the 
common  pyogenic  bacteria,  staphylococcus  pyogenes  aureus  and  the  strep- 
tococcus. The  next  in  importance  is  the  gonococcus,  the  role  of  which, 
especially  in  cases  accompanied  by  joint  suppuration,  has  only  recently 
been  appreciated.  Pneumococcus  infections  occasionally  complicate  the 
others  mentioned.  While  streptococcus  infections  are  in  general  more 
serious  than  those  due  to  the  staphylococcus,  some  of  the  most  severe 
ones  met  with  belong  to  the  latter  class. 
7 


82  DISEASES  OF  THE   NEWLY   BORN. 

Clinical  Varieties. — Omphalitis. — In  this  variety  there  is  inflamma- 
tion of  the  umbilicus,  and  cellulitis  of  the  abdominal  wall  in  the  im- 
mediate neighbourhood.  This  results  in  the  formation  of  an  umbilical 
phlegmon.  It  may  terminate  in  resolution,  in  abscess,  or  in  gangrene. 
The  usual  termination  is  in  abscess.  These  abscesses  may  be  small  and 
superficial,  or  they  may  be  more  deeply  seated  between  the  abdominal 
muscles  and  the  peritonaeum.  Omphalitis  usually  begins  in  the  second 
or  third  week  of  life,  before  the  umbilicus  has  cicatrised.  The  process 
may  result  in  erysipelatous  inflammation  and  it  may  spread  to  the  peri- 
tonaeum. 

Inflammation  of  the  Umhilical  Vessels. — This  is  one  of  the  most 
frequent  primary  processes  in  pyaemic  infection.  The  umbilical  arteries 
are  more  frequently  involved  than  the  vein.  According  to  Runge,  in- 
flammation of  the  vessels  is  always  preceded  by  inflammation  of  the 
connective  tissue  which  surrounds  them,  as  the  poison  is  taken  up  by  the 
lymphatics  and  not  by  the  blood-vessels.  Omphalitis  is  frequently  pres- 
ent, but  in  some  cases  the  umbilicus  shows  nothing  abnormal. 

In  arteritis  the  vessels  may  be  involved  to  any  degree:  sometimes 
only  a  short  distance  from  the  abdominal  wall,  sometimes  quite  to  the 
bladder.  They  contain  pus,  and  often  septic  thrombi.  Saccular  dilata- 
tion is  frequently  present  at  several  points.  Pus  sometimes  exudes  from 
the  umbilical  stump  on  pressure.  The  other  lesions  accompanying 
arteritis  are  those  of  pyaemic  infection,  more  or  less  widely  distributed. 
There  are  frequently  peritonitis,  suppuration  of  the  joints,  erysipelas, 
multiple  abscesses  of  the  cellular  tissue,  sometimes  suppurative  parotitis. 
Atelectasis  is  common.  Pneumonia  was  found  in  twenty-two  of  Runge's 
fifty-five  cases. 

In  cases  of  phlebitis,  the  umbilical  vein  is  usually  involved  for  its 
entire  length  from  the  abdominal  wall  to  the  liver.  This  may  lead  to 
an  acute  interstitial  hepatitis  going  on  to  suppuration,  or  to  phlebitis 
of  the  portal  vein  and  some  of  its  branches.  In  either  case  there  is 
more  or  less  parenchymatous  hepatitis,  and  often  multiple  abscesses  of 
the  liver,  most  of  the  patients  being  jaundiced.  Peritonitis  also  is  a  fre- 
quent complication. 

Peritonitis. — This  is  one  of  the  most  frequent  pathological  processes 
in  pyaemic  infection,  and  is  very  often  the  cause  of  death.  It  is  generally 
associated  with  umbilical  arteritis,  and  often  with  erysipelas.  In  a 
considerable  number  of  cases  it  is  the  most  important  lesion  found. 
It  may  be  localised  or  general.  Localised  peritonitis  is  generally  in 
the  neighbourhood  of  the  umbilicus  or  of  the  liver.  It  may  result  in 
adhesions,  or  in  the  formation  of  peritoneal  abscesses.  More  frequently 
the  peritonitis  is  general,  and  resembles  the  septic  peritonitis  of  adults. 
There  is  a  great  outpouring  of  fibrin  coating  the  intestines  and  other 
viscera  and  the  inner  surface  of  the  abdominal  wall,  causing  adhesions 


THE  ACUTE   PYOGENIC   DISEASES.  83 

between  the  abdominal  contents.  Collections  of  sero-pus  are  found  in 
the  pelvis  and  in  various  pockets  formed  by  the  adhesions.  Sometimes 
blood  is  present  in  the  exudation. 

The  special  symptoms  which  indicate  peritonitis  are  vomiting,  ab- 
dominal tenderness  and  distention,  and  protrusion  of  the  umbilicus. 
The  abdominal  enlargement  is  chiefly  from  gas,  l)ut  may  be  partly  from 
fluid.  There  are  present  thoracic  respiration,  dorsal  decubitus,  flexion 
of  the  thighs  and  fixation  of  all  the  muscles,  tlie  child  lying  perfectly 
quiet.  The  temperature  is  usually  but  not  necessarily  high.  Marked 
leucocytosis  is  generally  present. 

Pneumonia. — The  most  common  form  seen  is  pleuro-pneumonia. 
There  is  an  abundant  exudate  of  grayish-yellow  fibrin  covering  the 
lung.  Occasionally  collections  of  pus  are  found  in  the  sacs  formed  by 
the  adhesions.  Serous  effusions  are  rare.  Tlie  pulmonary  lesion  consists 
usually  in  a  broncho-pneumonia,  with  consolidation  of  larger  or  smaller 
area§  in  the  lungs — more  often  in  the  upper  than  in  the  lower  lobes. 
It  is  not  uncommon  for  minute  abscesses  to  be  found  in  the  lung  at 
various  points.  There  is  a  purulent  bronchitis  of  the  larger  and  smaller 
tubes. 

The  symptoms  are  obscure  and  often  indefinite.  The  only  character- 
istic ones  are  cyanosis  and  rapid  respiration,  with  recession  of  the  chest 
walls  on  inspiration.  The  physical  signs  are  inconstant  and  uncertain. 
Pneumonia  often  cannot  be  diagnosticated  during  life.  In  most  of  the 
fatal  cases  of  pyogenic  infection,  whatever  its  type,  there  is  found  some 
involvement  of  the  lungs.  The  changes  are  most  extensive  in  cases  in 
which  the  serous  membranes  are  involved. 

Pericarditis  is  rare  and  usually  associated  with  pleurisy.  Endocar- 
ditis is  very  rare.     Hirst  has,  however,  reported  a  case. 

Meningitis. — When  meningitis  is  present  it  is  usually  associated  with 
peritonitis  or  with  pleurisy.  The  lesions  are  those  of  acute  purulent 
meningitis  with  a  copious  exudation,  sometimes  associated  with  menin- 
geal hemorrhages,  or  with  acute  encephalitis  and  the  production  of 
multiple  minute  abscesses  in  the  cortex.  The  local  symptoms  are  often 
not  marked,  and  are  sometimes  very  obscure.  The  most  characteristic 
are  stupor,  dilated  pupils,  opisthotonus,  bulging  fontanel,  general  rigid- 
ity, convulsions,  and  occasionally  localised  paralyses.  The  temperature 
is  generally  high.  A  positive  diagnosis  can  generally  be  made  by  lumbar 
puncture,  by  which  means  also  the  exciting  cause  of  the  meningitis  can 
usually  be  determined. 

Gastro-enteritis. — Diarrhoea  is  a  frequent  symptom  in  all  septic  cases, 
constipation  being  rarely  present.  In  many  instances  vomiting  is  a 
prominent  symptom.  In  a  small  proportion  of  cases  the  most  important 
local  lesions  are  in  the  intestines,  generally  in  the  nature  of  a  superficial 
catarrhal  inflajnujation. 


84  DISEASES  OF  THE   NEWLY   BORN. 

Stomatitis. — Infections  of  the  oral  mucous  membranes  are  not  in- 
frequent but  sometimes  very  severe.  They  may  be  due  to  the  strepto- 
coccus, staphylococcus  aureus  or  the  gonococcus.  An  occasional  compli- 
cation of  oral  infections  is  abscess  of  the  parotid. 

Osteomyelitis. — Allard  has  reported  a  series  of  cases  in  which,  after 
the  general  and  local  symptoms  of  pyogenic  infection  had  existed  for 
some  time,  suppuration  occurred  over  various  bones,  especially  the 
humerus,  tibia,  metatarsal  bones,  sacrum,  etc.  Trephining  revealed  the 
lesions  of  osteomyelitis.  The  abscesses  usually  made  their  appearance 
between  the  fourth  and  the  sixth  week.  The  most  rapid  case  died 
on  the  fourteenth  day,  and  none  lasted  more  than  two  and  a  half 
months. 

Joint  Suppuration. — In  certain  pyaemic  cases,  and  in  some  in  which 
there  are  no  other  symptoms,  acute  suppuration  in  the  joints  occurs. 
This  may  come  on  very  acutely  in  the  first  or  second  week,  or  more 
slowly  as  late  as  the  second  or  third  month.  In  the  acute  cases, it  is 
exceptional  to  have  but  one  joint  involved;  frequently  there  are  four  or 
five.  The  small  joints  are  rather  oftener  affected  than  the  large  ones, 
but  almost  any  articulation  in  the  body  may  be  involved.  With  multi- 
ple joint  suppuration  there  are  present  the  general  symptoms  of  pyaemia 
— high  temperature,  marked  prostration,  wasting,  and  usually  secondary 
visceral  inflammations  develop.  In  those  which  occur  late,  or  which 
develop  more  slowly,  fewer  joints  are  involved,  often  but  a  single  one, 
the  febrile  symptoms  are  less  marked  or  wanting.  In  my  own  experience, 
the  organism  most  frequently  found  in  these  cases  is  the  gonococcus; 
next  to  this  in  importance  is  the  streptococcus  and  occasionally  the 
pneumococcus  is  found.  The  joint  lesion  is  usually  a  superficial  one, 
the  bones  generally  escaping.  The  gonococcus  cases  probably  occur  most 
frequently  as  a  complication  of  ophthalmia;  but  I  have  seen  several  in 
which  ophthalmia  was  not  present  and  where  the  point  of  entry  could 
not  be  determined. 

Many  of  the  abscesses  supposed  to  be  in  the  joints  are  shown  at  opera- 
tion to  be  at  the  epiphyses;  from  this  source  the  joints  may  be  involved 
secondarily.  A  point  to  be  remembered  in  the  diagnosis  of  these  joint 
inflammations  is  their  resemblance  to  the  epiphysitis  of  hereditary  syph- 
ilis and  other  symptoms  of  that  disease  should  be  looked  for.  The  con- 
fusion is  increased  by  the  fact  that  in  syphilitic  cases  abscesses  may 
follow  as  a  consequence  of  a  secondary  infection. 

Abscesses  in  the  Cellular  Tissue. — These  are  quite  frequent,  and  may 
occur  with  suppuration  in  the  joints  or  internal  organs,  or  they  may 
exist  as  the  only  lesion.  They  are  nearly  always  multiple  and  may  be 
found  in  almost  any  location.  They  vary  in  size  from  that  of  a  small 
pea  to  one  containing  half  an  ounce  of  pus.  They  are  due  to  the  intro- 
duction of  pyogenic  germs,  usually  staphylococci.    Their  course  is  benign. 


THE  ACUTE  PYOGENIC   DISEASES.  85 

and  they  require  no  treatment  except  incision  and  cleanliness.  Wlien 
there  is  a  disposition  to  their  cqntinued  formation,  the  skin  should  be 
washed  with  an  antiseptic  solution. 

Erysipelas. — This  is  seen  especially  during  the  first  two  weeks  of 
life,  and  usually  starts  from  the  umbilicus  or  some  abrasion  of  the  skin, 
most  frequently  about  the  genitals  or  the  scalp.  When  originating  at 
the  umbilicus  it  is  generally  complicated  by  other  lesions,  such  as  peri- 
tonitis and  umbilical  phlebitis.  If  it  starts  from  any  other  part  of  the 
body  it  may  be  uncomplicated.  Erysipelas  beginning  at  the  umbilicus 
gives  rise  to  an  area  of  induration  and  a  circumscribed  erythema.  At 
first  it  may  resemble  a  simple  cellulitis ;  but  the  steadily  increasing  area 
of  elevated  induration  and  redness  soon  indicates  the  nature  of  the  in- 
flammation. From  whatever  point  starting,  the  erysipelatous  inflam- 
mation, owing  to  the  feeble  resistance  of  the  tissues,  in  most  cases 
spreads  widely.  The  entire  abdomen,  chest,  and  back  may  be  involved, 
and  it  may  even  spread  to  the  extremities.  Nearly  the  whole  trunk  may 
be  affected  in  four  or  five  days.  It  usually  involves  only  the  skin  and 
superficial  cellular  tissue;  but  it  may  involve  the  deeper  areolar  planes 
and  terminate  in  diffuse  suppuration,  or  even  in  gangrene. 

The  ^constitutional  symptoms  are  severe :  great  prostration,  continu- 
ously high  temperature — 102°  to  105°  F. — rapid  wasting,  and  frequently 
vomiting,  diarrhoea,  or  convulsions  are  present.  The  disease  is  always 
serious,  and  usually  fatal.  It  is  often  complicated  by  broncho-pneu- 
monia. General  oedema  of  the  affected  parts  may  persist  for  a  few  weeks 
after  the  inflammation  subsides. 

Distribution  of  the  Lesions. — The  frequency  of  the  different  visceral 
lesions  in  eighty-seven  autopsies  published  by  Bednar  was  as  follows: 
Peritonitis  in  twenty-nine,  pneumonia  in  fifteen,  pleurisy  in  ten,  menin- 
gitis in  nine,  meningeal  haemorrhage  in  eight,  encephalitis  in  eight,  cere- 
bral haemorrhage  in  four,  entero-colitis  in  five,  pericarditis  in  four.  In 
thirty-one  cases  there  was  umbilical  arteritis,  and  in  nine  cases  umbilical 
phlebitis.  There  was  one  case  each  of  pulmonary  haemorrhage,  pleural 
haemorrhage,  acute  hydrocephalus,  acute  bronchitis,  and  suppuration  in 
the  cellular  tissue.  Runge's  later  observations  of  thirty-six  cases  showed 
umbilical  arteritis  in  thirty,  umbilical  phlebitis  in  three,  and  normal 
umbilicus  in  three.  He  found  pneumonia  in  twenty-two  of  fifty-five 
cases.  Other  lesions  frequently  associated  are  atelectasis,  swelling  and 
softening  of  the  spleen,  cloudy  swelling  of  the  liver  and  kidneys,  occa- 
sionally with  foci  of  suppuration  in  these  organs. 

General  Symptoms. — These  may  begin  at  any  time  during  the  first 
ten  days — very  rarely  after  the  twelfth  day.  Fever  is  an  exceedingly 
variable  symptom — it  may  be  very  high;  it  may  be  almost  absent;  oc- 
casionally there  is  subnormal  temperature.  The  course  of  the  tempera- 
ture is  very  irregular.    Wasting  is  constant  and  quite  rapid.    It  depends 


86  DISEASES  OF  THE  NEWLY  BORN. 

Upon  the  inability  to  take  and  digest  food,  upon  the  intestinal  complica- 
tions, and  upon  infection.  In  quite  a  number  of  cases  wasting  is  almost 
the  only  symptom.  Icterus  is  common;  in  many  of  the  worst  cases  it 
is  intense.  It  is  met  with  where  the  liver  is  the  seat  of  an  acute  paren- 
chymatous or  acute  suppurative  inflammation,  and  in  many  other  cases 
where  it  depends  apparently  upon  the  blood  changes.  Haemorrhages 
are  common,  and  may  be  the  direct  cause  of  death.  They  may  come 
from  the  umbilicus,  the  intestine,  or  almost  any  mucous  membrane. 
They  are  sometimes  subcutaneous,  causing  a  general  haemorrhagic  erup- 
tion. Nervous  symptoms  are  generally  present,  and  are  sometimes 
marked.  They  are  restlessness,  rolling  of  the  head,  a  constant  whining 
cry,  twitchings  of  the  muscles  of  the  extremities  or  face,  stiffening  of 
the  body,  more  rarely  general  convulsions.  Late  in  the  disease,  dulness 
and  stupor  are  present.  The  pulse  is  rapid  and  weak  and  the  respirations 
are  often  irregular,  even  when  there  is  no  cerebral  complication.  Diar- 
rhoea is  frequent;  the  stools  are  green,  brown,  sometimes  black  from 
the  presence  of  blood,  and  are  often  very  foul.  Vomiting  is  less  com- 
mon. In  addition  to  these  there  are  symptoms  due  to  the  various  forms 
of  local  inflammation — peritonitis,  meningitis,  pneumonia,  erysipelas, 
subcutaneous  suppuration  and  gangrene,  these  all  being  found  in  vary- 
ing degrees  and  in  various  combinations. 

Prophylaxis. — Pyogenic  infection  of  the  child,  like  puerperal  fever  in 
the  mother,  may  be  considered  a  preventable  disease.  Its  occurrence  is 
usually  due  to  a  failure  to  carry  out  proper  rules  regarding  cleanliness 
and  asepsis  in  connection  with  delivery.  The  statistics  of  the  Moscow 
Lying-in  Asylum,  published  by  Miller  in  1888,  show  that  previous  to 
the  general  introduction  of  aseptic  methods,  from  six  to  eight  per  cent 
of  all  infants  born  in  the  institution  died  from  some  variety  of  infection. 
In  twenty-three  hundred  successive  labours  at  the  Sloane  Maternity 
Hospital,  covering  about  eight  years,  not  a  single  marked  case  occurred. 
From  these  figures  it  will  be  evident  that  in  the  vast  majority  of  cases 
the  occurrence  of  a  case  of  infection  of  a  serious  nature  is  the  fault  of 
the  physician  or  nurse  in  attendance. 

The  umbilicus  should  be  cleansed  and  treated  like  any  other  fresh 
wound.  Dry  dressing  should  invariably  be  employed,  and  sterilised 
gauze  or  salicylated  cotton  in  preference  to  household  linen.  If  suppu- 
ration occurs  at  the  time  the  cord  separates,  the  parts  should  be  cleansed 
daily  with  a  bichloride  solution,  and  a  wet  dressing  of  the  same  applied. 
The  ligatures  and  everything  which  comes  in  contact  with  the  umbilical 
wound  should  be  sterilised.  Careful  attention  should  be  given  to  the 
mouth,  genitals,  and  all  the  muco-cutaneous  surfaces,  to  prevent  excoria- 
tions and  intertrigo.  Finally,  every  septic  case  occurring  in  an  insti- 
tution should  be  immediately  isolated.  A  nurse  in  charge  of  a  septic 
mother  should  not  have  the  care  of  the  infant. 


OPHTHALMIA.  87 

Prognosis. — Pyogenic  infections  in  tlie  newly  born,  even  in  their 
mildest  forms,  are  serious,  and  iij  their  most  severe  forms  almost  always 
fatal.  Very  few  cases  recover  in  which  erysipelas  or  any  important 
visceral  inflammation  is  present.  The  resistance  of  these  patients  is  so 
feeble  that  the  tendency  of  every  inflammation  is  to  spread,  until  they 
die  from  exhaustion.  Only  patients  with  localised  inflammations,  such 
as  those  of  Joints,  skin,  etc.,  are  likely  to  get  well. 

Treatment. — This  practically  resolves  itself  into  the  treatment  of  in- 
dividual symptoms  as  they  arise.  Wherever  suppuration  occurs,  external 
abscesses  should  be  evacuated  and  treated  antiseptically.  For  the  local 
inflammations  of  the  lungs,  peritonaeum,  and  brain,  little  or  nothing  can 
be  done  in  the  way  of  direct  treatment.  Such  inflammations  are  to  be 
prevented,  but  can  seldom  be  cured.  The  general  indications  are  to  look 
closely  to  the  child's  general  nutrition  by  careful  attention  to  all  details 
of  nursing  and  feeding,  using  stimulants  whenever  required  by  the  con- 
dition of  the  pulse.  For  a  local  application  in  erysipelas,  nothing  in  my 
experience  has"  proven  better  than  ichthyol  ointment,  ten  to  twenty-five 
per  cent-  strength.  It  should  be  applied  daily,  spread  upon  muslin, 
which  is  then  covered  by  gutta-percha  tissue  to  prevent  drying.  In  a 
disease  so  fatal  as  erysipelas,  by  ordinary  treatment,  vaccines  should 
certainly  be  tried.  In  some  cases  they  seem  to  have  been  of  undoubted 
value. 

OPHTHALMIA. 

Ophthalmia  of  the  newly  born  is  to  be  classed  among  the  pyogenic 
diseases.  It  usually  consists  in  a  purulent  conjunctivitis.  In  the  more 
severe  cases  there  may  be  ulceration  of  the  cornea,  and  even  perforation 
into  the  anterior  chamber  of  the  eye. 

The  highly  infectious  nature  of  this  ophthalmia  is  established.  In 
the  most  severe  cases  the  micro-organism  generally  found  has  been  the 
gonococcus;  but  in  the  milder  forms  the  gonococcus  may  be  absent,  and 
any  of  the  common  pyogenic  germs  may  be  found.  In  the  gonococcus 
cases  the  infection  occurs  during  labour,  from  the  secretions  of  the 
mother,  from  the  examining  fingers  of  the  physician,  or  from  instru- 
ments; or  after  birth  from  infected  cloths  and  other  materials  which 
come  in  contact  with  the  eye.  Healthy  lochia  produce  only  a  catarrhal 
inflammation.  The  infection  occurring  after  birth  may  take  place  at 
any  time.  That  due  to  gonococcus  infection  from  the  mother  is 
generally  manifested  on  the  third  day,  and  is  often  virulent  from  the 
outset. 

The  symptoms  are  swelling  of  the  lids,  chemosis,  copious  purulent 
discharge,  sometimes  haemorrhages  from  the  lids,  ulceration,  and  there 
may  even  be  sloughing  of  the  cornea.  The  course  of  the  disease  depends 
upon  the  cause  and  upon  the  treatment  employed.     In  the  cases  not 


88  DISEASES  OF  THE   NEWLY  BORN. 

due  to  the  gonococcus  the  course  is  generally  benign,  and  with  ordinary 
cleanliness  usually  results  in  recovery  without  any  permanent  damage 
to  the  sight.  The  gonococcus  cases,  unless  energetically  treated  from 
the  outset,  are  very  frequently  followed  by  permanent  loss  of  vision.  The 
best  statistics  upon  the  causes  of  blindness  in  adults  show  that  from 
twenty-six  to  thirty  per  cent  of  such  cases  are  due  to  ophthalmia  in 
the  newly  born.  This  disease  is  occasionally  complicated  by  other  symp- 
toms of  gonococcus  infection  of  a  pyaemic  nature.  Many  cases  followed 
by  acute  articular  symptoms  have  been  observed. 

Prophylaxis  is  of  the  utmost  importance.  Crede's  statistics  show  that 
in  1874  the  frequency  of  ophthalmia  in  his  lying-in  hospital  was  13.6 
per  cent.  In  the  three  years  ending  1883,  among  1,160  newly-born 
children  only  one  or  two  cases  occurred.  The  method  of  prophylaxis 
which  he  adopted  consists  in  dropping  into  the  eyes  of  every  child,  im- 
mediately after  birth,  one  or  two  drops  of  a  two-per-cent  solution  of 
nitrate  of  silver.  The  general  adoption  of  Crede's  method,  or  of  some 
similar  means  of  disinfection,  has  resulted  in  a  very  great  diminution  in 
the  frequency  of  ophthalmia  throughout  the  world.  These  prophylactic 
means  should  be  obligatory  in  all  institutions,  and  should  be  used  in 
all  cases  in  private  practice  wherever  there  is  any  possible  suspicion  of 
the  existence  of  gonorrhoea.  In  all  other  cases  the  eyes  should  be  care- 
fully cleansed  with  a  saturated  solution  of  boric  acid.  The  use  before 
delivery  of  an  antiseptic  vaginal  douche  is  theoretically  indicated,  but 
practically  it  has  been  found  to  be  inadequate  for  the  prevention  of  the 
disease. 

Treatment. — Everything  which  comes  in  contact  with  the  eyes  should 
be  carefully  disinfected.  All  cloths,  cotton,  etc.,  used  for  cleansing 
should  be  immediately  burned.  The  strictest  antiseptic  precautions 
should  be  insisted  on  to  prevent  the  spread  of  the  infection  by  nurses. 
In  institutions  containing  infants,  severe  cases  of  ophthalmia  should 
always  be  isolated.  The  most  important  thing  is  to  keep  the  eyes  clean. 
In  severe  cases  they  must  be  cleansed  every  twenty  minutes,  night  and 
day.  It  may  be  done  by  irrigation,  or  by  using  an  eye-dropper  with  a 
bulbous  tip,  inserted  alternately  at  the  inner  and  the  outer  angle  of 
the  eye,  and  the  fluid  injected  with  force  sufficient  to  empty  thoroughly 
the  conjunctival  sac.  Either  a  saturated  solution  of  boric  acid,  or  a 
1-5,000  solution  of  bichloride,  may  be  used  in  this  way.  Once  or  twice 
in  twenty-four  hours  two  or  three  drops  of  a  ten-per-cent  solution  of 
argyrol  should  be  used  in  each  eye  after  cleansing  with  sterile  water. 
Next  to  these  measures  is  the  use  of  cold.  It  may  be  applied  as  ice 
compresses  which  are  changed  every  minute  or  two  from  a  block  of  ice 
to  the  eye.  These  may  be  continued  one-fourth  of  the  time  in  the  milder 
cases ;  in  the  severe  ones  almost  constantly.  When  the  cornea  is  involved 
the  pupil  should  be  dilated  by  atropine.    If  only  one  eye  is  affected  the 


TETANUS.  89 

sound  one  should  be  protected  by  covering  it  with  a  compress  kept  wet 
with  an  antiseptic  solution. 

TETANUS. 

Tetanus  is  an  acute  infectious  disease  characterised  by  tonic  muscular 
spasm,  which  increases  in  severity  by  paroxysms  occurring  at  longer  or 
shorter  intervals.  It  may  be  limited  to  the  muscles  of  the  jaw  (trismus), 
or  may  affect  all  the  muscles  of  the  trunk,  extremities,  and  neck. 

The  germ  of  tetanus  usually  gains  access  to  the  body  of  the  infant 
through  the  umbilical  wound.  It  exists  in  the  soil,  and  the  disease 
prevails  endemically  in  certain  localities.  It  is  common  in  certain  parts 
of  Long  Island  and  New  Jersey.  Among  the  negroes  in  some  parts  of 
the  South  it  has  for  many  years  occurred  with  great  frequency.  It  is 
stated  that  on  one  of  the  islands  of  the  Hebrides  every  fourth  or  fifth 
child  dies  of  tetanus.  In  a  smgle  house  in  Copenhagen  eighteen  cases 
were  observed.  Tetanus  presents  no  essential  lesions.  It  is  rare  except 
where  dirt  and  filth  prevail ;  but  these  alone  are  not  sufficient  to  produce 
the  disease.    It  is  rare  in  the  tenements  of  New  York. 

Symptoms. — These,  as  a  rule,  begin  on  the  fifth  or  sixth  day,  or  at 
the  time  of  the  separation  of  the  cord.  The  first  symptoms  may  not 
appear  until  the  tenth  or  twelfth  day,  but  rarely  later  than  this.  Gen- 
erally the  first  thing  noticed  is  difficulty  in  nursing,  which,  on  examina- 
tion, is  found  to  be  due  to  rigidity  of  the  jaws  (trismus).  Nursing  may 
be  impossible  on  this  account.  The  muscles  of  the  jaw  feel  hard,  the  lips 
pout,  and  all  the  muscles  of  the  face  seem  firm.  Soon  a  slight  stiffening 
of  the  body  occurs,  the  child  straightening  the  back  as  it  lies  upon  the 
lap  and  continuing  rigid  for  a  moment  or  two.  In  the  interval  it  is  at 
first  completely  relaxed.  These  paroxysms  soon  increase  in  frequency 
until  they  may  come  on  every  few  minutes,  being  excited  by  any  move- 
ment of  the  hody.  The  relaxation  is  then  only  partial,  and  the  neck  and 
extremities  and  sometimes  nearly  the  whole  body  may  become  rigid  and 
stiff  as  a  piece  of  wood.  The  arms  are  extended,  the  thumbs  adducted, 
and  the  hands  clenched.  The  thighs  and  legs  are  extended,  and  no 
motion  is  possible  at  the  hip  or  knee.  The  jaws  can  be  separated  slightly 
or  not  at  all.  The  firm  contractions  of  the  facial  muscles  give  a  peculiar 
expression  to  the  features.  There  is  a  low,  whining  cry.  Swallowing  is 
difficult,  sometimes  impossible.  The  pulse  is  rapid  and  soon  becomes 
weak.  The  temperature  at  first  is  normal,  but  in  the  most  acute  cases 
rises  rapidly  to  104°  or  even  106°  F. ;  in  the  milder  cases  it  does  not  go 
above  101°  F. 

Death  is  due  to  exhaustion,  to  fixation  of  the  respiratory  muscles,  or 
to  spasm  of  the  larynx.  In  the  less  severe  cases  all  the  symptoms  are 
milder,  and  there  may  be  intervals  in  which  the  rigidity  is  scarcely  no- 
ticeable, so  that  respiration  and  deglutition  may  be  carried  on  for  some 


90  DISEASES  OF  THE  NEWLY  BORN. 

time.  In  cases  which  terminate  in  recovery  the  temperature  is  but 
slightly  elevated.  The  tonic  contractions  gradually  become  less  severe, 
and  the  paroxysms  less  frequent.  The  children  usually  suffer  for  sev- 
eral weeks  from  the  general  symptoms  of  malnutrition,  Avhich  are  pro- 
portionate to  the  severity  of  the  attack.  Of  eighty-eight  fatal  cases 
which  are  reported  by  Stadtfeldt  all  but  five  died  between  the  ages  of 
six  and  ten  days.  The  duration  of  the  disease  in  the  fatal  cases  is  seldom 
more  than  forty-eight  hours,  often  less  than  twenty-four  hours;  in 
those  terminating  in  recovery,  between  one  and  three  weeks. 

Frogfnosis. — Few  diseases  of  infancy  are  more  fatal  than  tetanus. 
Where  it  prevails  endemically  it  is  regarded  by  the  laity  as  so  uniformly 
fatal  that  usually  no  physician  is  called.  Scattered  through  medical  lit- 
erature are  quite  a  large  number  of  isolated  cases  in  which  recovery  has 
occurred.  At  the  present  time  the  proportion  of  fatal  cases  is  probably  be- 
tween ninety  and  ninety-five  per  cent.  Sporadic  cases  more  frequently 
recover  than  those  occurring  in  districts  where  the  disease  is  endemic. 
The  later  the  development  of  the  symptoms,  the  slower  their  course,  and 
the  lower  the  temperature  the  more  likely  is  the  case  to  recover. 

Prophylaxis. — A  proper  understanding  of  the  nature  of  the  disease 
has  brought  with  it  the  means  of  rational  prevention.  The  first  essen- 
tial is  obstetrical  cleanliness,  which  must  include  scissors,  hands,  dress- 
ings, ligatures — in  short,  everything  which  comes  in  contact  with  the 
umbilical  wound.  In  districts  where  tetanus  is  endemic,  thorough  asep- 
tic treatment  of  the  umbilicus  should  be  insisted  upon,  both  at  the  first 
dressing  and  later,  particularly  at  the  time  of  the  separation  of  the  cord. 

Treatment. — All  drugs  whose  physiological  action  is  that  of  motor 
depressants  of  the  spinal  cord  have  a  certain  amount  of  value  in  tetanus. 
The  most  important  ones  are  chloral  and  the  bromides.  Nearly  all  the 
reported  cures  have  been  by  one  of  these  drugs  or  a  combination  of 
them.  The  mistake  usually  made  is  in  using  too  small  doses.  Enough 
to  produce  the  physiological  effects  of  the  drug  must  be  given.  The 
initial  dose  should  not  be  large,  but  it  should  be  repeated  until  the  full 
effects  are  obtained.  Chloral,  however,  has  been  the  drug  most  gen- 
erally relied  upon.  An  hourly  dose  of  one  or  two  grains  is  usually 
required.  If  no  effect  is  visible  in  ten  or  twelve  hours  the  dose  may  be 
further  increased,  as  the  patient  is  in  much  greater  danger  from  the 
disease  than  he  can  possibly  be  from  the  drug.  Chloral  may  be  given 
by  the  mouth  or  by  the  rectum,  but  must  always  be  well  diluted.  The 
single  case  of  recovery  which  I  have  seen  was  one  treated  by  the  bromide 
of  potassium.  This  infant  took  eight  grains  every  two  hours  for  three 
days,  afterward  smaller  doses.  The  child  must  at  all  times  be  kept  as 
quiet  as  possible,  without  unnecessary  handling  or  bathing.  If  nursing 
or  feeding  by  the  mouth  is  impossible,  because  the  jaws  cannot  be  sepa- 
rated, the  child  may  be  fed  by  a  tube  passed  through  the  nose.     This  is 


FATTY   DEGENERATION  OF  THE   NEWLY   BORN.  91 

greatly  to  be  preferred  to  rectal  alimentation.     Drugs  may  l)e  adminis- 
tered in  the  same  way. 

The  Antitoxine  Treatment. — This  is  of  especial  value  in  prophylaxis. 
To  be  efficient  as  a  curative  measure  it  must  be  used  early,  for  after  the 
disease  has  developed  it  is  very  doubtful  whether  much  can  be  accom- 
plished by  its  use ;  but  as  it  is  harmless,  it  should  be  employed. 

EPIDEMIC   HEMOGLOBINURIA    {WinckeVs   Disease). 

The  essential  features  of  this  disease  are  haemoglobinuria  with  icterus 
and  cyanosis,  this  combination  giving  the  skin  a  deeply  bronzed  hue 
{maladie  bronzee).  It  is  a  rare  disease,  but  has  generally  occurred  epi- 
demically in  institutions.  It  is  usually  fatal.  It  is,  without  doubt,  in- 
fectious, but  its  cause  has  not  been  discovered.  Although  generally 
called  by  the  name  of  Winckel,  who  in  1879  made  a  report  upon  an 
epidemic  of  twenty-three  cases,  the  disease  was  quite  well  described  by 
Charrin  in  1873,  with  a  report  of  fourteen  cases,  and  observed  by  Bige- 
low,  in  Boston,  in  1875.  All  the  cases  included  in  Winckel's  report 
occurred  in  one  institution,  affecting  one-fourth  of  the  children  born 
during  the  period. 

There  is  cyanosis,  with  a  more  or  less  intense  icterus  of  the  skin  and 
internal  organs.  The  umbilical  vessels  are  usually  normal.  The  kid- 
neys are  swollen,  show  small  haemorrhages  into  their  substance,  and 
under  the  microscope  the  straight  tubes  are  seen  to  be  filled  with  crys- 
tals of  haemoglobin,  but  contain  no  blood-cells.  The  bladder  frequently 
contains  brownish,  smoky  urine.  The  spleen  is  swollen  and  filled  with 
blood  pigment,  which  is  diffused  throughout  the  cells  of  the  pulp,  and 
free  in  the  blood-vessels.  Punctate  haemorrhages  are  seen  in  most  of 
the  other  viscera. 

The  symptoms  usually  begin  from  the  fourth  to  the  eighth  day  after 
birth,  and  are  fulminating  in  character,  seldom  lasting  more  than  two 
days.  There  are  rapid  prbe  and  respiration,  general  restlessness,  pros- 
tration, cyanosis,  and  general  icterus,  which  may  be  intense.  The  tem- 
perature is  normal  or  slightly  elevated.  There  is  rapid  asthenia,  often 
terminating  in  coma  or  convulsions.  The  urine  is  passed  frequently,  in 
small  quantities.  It  is  of  a  smoky  colour,  and  contains  haemoglobin 
in  considerable  quantity,  renal  epithelium,  and  sometimes  granular  casts 
and  blood-cells,  but  does  not  contain  bile  pigment.  Albumin  is  some- 
times present,  but  not  in  large  quantity. 

Treatment  is  of  little  avail,  since  all  severe  cases  die. 

FATTY  DEGENERATION  OF  THE  NEWLY  BORN  (Buhl's  Disease). 

A  disease  has  been  described  by  the  author  whose  name  it  bears,  the 
essential  nature  and  causation  of  which  are  unknown.     It  occurs  as 


92  DISEASES  OF  THE  NEWLY  BORN. 

isolated  cases,  and  is  characterised  by  inflammatory  changes  leading  to 
fatty  degeneration  in  the  viscera,  especially  the  heart,  liver,  and  kidneys ; 
it  seldom  lasts  more  than  two  weeks,  and  is  almost  invariably  fatal. 
Many  of  the  lesions  are  similar  to  the  ordinary  post-mortem  changes, 
and  when  found  they  should  not  be  interpreted  as  pathological  unless 
the  autopsy  is  made  witliin  twelve  hours  after  death. 

The  clinical  features  of  this  disease,  as  described,  resemble  those  of 
pyogenic  infection ;  and  since  the  observations  were  made  before  modern 
methods  of  bacteriological  study,  it  is  highly  probable  that  Buhl's  disease 
is  merely  a  form  of  pyogenic  infection  in  the  newly  born. 

PEMPHIGUS  NEONATORUM— BULLOUS  IMPETIGO. 

Pemphigus  is  a  term  which  designates  a  lesion  rather  than  a  disease. 
By  it  is  meant  an  eruption  of  bullie  occurring  usually  upon  a  red  base, 
the  contents  being  in  most  cases  clear  serum.  A  condition  somewhat 
resembling  pemphigus  sometimes  follows  the  use  in  the  newly  born  of 
too  hot  baths.  Again,  bulla?  are  seen  as  one  of  the  lesions  of  congenital 
syphilis;  they  are  then  usually  present  at  birth  or  appear  soon  after. 
They  are  most  frequently  seen  upon  the  palms  and  soles.  Infants  so 
affected  are  generally  in  wretched  condition,  and  soon  die. 

The  only  condition  to  which  the  term  pempliigus  neonatorum  should 
be  applied  is  quite  different  from  both  the  preceding,  and  it  has  nothing 
in  common  with  the  pemphigus  of  later  life.  A  better  name  is  bullous 
impetigo,  for  its  identity  with  impetigo  contagiosa  seen  in  older  patients  is 
now  generally  admitted.  The  disease  is  infectious,  somewhat  contagious, 
and  occasionally  occurs  in  small  epidemics  in  institutions.  Its  spread 
in  communities  has  been  traced  to  midwives.  The  only  important  dif- 
ference between  this  disease  and  the  common  impetigo  contagiosa  seen 
in  older  children,  is  its  severity  and  its  association  with  visceral  infec- 
tions. Most  patients  with  bullous  impetigo  are  delicate,  neglected,  and 
living  in  dirty  surroundings;  but  not  all  are.  I  have  seen  it  in  robust 
infants  who  had  received  fairly  good  care. 

The  greater  number  of  cases  studied  thus  far  have  shown  the  pres- 
ence in  the  blebs  of  the  staphylococcus  pyogenes  aureus;  less  frequently 
the  streptococcus  has  been  the  cause.  The  staphylococcus  aureus  was 
found  in  several  typical  cases  occurring  in  my  own  hospital  service.  In 
one  of  these  which  came  to  autopsy,  a  general  staphylococcus  septicaemia 
was  present. 

The  clinical  picture  presented  by  pemphigus  neonatorum  is  so  strik- 
ing that  it  can  scarcely  be  mistaken.  The  symptoms  begin  in  most 
cases  between  the  fourth  and  tenth  day  of  life.  The  bullae  first  appear- 
ing are  scattered  and  often  not  larger  than  one-fourth  or  one-half  inch 
in  diameter.     They  may  be  seen  upon  any  part  of  the  body,  but  are 


PEMPHIGUS  NEONATORUM— BULLOUS   LMPETIGO.  93 

especially  frequent  about  the  face,  hands,  and  other  exposed  parts.  They 
rupture  or  dry  and  form  crusts  without  suppuration.  The  small  bullae 
may  gradually  increase  in  size  or  several  may  coalesce  until  they  cover 
an  area  two  or  three  inches  in  diameter.  As  tiie  disease  progresses,  new 
bullae  may  appear  over  almost  any  part  of  the  body.  Tlie  skin  is  at  first 
slightly  reddened,  then  an  exudation  of  serum  occurs  l)eneath  the  epi- 
dermis which  loosens  and  slides  upon  tlie  true  skin.  After  rupture  of 
the  large  bullae,  the  epidermis  at  the  margin  forms  a  thin  filmy  border 
or  hangs  in  shreds  easily  detached.  The  base  of  the  large  vesicles  is 
a  moist  bright-red  surface.  When  many  have  formed,  the  appearance 
closely  resembles  that  seen  after  an  extensive  luirn. 

The  course  of  the  local  symptoms  is  at  first  slow;  then  tlie  bullae  may 
spread  with  great  rapidity  and  death  occur  in  from  twenty-four  to  forty- 
eight  hturs.  In  less  severe  cases  the  course  is  more  prolonged,  the  blebs 
are  smaller,  and  recovery  may  take  place. 

The  constitutional  symptoms  are  at  first  wanting,  but  increase  with 
the  number  and  extent  of  the  bullae.  There  may  be  a  slight  rise  of 
temperature  or  it  ma}^  be  subnormal.    There  is  progressive  weakness  and 


Fig.  16. — Pemphigus  Neonatorum.  Symptoms  began  on  13th  day;  death  on  16th  day  of 
asthenia ;  temperature  subnormal.  The  dark  areas  in  the  picture  are  entirely  denuded 
of  epidermis;  they  were  formed  by  the  coalescence  of  large  bullae. 

great  depression,  much  like  that  following  a  burn,  and  death  occurs  from 
exhaustion  or  from  some  visceral  inflammation  such  as  pneumonia  or 
meningitis. 

It  is  important  to  distinguish  pemphigus  neonatorum  from  congenital 
syphilis.  In  syphilitic  cases,  the  liver  and  spleen  are  usually  markedly 
enlarged,  and  other  characteristic  changes  may  be  present  in  the  nails, 
mucous  membranes,  or  elsewhere. 

Treatment  is  of  little  avail  in  the  most  severe  cases,  when  the  bullae 
cover  a  considerable  part  of  the  surface  of  the  body.  The  bullae  should 
be  opened  and  drained,  and  the  surfaces  dressed  with  gauze  covered  with 
a  two-per-cent  ointment  of  white  precipitate.     There  is  little  danger  of 


94  DISEASES  OF  THE   NEWLY   BORN. 

mercurial  poisoning.  When  dressings  are  changed  the  skin  should  be 
sponged  with  a  bichloride  solution,  1-5,000  strength,  or  a  one-per-cent 
solution  of  ichthyol  or  permanganate  of  potash.  On  account  of  the  con- 
tagious nature  of  the  disease  cases  occurring  in  institutions  should  be 
isolated. 


CHAPTER    V. 
HEMORRHAGES. 

HEMORRHAGES  are  quite  frequent  during  the  first  days  of  life,  and 
are  important  not  only  from  the  fact  that  they  are  often  the  cause  of 
death,  but,  when  the  brain  is  the  seat,  from  their  remote  effects.  •  There 
are  several  conditions  in  the  newly  born  which  predispose  to  bleeding — 
the  extreme  delicacy  of  the  blood-vessels,  and  the  great  changes  taking 
place  in  the  blood  itself  and  in  the  circulation  in  the  transition  from 
intra-uterine  to  extra-uterine  life.  Haemorrhages  may  complicate  many 
of  the  diseases  of  the  early  days  of  life,  such  as  syphilis  or  sepsis,  or  they 
may  exist  alone. 

The  cases  may  be  divided  into  two  groups:  (1)  Traumatic  or  Acci- 
dental Haemorrhages,  which  depend  upon  causes  connected  with  delivery ; 
(2)  Spontaneous  Haemorrhages,  or  The  Haemorrhagic  Disease  of  the 
Newly  Born. 

TRAUMATIC   OR  ACCIDENTAL  HEMORRHAGES. 

These  are  mainly  due  to  pressure  in  natural  labour,  or  to  means  era- 
ployed  in  artificial  delivery,  but  some  of  them  may  possibly  result  from 
injuries  received  before  birth.  They  are  more  frequent  in  large  children, 
in  difficult  labours,  and  where  from  any  cause  the  body  of  the  child  lias 
been  subjected  to  undue  pressure. 

Hematoma  of  the  Sterno-Mastoid. — Haematoma  of  the  sterno-mastoid 
muscle  leads  to  the  formation  of  a  tumour  in  the  belly  of  the  muscle. 
It  is  a  rather  rare  condition,  usually  noticed  in  the  second  or  third  week 
of  life,  and  it  disappears  spontaneously,  rarely  causing  any  permanent 
deformity.  The  tumour  varies  from  three  quarters  of  an  inch  to  one 
inch  and  a  half  in  length,  being  about  the  size  and  shape  of  a  pigeon's 
egg.  It  is  movable,  almost  cartilaginous  to  the  touch,  and  sometimes 
slightly  tender.  The  situation  of  the  tumour  is  usually  about  the  centre 
of  the  muscle.    There  is  no  discoloration  of  the  skin. 

In  about  two-thirds  of  the  cases  it  occurs  after  breech  presentations. 
It  is  much  more  frequent  upon  the  right  than  upon  the  left  side.  In 
twenty-seven  cases  collected  by  Henoch  the  right  side  was  involved  in 
twenty-one  and  the  left  in  only  six  cases.    The  explanation  of  this  differ- 


TRAUMATIC   OR  ACCIDENTAL   HAEMORRHAGES.  95 

ence  is  to  be  found  in  the  obstetrical  position.  Rarel}',  both  sides  may 
be  involved.  The  head  is  usually  slightly  inclined  toward  the  shoulder 
of  the  affected  side  and  rotated  toward  the  opposite  side.  The  swelling 
slowly  diminishes  in  size,  and  in  most  cases  by  the  end  of  the  third 
month  has  nearly  or  quite  disappeared.  Occasionally  a  slight  torticollis 
remains  for  a  longer  time,  but  in  the  majority  of  cases  the  recovery  is 
perfect.  Haematoma  of  the  sterno-mastoid  is  due  to  the  twisting  of  the 
head  during  parturition.  It  is  not  an  evidence  of  the  employment  of 
any  improper  force  in  delivery.  The  twisting  of  the  head  produces 
laceration  of  some  of  the  blood-vessels  of  the  muscle,  and  in  some  cases 
there  is  doubtless  rupture  of  some  of  the  fibres  of  the  muscle  itself. 
Following  this  there  occurs  a  certain  amount  of  inflammation  of  the 
muscle  and  its  sheath.  The  tumour  is  due  partly  to  blood-extravasation 
and  partly  to  inflammatory  products.  In  one  or  two  recent  cases  in 
which  the  sheath  of  the  muscle  has  been  opened  it  has  been  found  filled 
with  blood. 

The  condition  requires  no  treatment.  Operative  interference  is  posi- 
tively contra-indicated. 

Cephalhsematoma. — This  is  a  tumour  containing  blood,  situated  upon 
the  head,  usually  over  one  parietal  bone,  and  tending  to  spontaneous 
disappearance  by  absorption.  The  source  of  the  blood  is  the  rupture  of 
the  small  vessels  of  the  pericranium. 

Etiology. — Cephalhaematoma  is  sometimes  due  to  a  distinct  trauma- 
tism like  the  application  of  forceps  or  to  some  other  injury  during 
labour.  In  the  majority  of  cases,  however,  there  is  no  evidence  of  such 
injury.  Besides  the  conditions  predisposing  to  all  haemorrhages,  there 
is  the  increased  pressure  in  the  blood-vessels  of  the  head  during  delivery, 
especially  when  labour  is  prolonged  or  difficult ;  there  may  be  changes  in 
the  bone,  such  as  an  imperfect  development  of  the  external  table;  and, 
finally,  there  may  be  changes  in  the  blood  itself.  Cephalhaematoma  is 
a  comparatively  rare  condition,  being  present,-  according  to  the  statis- 
tics of  the  Sloane  Maternity  Hospital,  in  20  of  1,300  consecutive  births, 
or  1 . 6  per  cent.  The  condition  is  more  common  after  first,  or  difficult 
labours,  and  in  vertex  presentations;  occurring  twice  as  often  in  males 
as  in  females,  probably  from  the  greater  size  of  the  head. 

Lesions. — In  the  20  Sloane  cases,  the  situation  was  over  the  right 
parietal  bone  in  12 ;  over  the  left  in  2 ;  over  both  parietals  in  4;  over  the 
occipital  in  2.  The  location  of  the  tumour  seems  to  have  a  very  close 
relation  to  the  position  of  the  head  in  the  pelvis.  In  8  of  the  right-sided 
cases  the  head  was  in  the  left  occipito-anterior  position.  Of  the  cases 
with  occipital  tumours,  both  were  breech  presentations.  Of  the  16 
cases  with  a  single  tumour  the  labour  was  natural  in  10,  tedious  in  4,  and 
in  2  forceps  were  used.    Of  the  4  double  cases,  2  were  forceps  deliveries. 

In  rare  cases  triple  tumours  are  met  with,  one  over  each  parietal  and 


96 


DISEASES  OF  THE   NEWLY   BORN. 


FiQ.  17. — Triple  Cephalhematoma. 
Infant  seven  days  old. 


one  over  the  occipital  bone  (Fig.  17).  The  attachment  of  the  periosteum 
along  the  sutures  usually  limits  the  tumour  to  the  surface  of  one  bone.  It 
never  extends  across  the  sutures  or  over  the  fontanel.  In  cases  where  there 

is  a  more  definite  injury,  such 
as  from  forceps,  the  tumour 
may  be  present  over  any  one 
of  the  cranial  bones,  but  more 
frequently  over  the  parietal.  Tlie 
seat  of  the  haemorrhage  is  be- 
tween the  periosteum  and  the 
cranium.  The  scalp  shows  punc- 
tate hasmorrhages  and  sometimes 
infiltration  witli  blood.  In  re- 
cent cases  the  blood  is  fluid ; 
later  it  is  coagulated.  The 
amount  of  extravasated  blood  is 
usually  from  half  an  ounce  to 
an  ounce.  The  cases  following 
natural  delivery  are  generally 
uncomplicated.  The  traumatic 
eases  may  be  complicated  by  ex- 
travasations between  the  bone  and  the  dura  (internal  cephalhaematoma), 
or  by  menigeal  or  cerebral  haemorrhages.  If  there  is  a  wound,  infection 
may  be  followed  by  purulent  meningitis  and  even  by  cerebral  abscess. 
Symptoms. — The  tumour  is  usually  noticed  from  the  first  to  the 
fourth  day  after  birth,  appearing  as  a  slight  prominence  in  one  of 
the  positions  mentioned.  Gradually  increasing  in  size,  it  attains  its 
maximum  at  the  end  of  a  week  or  ten  days,  and  then  slowly  dimin- 
ishes. In  size  and  shape  the  usual  tumour  may  be  compared  to  the 
bowl  of  a  tablespoon.  In  marked  cases  it  may  be  one-third  the  size  of 
the  child's  head.  To  the  touch  it  is  soft,  elastic,  fluctuating,  and  irre- 
ducible. It  does  not  increase  with  the  cry  or  cough.  There  is  no  extra 
heat  and  no  signs  of  inflammation.  Usually  the  tumour  does  not  pul- 
sate, although  in  rare  instances-  pulsating  cephalhaematomata  have  been 
seen.  Very  soon  the  tumour  is  surrounded  by  a  marginal  ridge.  At 
first  this  is  apparently  from  coagulation  of  blood,  but  later  it  may  be 
bony.  The  prominent  ridge  with  the  soft  centre  gives  a  sensation  some- 
what like  that  of  a  depressed  fracture.  Sometimes  on  pressure  there  is 
obtained  a  sort  of  parchment-crackling.  This  is  generally  found  as  the 
swelling  is  subsiding,  and  is  sometimes  clearly  due  to  the  formation 
of  minute  bony  plates  upon  the  inner  surface  of  the  periosteum. .  It 
may  be  found  when  there  is  nothing  but  thin  coagula  to  explain  it.  In 
certain  cases  following  severe  traumatism,  cephalhematoma  may  be 
complicated  with  wounds  of  the  scalp,  fracture  of  the  skuU,  and  even 


TRAUMATIC   OR  ACCIDENTAL   HAEMORRHAGES.  97 

lacerations  of  the  dura  mater  or  the  brain.  In  such  cases  the  tumour 
may  become  inflamed,  but  in  the  spontaneous  cases  this  is  extremely  rare. 
The  usual  signs  of  abscess  develop,  which  may  open  externally  or  bur- 
row.    Fortunately  this  termination  is  seldom  seen. 

As  a  rule,  without  any  interference,  the  uncomplicated  cases  go  on 
to  recovery.  The  complete  disappearance  of  the  tumour  may  be  expected 
in  from  six  weeks  to  three  months,  depending  on  its  size;  but  a  hard, 
uneven  elevation  may  remain  at  its  site  for  a  longer  time.  The  cases 
due  to  severe  traumatism  are  more  serious,  the  gravity  depending  not 
upon  the  cephalhsematoma  but  upon  the  complicating  lesions. 

Diagnosis. — Cephalhaematoma  may  be  confounded  with  encephalocele. 
This,  however,  occurs  along  the  line  of  the  sutures  or  at  the  fontanels,  is 
partially  reducible,  pressure  causes  cerebral  symptoms,  and  frequently 
the  tumour  increases  with  respiratory  movements.  Caput  succedaneum 
often  appears  in  the  same  place  as  a  cephalhaematoma  and  at  the  same 
time,  but  this  is  an  cedematous,  not  a  fluctuating  tumour,  and  begins  to 
disappear  by  the  second  or  third  day.  From  a  depressed  fracture  of 
the  skull,  it  is  differentiated  by  the  fact  that  in  cephalhaematoma  there 
is  a  tumour  and  not  a  depression ;  the  prominent  margin  which  is  raised 
above  the  contour  of  the  skull,  is  not  osseous  and  the  skull  can  be  felt 
at  the  bottom  of  the  centre  of  the  tumour. 

Treatment. — The  treatment  in  the  uncomplicated  cases  is  simply 
protective,  all  such  cases  tending  to  spontaneous  recovery.  No  local  or 
general  treatment  to  promote  absorption  is  required.  The  child  should 
be  so  placed  and  so  handled  that  no  injury  may  be  done  to  the  affected 
part.  Compresses  are  unnecessary.  If  complications  exist,  such  as  in- 
jury to  the  bones,  dura,  or  brain,  they  are  to  be  treated  in  accordance  with 
general  surgical  principles.  Operative  interference  is  called  for  only 
when  suppuration  has  occurred,  or  when  there  are  brain  symptoms  which 
point  to  the  existence  of  internal  as  well  as  external  cephalhaematoma. 

Visceral  Hsemorrhages. — While  these  are  most  frequent  in  large  chil- 
dren and  following  difficult  labours,  they  may  occur  in  small  children 
and  where  the  labour  has  been  easy  and  normal — -their  occurrence  here 
being  due  to  the  feeble  resistance  of  the  blood-vessels.  From  one  hun- 
dred and  thirty  autopsies  upon  still-born  children  or  those  dying  soon 
after  birth,  Spencer  concludes  that  intracranial  haemorrhages  are  more 
frequent  in  head-forceps  than  in  breech  cases,  and  more  frequent  in 
breech  than  in  natural  vertex  deliveries.  Other  visceral  haemorrhages 
are  much  more  frequent  in  breech  cases. 

Not  all  visceral  haemorrhages  are  to  be  classed  as  traumatic.  They 
are  often  seen  with  the  spontaneous  haemorrhages  from  the  skin  or 
mucous  membranes.  When,  however,  they  are  single,  they  seem  to  be 
of  traumatic  rather  than  of  pathological  origin. 

The  most  important  of  the  visceral  haemorrhages  are  intracranial. 
8 


9g  DISEASES  OF  THE  NEWLY   BORN. 

These  are  discussed  in  the  chapter  devoted  to  Birth  Paralyses.  Karely 
there  may  be  large  haemorrhages  into  the  lung.  Here  the  blood  fills  the 
air  vesicles  and  the  small  bronchi,  and  coagula  may  be  found  even  in  the 
larger  bronchi.  A  large  part  of  a  lobe  or  an  entire  lobe  may  be  involved. 
On  section  the  condition  resembles  atelectasis,  and  it  may  give  the  physi- 
cal signs  of  consolidation. 

The  abdominal  viscera  suffer  more  than  those  of  the  thorax  because 
less  protected  against  pressure.  Small  haemorrhages  are  not  uncommon 
upon  the  surface  of  any  of  the  viscera  covered  by  peritonaeum.  Intra- 
peritoneal haemorrhages  are  rare,  but  may  be  very  extensive,  amounting 
to  one  or  two  pints.  Sometimes  no  ruptured  vessel  can  be  found.  The 
haemorrhage  may  be  primarily  in  the  peritoneal  cavity,  or  it  may  result 
from  rupture  of  one  of  the  viscera,  especially  the  suprarenal  capsule.  It 
may  be  large  enough  to  produce  death  from  loss  of  blood. 

Small  surface  haemorrhages  of  the  liver  are  not  infrequent.  Occa- 
sionally one  of  considerable  size  occurs  separating  the  peritoneal  cover- 
ing and  forming  a  tumour  generally  upon  the  superior  surface.  Such 
laceration  may  be  produced  during  labour,  and  a  slow  accumulation  of 
blood  may  take  place  beneath  the  capsule,  death  resulting  from  rupture 
into  the  peritoneal  cavity.  Laceration  of  the  capsule  of  the  liver  in  a 
still-born  infant  has  been  reported.  Of  the  large  haemorrhages,  those 
into  the  suprarenal  capsules  are  perhaps  the  most  frequent.  The  cap- 
sule may  be  distended  to  nearly  the  size  of  an  orange,  the  kidney  being 
surrounded  by  a  mass  of  blood-clots.  Blood  may  be  extravasated  into 
the  retroperitoneal  connective  tissue,  and  rupture  may  take  place  into 
the  peritoneal  cavity. 

Except  in  the  intracranial  variety,  visceral  haemorrhages  cause  few 
symptoms,  and  in  the  great  majority  of  cases  the  diagnosis  is  not  made. 
Intrapulmonary  haemorrhages  have  given  rise  to  the  signs  of  consolida- 
tion of  the  lung  and  even  to  haemoptysis.  The  abdominal  haemorrhages 
are  the  most  obscure.  There  may  be  a  general  abdominal  distention 
with  the  usual  symptoms  of  loss  of  blood,  or  there  may  be  a  circum- 
scribed swelling.  In  many  cases  nothing  is  noticed  until  a  rupture  of 
a  subperitoneal  haemorrhage  takes  place  into  the  general  peritoneal 
cavity,  when  there  may  be  sudden  collapse  and  death. 

The  visceral  haemorrhages  are  not  amenable  to  treatment.  The  prog- 
nosis depends  upon  the  size  and  position  of  the  haemorrhage.  In  the  cases 
of  abdominal  haemorrhage  the  diagnosis  is  extremely  obscure  and  is  rarely 
made  during  life. 

SPONTANEOUS  HAEMORRHAGES— THE  HEMORRHAGIC  DISEASE  OP 

THE    NEWLY   BORN. 

A  disposition  to  bleeding  is  seen  with  many  diseases  of  the  first  few- 
days  of  life,  especially  those  of  an  infectious  character,  like  syphilis  and 


THE   HEMORRHAGIC   DISEASE.  99 

pyaemia.  With  most  of  these,  however,  the  haemorrhages  are  small,  and 
the  condition  may  be  compared  to  the  hemorrhagic  tendency  seen  in 
certain  forms  of  infection  of  later  life,  such  as  measles,  smallpox,  and 
malignant  endocarditis.  There  is,  however,  a  class  of  cases  in  which  the 
haemorrhages  are  not  associated  with  any  other  known  process,  and  in 
which  the  escape  of  blood  from  the  small  blood-vessels  is  the  chief  or 
essential  symptom.  In  these  cases  the  bleeding  is  much  more  extensive 
than  in  the  others  mentioned.  These  hsemorrhages  are  characterised  l)y 
the  fact  that  they  are  spontaneous  in  origin,  having  no  connection  with 
delivery,  they  are  multiple  in  location,  and,  while  little  influenced  by 
treatment,  they  tend  to  cease  spontaneously  after  quite  a  limited  time. 
They  are  most  often  from  the  iimbilicus,  the  mucous  membranes  of  the 
stomach  and  intestines,  or  beneath  the  skin,  but  they  may  be  from  almost 
any  mucous  surface  or  into  any  organ  of  the  body. 

Etiology. — These  haemorrhages  are  not  common,  and  are  met  with 
much  more  often  in  institutions  than  in  private  practice.  In  5,225  births 
in  the  Boston  Lying-in  Asylum,  Townsend  reports  32  cases  of  hjemor- 
rhage,  or  0.6  per  cent.  In  the  Lying-in  Asylum  of  Prague,  Ritter  ob- 
served 190  cases  in  13,000  births,  or  1.4  per  cent.  In  the  Foundling 
Asylum  of  Prague,  Epstein  reports  haemorrhages  in  8  per  cent  of  740 
infants. 

The  condition  is  not  a  manifestation  of  haemophilia.  Of  576 
bleeders  collected  by  Grandidier,  only  12  had  a  history  of  haemorrhage 
at  the  time  of  the  falling  off  of  the  cord,  and  symptoms  very  rarely 
appeared  before  the  end  of  the  first  year.  Haemorrhages  in  the  newly 
born  are  only  slightly  more  frequent  in  males,  while  in  haemophilia 
they  predominate  13  to  1.  The  haemorrhagic  disease  of  the  newly  born 
is  self-limited,  and  runs  a  definite  course  to  recovery  or  death.  The 
tendency  to  bleed  does  not  extend  beyond  a  few  weeks,  and  often  lasts 
but  a  few  days.  Circumcision  has  been  done  within  a  few  days  after 
the  cessation  of  the  haemorrhages  without  any  unusual  bleeding.  In  a 
case  under  my  observation  with  the  most  extensive  subcutaneous  haem- 
orrhages I  have  ever  seen,  all  tendency  to  bleed  had  ceased  before  the 
separation  of  the  cord,  although  there  had  previously  been  bleeding  at 
the  navel.  The  bleeding  occurs  with  about  equal  frequency  in  feeble 
and  in  well-nourished  infants.  Syphilis  is  associated  in  but  a  small 
proportion  of  the  cases.  On  the  other  hand  of  132  cases  of  congenital 
syphilis  observed  by  Mracek,  only  14  per  cent  suffered  from  haemor- 
rhages. 

A  more  frequent  association  with  sepsis  has  been  noted.  Of  the  61 
eases  observed  by  Epstein  not  less  than  29,  and  of  the  190  cases  of  Rit- 
ter, 24  were  associated  with  sepsis.  During  one  year  there  were  8 
marked  cases  of  haemorrhage  in  the  Nursery  and  Child's  Hospital  in 
about  225  deliveries.     While  more  cases  of  sepsis  occurred  among  the 


100  DISEASES  OF  THE  NEWLY  BORN. 

children  during  that  year  than  usual,  it  was  striking  that  not  one  of 
these  hsemorrhagic  cases  gave  any  evidence  of  sepsis,  and  that  none  of 
the  septic  cases  had  bleeding.  An  epidemic  of  10  cases  of  haemorrhages 
among  54  births  at  the  New  York  Infirmary  for  Women  and  Children 
was  studied  in  1899  by  Kilham  and  Mercelis.  These  all  occurred  in  the 
course  of  two  months;  the  epidemic  ceased  as  soon  as  the  cases  were 
properly  isolated. 

The  circumstances  in  which  the  haemorrhagic  disease  occurs  point 
strongly  to  an  infectious  origin.  Quite  a  number  of  these  cases  have 
now  been  studied  bacteriologically,  but  with  no  uniform  results. 

While  these  hasmorrhages  are  not  traumatic,  bleeding  is  exceedingly 
prone  to  occur  in  the  skin  over  pressure  points  such  as  the  back,  the 
elbows,  the  occiput,  and  the  sacrum.  It  is  also  common  from  the  mu- 
cous membranes  which  are  the  seat  of  pathological  processes,  especially 
from  the  eyes,  the  nose,  and  the  genitals. 

Lesions. — In  very  many  of  the  cases  the  autopsy  shows  nothing  except 
the  haemorrhages  in  the  various  situations  and  the  blanching  of  the 
organs  due  to  the  loss  of  blood.  The  haemorrhages  of  the  brain  are  usu- 
ally meningeal  and  diffuse.  They  are  considered  more  at  length  in  the 
chapter  upon  Birth  Paralyses.  The  pulmonary  haemorrhages  are  usu- 
ally small  and  unimportant,  and  large  haemorrhages  into  the  pleura  or 
pericardium  are  very  rare.  The  stomach  and  intestines  may  contain 
considerable  blood  variously  disorganised  in  the  different  parts  of  the 
canal,  and  there  may  be  ecchymoses  of  the  mucous  membrane.  In  addi- 
tion, ulcers  may  be  found  in  the  stomach  and  duodenum.  In  twenty- 
four  autopsies  upon  cases  with  haemorrhage  from  the  stomach  and  intes- 
tines collected  by  Dusser,  ulcers  were  found  in  the  stomach  in  nine 
.  cases,  and  in  the  intestines  in  four.  These  ulcers  are  multiple,  small, 
and  usually  superficial,  but  may  extend  to  the  muscular  coat  and  may 
even  perforate.  The  intestinal  ulcers  are  found  only  in  the  duodenum 
and  resemble  those  of  the  stomach.  The  cause  of  these  ulcers  is  some- 
what obscure;  some  of  them-  are  undoubtedly  dependent  upon  inflam- 
matory changes,  probably  of  infectious  origin;  others  have  been  com- 
pared to  the  peptic  ulcers  of  later  life,  and  are  attributed  to  thrombi  in 
the  blood-vessels  of  the  mucous  membrane.  These  ulcers  are  found  in 
but  a  small  proportion  of  the  cases  in  which  bleeding  occurs  from  the 
alimentary  tract,  and  they  may  be  wanting  even  where  it  has  been  very 
profuse. 

Small  extravasations  may  be  seen  upon  the  surface  or  in  the  sub- 
stance of  any  of  the  abdominal  organs.  The  changes  found  in  the  blood 
have  not  been  uniform  and  have  as  yet  been  only  imperfectly  studied. 

Symptoms.— The  onset  is  most  frequently  in  the  first  week  of  life; 
very  rarely  after  the^  twelfth  day.  The  haemorrhages  are  usually  mul- 
tiple.    Their  location  in  Bitter's  190  cases  was  as  follows:  Umbilicus, 


THE  HEMORRHAGIC   DISEASE.  101 

138  (umbilicus  alone,  97);  intestines,  39;  mouth,  28;  stomach, 
20;  conjunctivas,  20;  ears,  9.  In  Townsend's  50  cases:  Intestines,  20; 
stomach,  14;  mouth,  14;  nose,  12;  umbilicus,  18  (umbilicus  alone,  3)  ; 
subcutaneous  ecchymoses,  21;  al)rasion  yf  skin,  1;  meninges,  4;  cephal- 
hsematoma,  3 ;  abdomen,  2 ;  pleura,  lungs,  and  thymus,  1  each. 

In  many  cases  nothing  is  noticed  until  the  haemorrhage  begins.  The 
first  bleeding  noticed  may  be  from  the  stomach,  intestines,  or  any  of  the 
mucous  surfaces,  beneath  the  skin,  or  from  the  umbilicus.  The  amount 
of  blood  lost  in  most  cases  is  not  great,  but  there  is  a  continuous  oozing. 
The  total  haemorrhage  may  be  only  a  few  drachms  or  it  may  reach  several 
ounces.  The  general  condition  is  one  of  considerable  prostration,  often 
from  the  outset.  In  all  cases  there  is  rapid  loss  of  weight.  The  tem- 
perature may  be  high,  low,  or  subnormal.  A  marked  elevation  of 
temperature  ma}'  depend  not  upon  the  haemorrhage  but  upon  associated 
conditions.    In  a  large  number  of  the  cases  there  is  diarrhoea. 

The  duration  of  the  disease  in  cases  which  recover  is  usually  but  one 
or  two  days.  In  fatal  cases  it  is  rarely  more  than  three  days,  and  often 
less  than  one.  Death  may  result  from  the  gradual  failure  of  all  the  vital 
forces  or  from  rapid  loss  of  blood. 

Umbilical  Hcemorrhage. — A  slight  oozing  from  tlie  umbilicus  not  in- 
frequently occurs  when  the  ligature  has  been  improperly  applied.  This 
is  generally  controlled  by  simple  measures.  Spontaneous  haemorrhage 
is  quite  different.  It  is  rather  later  than  bleeding  from  the  mucous 
membranes,  usually  occurring  between  the  fourth  and  the  seventh  day. 
There  may  be  bleeding  into  the  cord  as  well  as  from  its  free  extremity. 
A  slight  stain  upon  the  dressing  is  usually  the  first  note  of  warning, 
but  in  exceptional  circumstances  a  gush  of  blood  is  the  first  symptom. 
The  haemorrhage  may  be  temporarily  arrested  by  various  means,  but  it 
shows  a  strong  tendency  to  recur  in  spite  of  everything  which  is  done. 
The  usual  duration  is  two  or  three  days.  It  has  been  known,  however, 
to  persist  for  twelve  or  fourteen  days,  and  it  may  be  fatal  in  less  than 
twenty-four  hours  from  the  time  it  is  noticed. 

Hcemorrhage  from  the  Stomach  and  Intestines. — Bleeding  occurs 
much  less  frequently  from  the  stomach  than  from  the  intestines.  The 
latter  is  called  melcena.  Gastro-enteric  haemorrhages  begin,  in  the  great 
majority  of  cases,  during  the  first  three  days  of  life.  The  blood  vomited 
is  usually  in  dark-brown  masses,  and  not  very  abundant;  more  rarely 
it  is  bright  red.  The  quantity  varies  from  one  drachm  to  half  an  ounce. 
Vomiting  is  liable  to  be  excited  by  nursing.  The  blood  discharged  from 
the  bowels  is  always  dark  coloured,  usually  intimately  mixed  with  the 
stool,  very  rarely  in  clots.  If  in  doubt  between  blood  and  meconium, 
one  should  look  for  the  corpuscles  with  the  microscope.  When  this  is 
not  conclusive  on  account  of  the  disorganisation  of  the  corpuscles,  a 
chemical  test  for  haemoglobin  should  be  made.     Concealed  haemorrhage 


102  DISEASES  OF  THE  NEWLY  BORN. 

into  the  stomach  may  take  place,  which  may  even  be  sufficient  to  pro- 
duce death,  no  blood  being  vomited  or  passed  by  the  bowels.  In  such 
cases  the  autopsy  may  reveal  quite  a  large  quantity  of  blood  both  in  the 
stomach  and  intestines. 

Hcemorrhage  from  the  Mouth. — The  quantity  of  blood  is  rarely  large; 
but  it  is  here  that  it  is  often  first  seen.  Its  source  may  be  the  mucous 
membrane  of  the  mouth,  pharynx,  oesophagus,  stomach,  or  bronchi.  It 
may  be  associated  with  ulceration  of  the  hard  palate,  with  thrush,  or  with 
fissures  of  the  lips. 

Hcemorrhages  from  the  nose  are  infrequent,  and  are  more  often  due  to 
syphilis  than  to  other  causes.  These  are  rarely  profuse,  but  are  fre- 
quently repeated. 

Subcutaneous  Hcemorrhages. — These  often  appear  in  places  exposed 
to  pressure,  such  as  the  sacrum,  heels,  occiput,  or  back,  but  may  occur 
anywhere.  In  some  cases  these  haemorrhages  are  very  extensive,  as  in 
one  recently  under  observation,  where  nearly  one-third  of  the  thorax  was 
covered.  Where  they  occur  alone  or  form  the  principal  lesion,  the  prog- 
nosis is  favourable. 

Hoematuria. — The  urine  is  not  only  stained  with  blood,  but  some- 
times contains  clots.  This  haemorrhage  may  have  its  origin  in  the  blad- 
der, urethra,  or  kidney.  Blood  coming  from  the  kidney  is  sometimes 
due  to  the  irritation  of  uric-acid  infarctions,  and  may  have  nothing  to 
do  with  the  gellieral  haemorrhagic  disease. 

Hcemorrhage  from  the  Conjunctiva. — The  blood  usually  comes  in 
drops  from  between  the  eyelids,  chiefly  from  the  tarsal  surface.  It  is 
generally  preceded  by  conjunctivitis. 

Hcpmorrhage  from  the  Female  Genitals. — This  not  infrequently  oc- 
curs without  hemorrhages  elsewhere,  and  under  such  circumstances  is 
rarely  serious.  Cullingsworth  collected  thirty-two  cases  in  children 
under  six  weeks  of  age — no  case  having  resulted  fatally.  These  are  not 
to  be  regarded  as  cases  of 'precocious  menstruation. 

Diagnosis. — This  is  generally  easy,  as  the  haemorrhages  are  usually 
multiple  and  some  of  them  external.  A  slight  haemorrhage  from  the 
intestine  may  be  easily  overlooked.  Large  haemorrhages  into  the  in- 
ternal organs  also  are  obscure  and  not  often  recognised.  Spurious 
haemorrhages  from  the  stomach  may  occur,  blood  being  vomited  which 
has  been  swallowed  during  birth  or  nursing.  The  source  of  bleeding 
may  also  be  the  mouth,  nose,  or  pharynx,  and  sometimes  blood  is  swal- 
lowed in  large  quantities  and  afterward  vomited.  These  cavities  should 
therefore  always  be  examined,  since  local  treatment  may  be  efficacious. 
Syphilis  should  be  suspected  when  the  bleeding  is  chiefly  nasal. 

Prognosis.— In  all  circumstances,  the  haemorrhagic  disease  in  the 
newly  born  has  a  bad  prognosis.  Of  709  cases  collected  by  Townsend, 
the  mortality  was  79  per  cent.    In  any  single  case  the  prognosis  depends 


THE  HEMORRHAGIC  DISEASE.  103 

upon  the  extent  and  severity  of  the  hgemorrhage,  upon  the  vigour  of  the 
child,  and  upon  how  well  it  can  be  nourished.  No  case  sliould  be  looked 
upon  as  hopeless,  for  perfect  recovery  has  repeatedly  taken  place  where  it 
seemed  impossible. 

Treatment. — Local  measures  may  be  employed  in  all  external  hnsmor- 
rhages  with  some  prospect  of  benefit.  The  bleeding  points  may  be 
touched  with  persulphate  of  iron  or  with  chromic  acid  fused  upon  a 
probe,  or  a  solution  of  adrenalin  chloride  may  be  used.  These  measures 
may  be  employed  alone  or  in  combination  with  pressure. 

Although  recoveries  have  been  reported  following  the  use  of  a  great 
variety  of  remedies,  it  is  by  no  means  established  that  the  result  was  due 
to  the  drugs  employed.  Many  of  the  milder  cases  recover  without  any 
special  treatment.  On  the  whole,  the  medicinal  treatment  is  very  unsatis- 
factory. The  drug  which  has  been  most  in  favour  is  adrenalin,  which  can 
be  used  internally  in  the  form  of  suprarenal  extract.  I  have  myself  seen 
one  case  in  which  decided  benefit  apparently  followed  its  use  in  severe 
gastric  haemorrhage.  Two  grains  or  more  can  be  given  every  two  hours. 
Gelatine  has  many  advocates.  It  is  used  by  subcutaneous  injection.  A 
two-per-cent  solution  which  has  been  twice  sterilised  is  employed,  from 
40  to  50  c.c.  being  administered  two  or  three  times  daily.  Calcium 
lactate  in  some  instances  appears  to  exert  a  positive  effect.  It  may  be 
given  in  frequently  repeated  doses  up  to  20  or  30  grains  a  day. 

The  latest  addition  to  the  treatment  of  this  condition  is  the  use 
subcutaneously  of  human  blood  serum.  This  was  first  suggested  by  J. 
E.  Welch,  of  New  York,  who  has  tried  it  in  seventeen  cases.  His  results 
have  been  confirmed  by  others.  Of  the  efficacy  of  this  treatment  there 
can  be  no  longer  any  question.  Whether  all  cases  of  hgemorrhage  of  the 
newly  born  are  due  to  the  same  cause  and  therefore  amenable  to  the 
same  treatment  is  not  yet  established.  Whenever  possible,  therefore, 
injections  of  blood  serum  should  be  tried  for  these  patients.  The  serum 
may  be  obtained  from  the  blood  of  any  healthy  adult  under  sterile  con- 
ditions; the  quantity  used  should  be  from  40  to  50  c.c.  injected  three 
times  a  day.  Larger  doses  may  be  used  without  danger.  It  should  be 
repeated  as  long  as  any  tendency  to  haemorrhage  exists.  Usually,  how- 
ever, if  it  acts  at  all  it  does  so  promptly.  In  most  patients  all  bleeding 
ceases  in  twenty-four  hours  after  the  first  injection. 

The  brilliant  results  which  have  followed  transfusion  as  first  prac- 
tised by  Carrel  should  lead  to  its  use  in  the  event  of  failure  by  other 
means,  whenever  it  is  practicable  to  adopt  it,  no  matter  how  grave  the 
symptoms  may  be.  The  general  treatment  should  have  reference  to 
maintaining  the  nutrition  by  careful  feeding,  judicious  stimulation,  and 
attention  to  the  circulation,  the  body  temperature,  and  the  general  con- 
dition of  the  child. 


104  DISEASES  OF  THE   NEWLY   BORN. 

CHAPTER    VI. 
BIRTH  PARALYSES. 

Birth  paralyses  are  cliiefly  due  either  to  pressure  upon  the  child  by 
the  parts  of  the  mother  or  to  artificial  means  employed  in  delivery. 
They  may  be  cerebral,  spinal,  or  peripheral. 

Cerebral  par-ali/ses  are  in  almost  every  instance  due  to  meningeal 
haemorrhage,  and  accompanied  by  a  certain  amount  of  injury  to  the 
brain  substance.  Very  infrequently  they  depend  upon  cerebral  haemor- 
rhage, laceration  of  the  brain,  or  pressure  from  a  depressed  fracture. 

Spinal  paralyses  are  extremely  rare,  and  only  a  few  examples  are  on 
record.  They  are  due  to  laceration  of,  or  haemorrhage  into,  the  cord  or 
its  membranes.  These  lesions  produce  paraplegia,  the  exact  distribution 
of  which  depends  upon  the  point  at  which  the  cord  is  injured. 

Peripheral  paralyses  usually  affect  the  face  or  the  upper  extremity. 
Paralysis  of  the  face  is  due  in  most  cases  to  the  application  of  for- 
ceps. Paralysis  of  the  upper  extremity  is  most  frequently  of  the  "  upper- 
arm  type,"  and  is  known  as  Erb's  paralysis.  It  usually  follows  extraction 
in  breech  presentations.  Peripheral  paralysis  of  tlie  lower  extremity 
is  almost  unknown. 

CEREBRAL  PARALYSIS. 

Cerebral  paralysis  is  often  used  synonymously  with  meningeal  haemor- 
rhage. This  lesion  is  not  infrequent,  and  is  of  great  importance  not 
only  from  its  immediate  effects,  but  because  upon  it  depend  many  of  the 
cerebral  paralyses  seen  in  later  life.  According  to  Cruveilhier,  at  least 
one-third  of  tlie  deaths  of  infants  which  occur  during  parturition  are 
due  to  this  cause. 

Etiology. — The  same  predisposing  causes  exist  in  the  cases  of  menin- 
geal haemorrhages  as  in  others  occurring  at  this  time.  A  small  number 
of  cases  are  associated  with  syphilis ;  others  with  pyogenic  infection.  In 
a  few  cases  there  is  a  history  of  an  injury — usually  a  fall  or  blow  upon 
the  abdomen^— during  the  last  months  of  pregnancy.  Meningeal  haemor- 
rhage may  occur  as  one  of  the  lesions  in  the  hsemorrhagic  disease  of  the 
newly  born.  The  most  important  causes,  however,  are  connected  with 
parturition.  These  haemorrhages  are  essentially  mechanical,  and  are 
favoured  by  everything  which  increases  or  prolongs  pressure  upon  tlie 
head.  The  conditions  with  which  they  are  associated  are  tedious  labour, 
breech  presentations  with  difficulty  in  extracting  the  head,  instrumental 
deliveries,  and  premature  births.  The  majority  occur  in  first-])orn  chil- 
dren.   In  many  of  the  cases  there  is  also  a  hsemorrhage  outside  the  skull. 

Lesions. — These  haemorrhages  are  more  common  at  the  base  than  at 
the  convexity,  and  at  the  posterior,  than  at  the  anterior  part  of  the  skull. 


PLATE  U. 


Meningeal  Hemorrhage  in  the  Newly  Born. 

From  a  patient  in  the  Nursery  and  Child's  Hospital,  dying  on  the  sixth  day. 
Primary  respirations  poor;  child  very  dull  and  apathetic,  refused  to  nurse  ;  once  vom- 
ited blood  and  had  an  ecchymosis  of  the  right  conjunctiva.  On  the  last  day,  high 
temperature  (105°  F.)  and  general  convulsions.  Some  changed  blood  found  in  the 
stomach  and  intestines  at  the  autopsy ;  brain  greatly  congested,  and  at  the  base  was 
the  clot  shown  in  the  picture. 


CEREBRAL  PARALYSIS.  105 

They  are  most  frequently  found  over  the  cerehellum  and  the  occipital 
lobes  of  the  cerebrum.  The  entire  extravasation  is  often  beneath  the  ten- 
torium. The  extent  of  the  haemorrhage  is  exceedingly  variable.  There 
may  be  a  single  large  clot  at  the  convexity  or  at  the  base  (Plate  II),  the 
haemorrhage  may  be  limited  to  the  convexity  of  one  hemisphere,  or  it 
may  cover  nearly  the  entire  surface  of  the  l)rain.  Diffuse  hemorrhages 
are  more  common  than  a  single  circumscril^ed  clot.  In  cases  with  ver- 
tex presentations  the  principal  lesion  is  usually  at  the  base,  and  often 
limited  to  that  region.  In  breech  cases  it  is  more  frequently  at  the 
convexity.  The  source  of  the  blood  may  be  a  laceration  of  one  of  the 
sinuses  of  the  dura  mater  caused  by  overlapping  of  the  parietal  bones. 
But  more  frequently  the  blood  comes  from  one  of  the  cerebral  veins, 
or  from  the  capillary  vessels  of  the  pia  mater.  In  thirty-seven  of  Bed- 
nar's  fifty-two  cases,  the  extravasation  Avas  beneath  the  pia  mater.  In 
the  remainder  it  was  between  the  pia  mater  and  tlie  dnra — i.  e.,  in  the 
arachnoid  cavity.  Haemorrhages  between  the  dura  and  the  skull  may 
be  said  never  to  occur  except  when  associated  with  fracture.  If  the 
child  is  still-born,  or,  if  death  has  occurred  on  the  first  or  second  day,  the 
blood  is  partly  fluid  and  partly  coagulated;  later  it  is  entirely  coagu- 
lated and  may  have  undergone  partial  absorption.  The  amount  of  ex- 
travasated  blood  varies  between  one  drachm  and  four  ounces,  the  average 
amount  being  about  one  ounce.  The  blood  extends  into  the  fissures 
between  the  convolutions  and  sometimes  into  the  ventricles  along  the 
choroid  plexus,  although  this  is  rare.  In  large  haemorrhages  the  brain 
substance  is  softened  and  in  places  may  be  quite  disintegrated ;  but  with 
small  extravasations  these  changes  are  very  slight  and  hard  to  demon- 
strate to  the  naked  eye,  though  causing  remote  consequences  often  of  a 
serious  nature.  In  cases  which  survive  for  two  or  three  weeks  there  is 
usually  a  certain  amount  of  meningitis.  The  later  changes — those  of 
arrested  development  of  the  cortex  and  cerebral  sclerosis — will  be  con- 
sidered in  the  chapter  devoted  to  Cerebral  Paralyses  in  the  section  on 
Diseases  of  the  Nervous  System.  Haemorrhages  into  the  membranes  of 
the  upper  part  of  the  cord  are  found  in  a  large  proportion  of  the  fatal 
cases.  Associated  haemorrhages  of  the  lungs  and  other  organs  are  not 
uncommon. 

Symptoms. — If  the  haemorrhage  is  large,  the  child  is  usually  still- 
born, although  its  movements  may  have  been  active  up  to  the  commence- 
ment of  labour.  When  the  haemorrhage  is  not  so  large  as  to  be  imme- 
diately fatal,  the  child  may  show  no  symptoms  except  dulness  or  stupor, 
with  feeble  or  irregular  respiration,  death  following  within  the  first 
twenty-four  hours.  A  large  proportion  of  the  cases  are  born  asphyxiated, 
and  frequently  they  are  resuscitated  only  after  considerable  effort.  They 
nurse  feebly  or  not  at  all.  Convulsions  are  common  in  cases  which  last 
for  four  or  five  days,  and  more  with  haemorrhages  at  the  convexity  than 


106  DISEASES  OF  THE   NEWLY   BORN. 

with  those  at  the  base.  Opisthotonus  is  often  present,  also  general  rigid- 
ity of  the  extremities,  clenching  of  the  hands,  and  increased  knee-jerks. 
Barely  there  is  complete  relaxation  of  all  the  muscles.  Sometimes  there 
are  automatic  movements.  The  respiration  is  usually  disturbed;  in 
most  cases  it  is  slow  and  irregular.  The  pulse  is  feeble  and  usually 
slow.  The  pupils  are  more  frequently  contracted  than  dilated,  and  there 
may  be  oscillation  of  the  eyeballs.  There  may  be  a  slight  exophthalmos. 
In  large  haemorrhages  there  is  marked  bulging  of  the  fontanel,  and  often 
separation  of  the  sutures.  If  the  haemorrhage  covers  one  hemisphere, 
there  is  complete  hemiplegia  of  the  opposite  side.  Small  localised  cor- 
tical haemorrhages  may  cause  paralysis  of  the  face,  arm,  or  leg,  according 
to  the  position  of  the  lesion,  or  localised  convulsions.  In  large  haemor- 
rhages at  the  base  convulsions  are  rare,  and  death  occurs  early,  usually 
in  the  first  two  days.  In  extensive  cortical  haemorrhages  convulsions  and 
rigidity  of  the  extremities  are  frequent,  and  life  may  be  prolonged  in- 
definitely. There  is  usually  no  fever,  but  exceptionally  the  temperature 
may  be  high. 

The  majority  of  the  fatal  cases  die  within  the  first  four  days.  In 
those  lasting  a  longer  time  the  symptoms  are  tonic  spasm  of  the  trunk, 
or  of  one  or  more  of  the  extremities,  witli  localised  paralysis — mono- 
plegia, diplegia,  or  hemiplegia,  according  to  the  lesion — and  localised 
or  general  convulsions  often  continuing  for  two  or  three  weeks  and 
gradually  subsiding.  In  the  mildest  cases  nothing  abnormal  may  be 
noticed  until  the  child  is  old  enough  to  walk  or  talk.  In  those  more 
severe  there  may  be  gradual  and  continuous  improvement  of  the  early 
symptoms,  and  the  case  may  go  on  to  apparent  recovery,  but  usually 
there  is  some  permanent  damage  to  the  brain. 

The  main  diagnostic  symptoms  in  recent  cases  are :  bulging  fontanel, 
slow  pulse,  stupor,  rigidity,  increased  reflexes,  convulsions,  and  paralysis, 
especially  when  localised,  and  opisthotonus.  These  vary  with  the  extent 
and  situation  of  the  lesion.    Lumbar  puncture  has  very  doubtful  value. 

Prognosis. — A  large  haemorrhage  at  the  base  quickly  causes  death; 
if  it  is  located  at  the  convexity,  although  the  child  may  survive,  there  is 
always  serious  damage  to  the  brain.  Even  from  small  hfemorrhages 
some  permanent  injury  usually  results,  though  the  extent  of  this  may 
not  be  evident  for  years. 

Treatment. — This  is  mainly  prophylactic,  the  chief  indication  being 
to  shorten  tedious  labours  by  the  early  use  of  the  forceps.  Where  the 
haemorrhage  has  been  attributed  to  the  forceps,  the  damage  has  rather 
been  the  result  of  the  long-continued  pressure  before  they  were  used. 
Nothing  can  be  done  after  delivery  to  limit  the  amount  of  the  haemor- 
rhage, except  to  keep  the  child  as  quiet  as  possible.  The  removal  of  the 
clot  by  surgical  operation  has  now  been  successfully  accomplished  by 
Gushing  and  others.     With  more  accurate  diagnosis  there  seems  to  be 


FACIAL  PARALYSIS.  107 

no  reason  why  a  considerable  number  may  not  be  saved.  For  the  best 
results  operation  should  be  done  as  soon  as  possible.  One  great  diffi- 
culty is  that  of  early  and  accurate  diagnosis.  Paralysis  whether  local- 
ised or  general  is  of  greater  value  in  diagnosis  than  are  convulsions. 
The  latter,  however,  are  especially  important  when  localised  or  contin- 
uous and  threatening  life.  The  operative  risk,  while  considerable,  is 
not  to  be  measured  against  the  permanent  mental  deficiency  usually 
resulting  in  most  of  these  children  when  nothing  is  done.  Cases  with 
similar  symptoms  are  sometimes  seen  in  which  there  is  no  extravasation 
of  blood  found  at  operation,  but  only  intense  congestion  with  an  exces- 
sive serous  exudate.  In  them  also  relief  may  follow  operation.  The 
hopeless  outlook  for  such  cases  when  not  relieved,  justifies  the  taking 
of  great  risks. 

FACIAL  PARALYSIS. 

The  usual  cause  of  facial  paralysis  is  the  use  of  the  forceps,  but  this 
does  not  explain  all  the  cases.  The  etiology  of  those  in  which  the  for- 
ceps have  not  been  used  is  still  somewhat  obscure.  In  peripheral  facial 
palsy  the  nerve  is  pressed  upon,  either  near  its  exit  from  the  stylo-mas- 
toid  foramen,  or  where  it  crosses  the  ramus  of  the  jaw,  at  which  point 
the  parotid  gland  gives  it  but  little  protection  in  the  newly  born.  If  the 
lesion  is  in  front  of  this  point,  any  one  of  the  terminal  branches  may 
be  affected;  most  frequently  it  is  the  temporo-facial  branch.  As  only 
one  blade  of  the  forceps  commonly  touches  the  face  in  this  region,  the 
paralysis  is,  as  a  rule,  unilateral. 

Eoulland  has  reported  several  cases  not  due  to  the  forceps.  In  these 
the  pressure  is  believed  to  have  been  produced  by  the  promontory  of  the 
sacrum  at  the  superior  strait,  or  by  the  ischium  at  the  inferior  strait,  as 
paralysis  followed  when  the  head  was  long  arrested  at  one  of  these  points. 
It  was  not  seen  with  face  or  breech  presentations.  When  facial  paralysis 
is  of  central  origin  it  depends  generally  upon  a  meningeal  haemorrhage, 
and  the  arm  and  leg  of  the  same  side  as  the  face  are  involved.  It  is, 
however,  possible  for  a  very  small  cortical  hfemorrhage  to  produce  paral- 
ysis of  the  face  only. 

In  repose,  the  only  symptom  noticed  may  be  that  the  eye  remains  open 
upon  the  affected  side,  owing  to  paralysis  of  the  orbicularis  palpebrarum. 
When  the  muscles  are  called  into  action,  as  in  crying,  the  whole  side  of 
the  face  is  seen  to  be  affected.  The  paralysed  side  is  smooth,  full,  and 
often  oppears  to  be  somewhat  swollen.  The  mouth  is  drawn  to  the  side 
not  affected.  In  this  paralysis,  the  tongue,  of  course,  is  not  implicated. 
It  is  therefore  rare  that  nursing  is  seriously  interfered  with.^  If  the 
paralysis  is  of  central  origin,  only  the  lower  half  of  the  face  is  involved, 

'  In  this  connection  it  is  to  be  remembered  that  the  principal  part  in  nursing  is 
done  by  the  tongue,  and  not  by  the  lips. 


108  DISEASES  OF  THE   NEWLY   BORN. 

while  in  peripheral  paralysis,  as  the  trunk  of  the  nerve  is  injured,  the 
upper  half  of  the  face,  including  the  orbicularis  palpehraruni,  is  also 
affected. 

The  paralysis  is  generally  noticed  on  the  first  or  second  day  of  life, 
and  does  not  increase  in  severity.  Its  course  and  termination  depend 
upon  the  extent  of  the  injury  done  to  the  nerve.  Some  idea  of  this  may 
often  be  gained  by  the  amount  of  injury  to  the  soft  parts,  although  this 
is  not  an  infallible  guide.  In  cases  not  due  to  the  forceps,  the  paralysis 
is  slight  and  disappears  in  a  few  days ;  the  great  majority  of  the  forceps 
cases  follow  the  same  favourable  course,  the  paralysis  gradually  disap- 
pearing without  treatment  in  about  two  weeks.  In  more  serious  cases 
it  may  last  for  months,  or  it  may  be  permanent.  The  reaction  of 
degeneration  is  present  in  these  severe  cases,  and  there  may  even  be 
perceptible  atrophy  of  the  muscles.  This  symptom  is  fortunately  ex- 
tremely rare. 

Treatment. — Nothing  should  be  done  for  the  first  ten  days  except  to 
protect  the  eye  and  keep  it  clean.  If  improvement  has  begun  by  the  end 
of  this  time,  the  probabilities  are  that  the  case  will  require  no  treatment. 
If  no  improvement  has  taken  place  by  the  end  of  the  third  or  fourth 
week,  electricity  should  be  used  regularly  and  systematically.  If  the 
muscles  respond  to  it,  the  faradic  current  may  be  employed;  if  not, 
galvanism  should  be  used.  The  electrical  treatment  should  be  continued 
for  several  months,  or  until  recovery  has  taken  place. 

PAR^VLYSIS  OF  THE  UPPER  EXTREMITY. 

When  this  is  due  to  a  peripheral  lesion  it  probably  never  involves  the 
entire  arm,  but  affects  only  certain  muscles  or  groups  of  muscles.  Al- 
though commonly  occurring  after  an  artificial  delivery,  it  may  be  seen  in 
cases  where  the  labour  has  terminated  naturally.  Eoulland  has  reported 
a  case  in  which  deltoid  paralysis,  occurring  in  a  l^rge  child,  was  attrib- 
uted to  pressure  upon  the  shoulder  during  labour.  In  vertex  presenta- 
tions, paralys-is  is  most  frequently  due  to  the  forceps  where  one  of  the 
blades  has  extended  down  upon  the  neck,  injuring  the  lower  cervical 
nerves.  It  may  be  produced  by  traction  with  the  finger  in  the  axilla. 
RouUand  reports  a  unique  case  of  paralysis  of  both  extremities,  appar- 
ently due  to  the  cord  being  very  tightly  wound  around  the  neck.  The 
great  proportion  of  all  cases  of  paralysis  of  the  upper  extremity  follow 
extraction  in  breech  presentations.  The  injury  is  usually  inflicted  by 
traction  upon  the  shoulder  in  the  delivery  of  the  head,  or  in  bringing 
down  the  arms  when  they  are  above  the  head.  In  the  latter  case  the 
paralysis  may  be  double  and  associated  with  fracture  of  the  clavicle 
or  humerus.  In  shoulder  presentations,  paralysis  may  be  produced  by 
traction  upon  the  arm  itself.     The  primary  lesion  consists  of  an  actual 


PARALYSIS  OF  THE   UPPER  EXTREMITY. 


109 


rupture  of  nerve  fibres  and  even  of  nerve  trunks,  probably  with  hemor- 
rhage into  the  nerve  sheath.  An  inflanimatory  process  follows  as  a  result 
of  which  all  these  structures  are  fused  together  in  one  cicatricial  mass. 

The  most  common  form  of  peripheral  paralysis  is  that  known  as  the 
"  upper-arm  type,"  or  Erb's  paralysis,  in  which  the  injury  is  inflicted  at 
the  anterior  border  of  the 
trapezius  muscle  at  the 
lower  part  of  the  neck,  usu- 
ally in  such  a  position  as 
to  affect  the  fifth  and  sixtli 
cervical  nerves.  The  mus- 
cles paralysed  are  the  del- 
toid, biceps,  brachialis  an- 
ticus,  supinator  longus,  and 
sometimes  the  supra-  and 
infra-spinatus.  All  these 
muscles  may  be  involved,  or 
only  part  of  them,  and  in 
varying  degrees.  In  case 
the  injury  is  slight,  the 
l^aralysis  may  not  be  noticed 
for  some  weeks.  If  severe, 
it  is  evident  in  the  first 
few  days.    The  arm  hangs 

lifeless  by  the  side ;  it  is  rotated  inward,  the  forearm  pronated,  the  palm 
looking  outward  (Fig.  18).  The  forearm  and  hand  are  not  affected.  In 
severe  cases  there  may  be  anaesthesia  of  the  outer  surface  of  the  arm,  in 
the  region  supplied  by  the  circumflex  and  external  cutaneous  nerves. 
This  is  rarely  marked,  and  in  its  slighter  degrees  it  is  very  difficult  to 
determine.  It  is  characteristic  of  this  paralysis  that  the  triceps  is  not 
affected,  so  that  power  to  extend  the  forearm  remains,  although  it  cannot 
be  flexed.  Atrophy  of  the  paralysed  muscles  occurs  after  a  few  weeks, 
but  the  muscles  are  so  small  and  so  covered  with  fat  that  it  is  rarely 
noticeable  before  the  second  year.  It  is  most  conspicuous  in  the  deltoid. 
In  all  severe  cases  the  reaction  of  degeneration  is  present.  In  some  of 
the  cases  of  long  standing  there  occurs  a  shortening  of  the  tendon  of  the 
subscapularis  muscle,  often  associated  with  subluxation  of  the  humerus. 
The  paralysis  may  be  complicated  with  fracture  of  the  clavicle,  the  neck 
of  the  scapula,  or  the  shaft  of  the  humerus,  or  with  epiphyseal  separa- 
tion of  its  head. 

The  prognosis  depends  upon  the  severity  of  the  injury  and  also  to 
some  degree  upon  the  time  when  treatment  is  begun.  Many  cases  recover 
spontaneously  in  two  or  three  months,  improvement  being  observed  within 
a  few  weeks^  first  in  the  biceps  and  last  in  the  deltoid.     Other  cases 


Fig.  18. — Erb's  Paralysis. 
Infant  two  months  old. 


110  DISEASES  OF  THE   NEWLY   BORN. 

more  severe  in  type  recover  after  months  as  a  result  of  systematic  treat- 
ment by  manipulation,  massage,  and  electricity.  The  electrical  reactions 
are  of  some  value  in  prognosis.  If  the  muscles  respond  to  faradism, 
rapid  improvement  can  generally  be  prophesied.  If  the  reaction  of  de- 
generation is  present,  improvement  will  be  slow  and  the  paralysis  is  likely 
to  be  permanent.    Permanent  paralysis  is  most  frequently  of  the  deltoid. 

The  diagnosis  is  usually  not  difficult,  since  the  great  majority  of  cases 
are  of  the  "  upper-arm  type "  with  classical  symptoms.  Peripheral 
palsy  of  the  arm  can  scarcely  be  confounded  with  that  of  cerebral  ori- 
gin. If  the  lesion  is  central  it  is  one  of  the  rarest  occurrences  for  the 
arm  alone  to  be  involved;  either  the  leg  or  face,  or  both,  are  generally 
likewise  affected.  If  the  case  does  not  come  under  observation  until  the 
child  is  a  year  old,  it  may  be  difficult,  or  without  a  good' history  it  may 
be  impossible  to  distinguish  peripheral  paralysis  from  that  due  to  polio- 
myelitis. The  peculiar  group  of  muscles  involved  in  Erb's  paralysis  is 
the  only  diagnostic  point. 

In  recent  cases  the  disability  resulting  from  the  tenderness  or  pain  of 
syphilitic  epiphysitis  may  simulate  paralysis,  but  there  is  lacking  the 
characteristic  position  of  the  arm,  and  a  careful  examination  discloses 
the  fact  that  the  paralysis  is  only  apparent.  This  may  affect  both  sides. 
Fracture  of  the  clavicle  or  epiphyseal  separation  of  the  head  of  the  hu- 
merus may  also  be  mistaken  for  paralysis.  In  cases  of  long  standing, 
paralysis  of  the  deltoid  may  resemble  dislocation  of  the  humerus.  The 
reaction  of  degeneration  differentiates  paralysis  from  surgical  injuries 
with  similar  deformities. 

The  treatment  consists  in  the  use  of  massage,  manipulation,  and 
electricity,  which  should  be  begun  at  the  end  of  the  first  month,  and 
used  regularly  and  systematically  for  months.  If  the  muscles  respond 
to  faradism  this  may  be  employed,  but  in  most  severe  cases  they  do  not, 
and  galvanism  must  be  used,  according  to  the  rules  laid  down  for  facial 
paralysis.  For  cases  which  do  not  recover  either  spontaneously  or  under 
treatment,  or  show  no  marked  improvement  before  nine  months,  opera- 
tion should  be  considered.  This  consists  in  dissecting  out  and  suturing 
the  nerve  trunks  whose  continuity  has  been  broken  by  the  injury.  A.  S. 
Taylor,  New  York,  from  quite  an  extended  experience,  has  reported 
marked  improvement  in  some  otherwise  hopeless  cases  by  this  operation. 


CHAPTER   VII. 

TUMOURS  OF  THE   UMBILICUS,   MASTITIS,  ETC. 

Granuloma. — This  is  nothing  more  than  a  mass  of  exuberant  granu- 
lations at  the  umbilical  stump.    The  mass  is  generally  about  the  size  of  a 


TUMOURS  OF  THE   UMBILICUS. 


Ill 


pea — sometimes  larger — bleeds  readily,  and  has  a  thin,  purulent  dis- 
charge. It  is  promptly  cured  by  the  application  of  any  simple  astringent; 
powdered  alum  is  probably  the  best.  In  case  this  is  not  successful,  the 
granulations  may  be  touched  with  nitrate  of  silver  or  snipped  off  with 
scissors. 

Adenoma,  Mucous  Polypus,  or  Diverticulum  Tumour — Umbilical  Fis- 
tula.— The  first  three  terms  are  used  synonymously  to  describe  an  um- 
bilical tumour  covered  with  a  mucous  membrane  which  is  similar  in 
structure  to  that  of  the  small  intestine.  It  is  usually  associated  with  an 
umbilical  fistula.  This  tumour  is  formed  by  a  prolapse  at  the  navel  of 
the  mucous  membrane  of  Meckel's  diverticulum.  This  diverticulum  is 
the  remains  of  the  omphalo-mesenteric  duct.  When  it  is  present  in  in- 
fants, it  is  found  in  various  stages  of  development.  Most  frequently 
there  is  a  blind  pouch  a  few  inches  long  given  off  from  the  lower  part 
of  the  ileum.  In  other  cases  it  may  remain  patent  quite  to  the  umbili- 
cus, causing  a  faecal  fistula  (Fig.  19,  A).  As  the  intestine  below  it  is 
generally  normal,  this  fistula  may  persist  for  months  or  even  years, 
giving  rise  to  no  symptoms  except  a  slight  faecal  discharge  from  the 
umbilicus.  In  certain  cases  intestinal  worms  have  been  discharged 
through  it.     It  may  close  spontaneously  or  be  closed  by  operation. 


Fig.  19. — Umbiucal  Fistula  and  Tumours   Produced   by    Prolapse  of   Meckel's 

Diverticulum.  (Barth.) 


A  prolapse  of  the  mucous  membrane  lining  the  diverticulum  produces 
an  umbilical  tumour  with  a  fistula  at  its  summit  (Fig.  19,  B).  This  is 
the  most  common  form.  A  cross-section  shows  under  the  microscope  the 
structure  of  the  intestinal  mucous  membrane  both  as  an  external  cover- 
ing and  lining  of  the  fistulous  tract.  The  prolapse  may  involve  not  only 
the  mucous  membrane  but  the  entire  intestinal  wall.  There  then  exists 
a  conical  tumour  with  a  fistula  wliich  has  but  one  external  opening,  but 
at  a  short  distance  from  the  surface  it  bifurcates,  one  branch  leading 
upward  and  one  downward  (Fig.  19,  C).  A  continuation  of  the  pro- 
lapse gives  a  broad  pedunculated  tumour  (Fig.  19,  D),  which  may  reach 
the  size  of  a  man's  fist.     Its  covering  is  the  same  as  in  the  other  forms. 


112  DISEASES  OF  THE  NEWLY   BORN. 

It  may  contain  several  coils  of  intestine.  In  this  form  there  are  usu- 
ally two  fistulous  openings  {a,  b)  which  communicate  with  the  intestine. 
In  all  of  these  cases  the  tumour  is  smooth,  irreducible,  of  a  rosy  pink 
colour,  and  from  its  surface  there  oozes  a  mucous  discharge.  Microscop- 
ical examination  shows  the  external  covering  to  be  the  same  in  structure 
as  the  intestinal  mucous  membrane.  These  tumours  are  generally  small, 
varying  in  size  from  a  pea  to  a  small  cherry,  but  they  may  be  very  much 
larger.  A  faecal  fistula  usually,  but  not  invariably,  coexists.  In  the  con- 
dition represented  in  Fig.  19.  B,  it  is  easy  to  see  how  an  obliteration  of 
the  fistula  may  occur.  The  small  tumours  are  readily  cured  by  the  liga- 
ture. The  larger  ones  are  usually  associated  with  other  serious  mal- 
formations of  the  intestines,  which  make  the  outlook  bad  in  almost  every 
instance. 

UMBILICAL   HERNIA. 

Hernia  into  the  umbilical  cord  is  a  rare  congenital  condition  of  a 
serious  nature.  It  is  due  to  some  foetal  defect,  and  varies  in  size  from 
a  small  protrusion  to  complete  eventration  in  which  nearly  all  the 
abdominal  organs  are  outside  the  body.  ]\Iany  cases  in  which  only  intes- 
tinal coils  are  contained  in  the  sac,  though  the  tumour  is  quite  large, 
are  amenable  to  surgical  treatment,  which  should  be  instituted  at  once. 
In  the  very  large  ones  the  prognosis  is  bad. 

The  common  umbilical  hernia  is  quite  a  different  condition,  and 
while  a  source  of  much  annoyance  it  is  rarely  serious.  It  is  much  more 
common  in  females  than  in  males,  and  occurs  especially  in  those  who  are 
poorly  nourished  and  rachitic.  The  tumour  is  usually  from  one-fourth 
to  one-half  an  inch  in  diameter;  it  may,  however,  be  very  large,  and  may 
even  become  strangulated,  when  a  surgical  operation  may  become  neces- 
sary. The  ordinary  cases,  however,  require  only  mechanical  treatment. 
The  most  important  thing  is  prevention.  For  this  purpose  it  is  neces- 
sary, after  the  cord  has  separated,  to  place  a  firm  pad  over  the  navel,  and 
to  use  a  snug  abdominal  band  for  the  first  two  or  three  months.  After 
this  period  it  is  uncommon  for  hernia  to  develop.  In  cases  coming  under 
observation  after  the  third  or  fourth  month,  the  pad  and  abdominal 
bandage  are  inadequate,  and  other  means  must  be  employed  to  retain 
the  hernia.  The  best  of  these  consists  in  the  use  of  two  adhesive  strips 
applied  obliquely  over  the  abdomen,  crossing  at  the  umbilicus,  the  skin 
along  the  median  line  being  folded  inward  so  as  to  overlap  the  tumour, 
this  forming  the  retention  pad.  A  simple  method  of  retention  is  to  place 
over  the  tumour  a  coin  or  button  covered  with  kid  and  hold  it  in  position 
by  a  strip  of  adhesive  plaster  ten  or  twelve  inches  long.  One  should  be 
cautious  about  using  the  small  conical  pads  frequently  employed,  as  these 
tend  to  dilate  the  opening  rather  than  to  close  it.  If  the  skin  is  made 
absolutely  clean  and  zinc-oxide  plaster  used,  excoriations  are  rare.    The 


MASTITIS.  113 

dressing  should  be  changed  every  few  days  and  worn  for  several  months. 
After  the  first  year  all  mechanical  treatment  is  unsatisfactory.  For  the 
very  small  tumours  it  is  really  unnecessary  to  use  any  form  of  apparatus, 
since  these  cases  ordinarily  show  little  or  no  tendency  to  increase  in  size, 
and  the  retention  apparatus  causes  more  annoyance  than  the  hernia. 
These  small  herniae  sometimes  disappear  spontaneously  during  childhood, 
and  rarely  need  be  considered  in  children  over  seven  years  of  age.  Oper- 
ation is  seldom  necessary. 

MASTITIS. 

According  to  Guillot,  a  certain  amount  of  secretion  in  the  breasts  of 
the  newly  born  is  physiological.  It  is  certainly  very  common.  It  is  most 
abundant  between  the  eighth  and  fifteenth  days,  but  may  continue  in 
small  quantities  as  late  as  the  third  month.  It  is  seen  with  equal  fre- 
quency in  both  sexes.  The  quantity  of  the  secretion  amounts  in  most 
cases  only  to  a  few  drops;  in  some,  however,  as  much  as  a  drachm  has 
been  obtained.  Chemical  analysis  has  shown  this  secretion  to  be  essen- 
tially the  same  as  the  adult  milk — containing  fat,  sugar,  protein,  and 
salts.  In  gross  appearance  it  resembles  colostrum.  The  researches  of 
Sinety  have  shown  that  the  mammary  gland  of  the  newly  born  contains 
cul-de-sacs  lined  with  secreting  cells,  resembling  those  of  the  adult. 
During  the  period  of  secretion  the  gland  is  slightly  reddened,  its  vessels 
turgid,  and  all  the  signs  of  functional  activity  are  present.  This  condi- 
tion in  itself  is  of  no  practical  importance,  and  in  most  cases,  if  left 
alone,  the  secretion  ceases  spontaneously  after  a  week  or  ten  days.  It 
sometimes  happens,  however,  that  the  presence  of  this  secretion  tempts 
the  nurse  or  attendant  to  rub  or  squeeze  the  breast.  Such  manipulation 
occasionally  leads  to  serious  results  by  exciting  a  mastitis  which  may  ter- 
minate in  abscess.  Mastitis  is  not  a  very  rare  condition,  and  although 
the  inflammation  is  not  usually  severe,  it  may  be  serious  and  even  fatal. 
The  predisposing  cause  is  the  congestion  which  accompanies  functional 
activity,  usually  in  the  second  week.  The  exciting  cause  is  most  often 
some  form  of  traumatism — undue  pressure,  the  squeezing  of  the  breasts, 
or  rough  handling  by  the  nurse.  Through  abrasions  or  fissures  thus  pro- 
duced, micro-organisms  find  a  ready  entrance  with  the  same  result  as  in 
the  adult.  It  seems  possible  that  the  germs  may  enter  through  the  lac- 
tiferous ducts  without  any  abrasion  of  the  skin.  Want  of  cleanliness  is 
always  a  favourable  condition  for  such  infection. 

The  symptoms  of  mastitis  usually  begin  during  the  second  week  of 
life.  There  are  redness,  swelling,  and  the  usual  signs  of  inflammation, 
which  may  terminate  in  resolution  or  in  suppuration.  The  process  may 
be  limited  to  the  mammary  region,  or  a  diffuse  phlegmonous  inflamma- 
tion may  be  set  up,  and  the  case  terminate  fatally.  In  the  female  it  is 
9 


114  DISEASES  OF  THE   NEWLY   BORN. 

possible  for  the  cicatrisation  which  follows  such  an  inflammation  to  in- 
terfere with  the  subsequent  development  of  the  gland.  The  general 
symptoms  are  restlessness,  loss  of  sleep,  disinclination  to  nurse,  and  loss 
of  weight.  In  cases  of  diffuse  phlegmonous  inflammation  the  general 
symptoms  are  those  of  pyogenic  infection. 

Mastitis  is  usually  due  to  want  of  cleanliness  or  traumatism;  the 
parts  should  therefore  be  kept  scrupulously  clean,  and  on  no  account 
should  squeezing  of  the  breasts  be  permitted.  They  should  be  protected 
by  a  simple  cotton  pad.  If  acute  inflammation  develops,  it  should  be 
treated  in  the  beginning  by  hot  applications.  Should  pus  form,  early 
incision  with  free  drainage  and  general  tonic  and  stimulant  treatment 
are  indicated. 

INTESTINAL   OBSTRUCTION. 

The  most  frequent  causes  of  intestinal  obstruction  in  the  newly  born 
are  malformations  of  the  intestine ;  rarely  it  may  be  due  to  pressure  from 
tumours,  or  from  a  persistent  omphalo-mesenteric  duct  or  artery.  The 
various  pathological  conditions  present  in  intestinal  malformations  are 
considered  in  the  chapter  on  Diseases  of  the  Intestines.  The  most  com- 
mon seat  of  obstruction  is  at  the  anus,  the  bowel  being  normally  formed 
throughout,  lacking  only  the  external  orifice.  The  next  most  frequent 
condition  is  obstruction  in  the  rectum,  which  may  be  due  either  to  a 
membranous  septum  in  the  gut,  or  to  obliteration  of  the  tube  for  some 
distance.  These  rectal  obstructions  are  readily  recognised.  By  the  ex- 
amining finger  or  a  bougie  the  lower  limit  of  the  obstruction  can  be  made 
out,  but  there  is  no  means  by  which  the  upper  limit  can  be  determined  ex- 
cept by  opening  tlie  abdomen.  When  the  obstruction  is  above  the  rectum, 
localisation  is  more  difficult ;  but  the  most  frequent  seat  is  the  duodenum. 
Of  38  cases  collected  by  Gaertner,  the  seat  of  obstruction  was  the  duode- 
num in  19  cases,  the  jejunum  in  3,  the  ileum  in  11,  the  colon  in  6,  the 
ileum  and  colon  in  1.    There  is  often  obstruction  at  more  than  one  point. 

The  symptoms  vary  with  the  seat  and  the  degree  of  the  obstruction. 
In  atresia  of  the  anus  or  rectum  there  is  at  first  simply  an  absence  of  all 
discharges  from  the  bowel.  Later  there  is  abdominal  distention  from 
dilatation  of  the  sigmoid  flexure  and  colon.  After  several  days  vomiting 
begins.  If  there  is  atresia  of  the  duodenum  or  any  part  of  the  small 
intestine,  vomiting  begins  early — usually  by  the  second  day  of  life — and 
it  is  persistent.  Nothing  is  passed  from  the  bowels  after  the  first  dark 
discharge  of  the  contents  of  the  colon,  which  is  chiefly  mucus.  There  is 
rapid  asthenia,  and  death  from  inanition  usually  occurs  in  four  or  five 
days.  The  higher  the  obstruction  the  shorter  the  duration  of  life.  If 
the  condition  is  one  of  stenosis  only,  the  symptoms  are  similar  to  those 
described  but  less  severe,  and  life  may  be  prolonged  for  several  weeks,  or 
even  months.    The  constipation  in  these  cases  is  not  absolute.    When  the 


DIAPHRAGMATIC  HERNIA. 


115 


cause  of  obstruction  is  external  pressure,  the  s3'mptoms  do  not  always 
begin  immediately  after  birth.  I  once  saw  a  cliild  in  whom  nothing 
abnormal  was  noticed  for  the  first  three  weeks,  but  at  the  end  of  that 
time  there  developed  all  the  signs  of  acute  intestinal  ol^struction.  Lapa- 
rotomy revealed  a  loop  of  intestine  constricted  by  a  tiny  cord,  which  was 
probably  the  remains  of  the  omphalo-mesenteric  duct. 

Cases  of  imperforate  anus  and  membranous  septum  in  the  rectum  are 
readily  relieved  by  proper  surgical  treatment.  In  the  other  varieties  of 
obstruction,  whether  in  the  rectum,  in  the.  colon,  or  in  the  small  intestine, 
although  life  may  be  prolonged  by  the  formation  of  an  artificial  anus, 
the  ultimate  result  is  almost  invariably  fatal,  death  usually  occurring 
from  marasmus  during  the  early  weeks  of  life. 


DIAPHRAGMATIC   HERNIA. 

This  is  due  to  a  congenital  deficiency  in  the  diaphragm,  which  is 
usually  on  the  left  side.  Of  118  cases  collected  by  Livingston,  83  were 
on  the  left  side,  18  on  the  right,  4  were  central,  2  were  double,  in  1  the 
diaphragm  was  absent.     With  small  openings  only  a  single  coil  of  in- 


FiG.  20,  A. — Diaphragmatic  Hernia  of  the 
Right  Side,  Posterior  View.  Child 
sixteen  months  old. 


Fig.  20,  B. — The  Same,  Immediately  af- 
ter Administration  of  Bismuth  in  Sus- 
pension. Stomach  in  the  right  thoracic 
cavity. 


testine,  with  large  ones  a  considerable  part  of  the  abdominal  contents, 
may  be  found  in  the  thorax.  This  causes  displacement  of  the  heart, 
usually  to  the  right  side,  prevents  the  full  expansion  of  the  left  lung, 
and  if  the  deformity  occurs  early  in  intra-uterine  life  the  lung  may 
remain  rudimentary.  If  a  large  deficiency  exists,  infants  may  live  but 
a  few  hours ;  with  smaller  ones,  life  may  be  prolonged  indefinitely. 


116  DISEASES  OF  THE  NEWLY   BORN. 

The  symptoms  noticed  soon  after  birth  are  usually  cyanosis,  rapid 
respiration,  a  sunken  abdomen,  an  overdistended  chest  and  dyspnoea. 
Children  often  live  but  a  few  hours.  In  those  who  survive  a  longer  time 
dyspnoea  is  generally  the  most  prominent  symptom.  It  may  be  constant, 
it  may  occur  in  severe  paroxysms,  or  there  may  be  attacks  of  cyanosis 
often  of  great  severity,  these  being  produced  by  an  accumulation  of 
gas  in  the  stomach  or  the  thoracic  part  of  the  intestine.  Other  symptoms 
may  at  times  suggest  intestinal  obstruction.  The  physical  signs  vary 
much  from  time  to  time.  Sometimes  those  of  pneumothorax  are  present ; 
at  others  there  is  so  much  dulness  with  the  feeble  respiratory  sounds, 
as  to  suggest  fluid.  The  signs  are  usually  upon  the  left  side,  with  dis- 
placement of  the  heart  to  the  right.  A  positive  diagnosis  can  be  often 
made  by  means  of  the  X-ray  after  the  administration  of  bismuth.  (See 
Figs.  20,  A,  and  20,  B.)     The  condition  is  not  amenable  to  treatment. 

CONGENITAL  STRIDOR. 

This  term  has  been  given  to  a  rather  rare  form  of  dyspnoea  seen  in 
very  young  infants,  beginning  usually  in  the  first  days  of  life.  Kespira- 
tion  is  noisy  and  inspiration  is  accompanied  by  a  marked  croaking,  or 
crowing  sound,  and  with  recession  of  the  soft  parts  of  the  chest  wall, 
which,  especially  at  times  of  excitement,  may  be  very  great,  yet  there 
is  no  cyanosis  and  no  subjective  distress.  In  spite  of  the  apparent  dif- 
ficulty of  respiration  the  child  seems  comfortable.  Expiration  is  usually 
easy  and  voice  and  cry  are  normal.  The  stridor  diminishes  when  the 
child  is  very  quiet  but  usually  does  not  quite  disappear  even  in  sleep. 

The  symptoms  begin  in  most  cases  immediately  after  birth  or  during 
the  first  week  or  ten  days  of  life.  They  may  increase  for  three  or  four 
weeks,  then  remain  about  stationary  until  the  sixth  or  eighth  month; 
after  which  with  the  growth  of  the  larynx  the  dyspnoea  and  stridor 
steadily  diminish.  By  the  end  of  the  second  year  it  is  usually  gone  or 
heard  only  on  occasion. 

For  our  knowledge  of  this  affection  we  are  especially  indebted  to  the 
observations  of  Thomson,  of  Edinburgh,  who  believes  that  the  condition 
is  primarily  functional  and  due  to  a  want  of  jjroper  co-ordination  of 
the  respiratory  muscles.  Secondarily  there  is  produced  a  folding  of  the 
epiglottis  upon  itself  along  the  median  line,  so  that  its  lateral  borders 
approximate  each  other.  In  many  of  the  cases  reported,  however,  the 
change  in  the  larynx  seems  to  be  rather  a  malformation  especially  of  the 
epiglottis,  which  greatly  narrows  the  superior  opening  of  the  larynx. 
Congenital  stridor  is  favoured  by  the  soft  collapsible  character  of  the 
structures  of  the  larynx  in  young  infants  and  the  strong  suction  force 
of  inspiration. 

The  prognosis  in  most  of  these  cases  is  good,  the  chief  dangers  being 


SCLEREMA.  117 

from  intercurrent  disease  ©r  from  broncho-pneumonia.  Considerable  de- 
formity of  the  thorax  may  be  produced  (pigeon  breast)  which  may  per- 
sist to  later  childhood. 

The  diagnostic  features  of  congenital  stridor  are  the  noisy  respiration 
with  marked  inspiratory  dyspnoea  and  crowing,  with  tlie  absence  of  dis- 
tress or  subjective  symptoms  of  any  kind.  It  seems  to  be  more  frequent 
in  delicate  children.  Conditions  with  which  it  may  be  confounded  are 
papilloma  of  the  larynx,  laryngismus  stridulus,  catarrhal  croup,  and 
laryngeal  spasm  associated  with  adenoids.  The  first  three  of  these  are 
excluded  by  the  history  and  by  the  absence  of  changes  in  tlie  voice; 
the  last  one  by  the  fact  that  the  child  is  not  a  mouth  breather,  that  the 
dyspnoea  is  not  increased  by  closing  the  mouth. 

Congenital  stridor  is  not  amenable  to  special  treatment.  Should  the 
dyspnoea  reach  an  alarming  degree  tracheotomy  may  be  performed.  The 
indications  are  to  maintain  the  child's  general  nutrition  and  to  protect 
it,  so  far  as  possible,  from  diseases  of  the  upper  respiratory  tract. 

SCLEREMA. 

Sclerema  is  a  condition  characterised  by  hardening  of  the  skin  and 
subcutaneous  tissues.  It  may  occur  in  circumscribed  areas  or  extend 
over  nearly  the  entire  body.  It  affects  infants  who  are  very  feeble  and 
usually  terminates  fatally.  Although  sclerema  is  chiefly  seen  in  the 
first  days  of  life  it  is  not  limited  to  the  newly  born,  but  may  occur  at 
any  time  during  the  first  few  months.  It  is  not  to  be  confounded  with 
oedema  of  the  newly  born,  with  which  condition  it  is,  however,  sometimes 
associated.  From  published  reports  it  appears  to  be  of  not  very  in- 
frequent occurrence  in  Europe,  chiefly  in  large  foundling  asylums.  In 
America,  sclerema  is  not  a  common  disease.  In  the  newly  born,  sclerema 
affects  those  who  are  premature  or  very  feeble,  sometimes  those  who  are 
syphilitic.  Later  it  may  follow  any  condition  leading  to  extreme  ex- 
haustion, especially  the  different  forms  of  diarrhceal  disease. 

The  first  thing  to  attract  attention  is  usually  the  induration  of  the 
skin.  It  is  often  seen  first  in  the  calves  or  the  dorsum  of  the  feet, 
sometimes  first  in  the  cheeks,  but  soon  extends  over  the  greater  part  of 
the  body.  It  is  especially  marked  in  the  cheeks,  buttocks,  thighs  and 
back,  and  regions  where  adipose  tissue  is  abundant.  It  may  affect  the 
body  uniformly  or  in  circumscribed  areas.  The  skin  may  be  smooth  or 
it  may  appear  somewhat  lobulated.  The  colour  is  normal  or  slightly 
bluish,  often  tinged  with  yellow.  The  lips  are  blue,  and  the  capillary 
circulation  so  feeble  that  after  pressure  upon  the  nails  the  blood  returns 
slowly  or  not  at  all.  The  limbs  are  stiff  and  board-like.  The  skin  is  cold 
to  the  touch,  and  often  the  thermometer  in  the  axilla  will  not  rise  above 
90°  F.     In  one  recorded  case  the  axillary  temperature  was  only  71°  F. 


118  DISEASES  OF  THE   NEWLY   BORN. 

The  general  feeling  of  the  body  has  been  well  likened  to  that  of  a  half- 
frozen  cadaver.  The  tongufe  and  the  mucous  nicml)rane  of  the  mouth 
are  cold ;  no  radial  pulse  can  be  felt ;  the  respiration  is  slow,  irregular, 
embarrassed,  and  at  times  the  movements  of  the  thorax  are  scarcely 
perceptible.  The  cry  is  a  feeble  whine,  scarcely  audible.  The  duration 
of  the  disease  is  usually  from  three  to  four  days.  Death  occurs  slowly 
and  quietly.  If  recovery  takes  place  there  is  gradual  improvement  in 
the  circulation  and  nutrition,  and,  later,  a  disappearance  of  the  areas 
of  induration. 

The  causes  of  sclerema  are  general,  the  most  important  factors  being 
loss  of  fluids,  great  feebleness  with  lowering  of  the  body  temperature, 
and,  in  consequence,  hardening  of  the  subcutaneous  fat.  There  are  no 
essential  lesions  in  this  disease.  Atelectasis  is  often  present,  and  may 
have  something  more  than  an  accidental  association,  as  incomplete 
aeration  of  the  blood  is  no  doubt  a  factor  in  the  production  of  the  symp- 
toms. Microscopical  examination  has  shown  the  skin  to  be  normal  in 
typical  cases. 

The  prognosis  is  very  bad,  because  of  the  grave  conditions  of  which  it 
is  the  expression,  but  it  is  not  invariably  fatal.  In  its  milder  forms, 
where  treatment  is  begun  early,  recovery  may  take  place.  The  diagnosis 
is  to  be  made  from  oedema  by  the  fact  that  there  is  no  pitting  upon 
pressure,  by  the  rigidity  of  the  body,  and  by  the  great  reduction  in  the 
temperature.  The  most  important  thing  in  treatment  is  artificial  heat; 
nothing  but  the  incubator  is  efficient.  In  addition  to  this,  care  should 
be  taken  to  promote  the  general  nutrition  by  careful  feeding  and  by 
all  other  means  possible. 

INANITION   FEVER. 

The  term  inanition  fever  is  not  altogether  a  satisfactory  one;  but, 
until  these  cases  are  better  understood,  it  is  adopted  because  it  empha- 
sises the  very  close  connection  which  exists  between  the  rise  of  tempera- 
ture and  the  condition  of  inanition  or  starvation.  Under  this  heading 
are  included  cases  seen  during  tlie  first  five  days  of  life — generally  from 
the  second  to  the  fourth  day — in  which  there  is  an  elevation  of  tem- 
perature, apparently  due  to  the  fact  that  the  infant  gets  very  little, 
frequently  nothing  at  all,  from  the  breast  at  which  it  is  l)eing  suckled. 
It  is  further  characteristic  of  these  cases  that  the  temperature  falls  when 
the  child  is  put  upon  a  full  breast,  or  when  artificial  feeding  is  begun, 
or  even  when  water  is  administered,  if  freely  given.  Some  have  ascribed 
the  symptoms  to  uric-acid  infarction  of  the  kidneys. 

So  far  as  my  knowledge  goes,  the.  first  to  call  attention  to  this  con- 
dition was  McLane  (New  York),  who  in  1890  reported  to  one  of  the 
medical  societies  an  extraordinary  case  of  hyperpyrexia  in  a  newly-born 


INANITION   FEVER.  119 

child.  The  infant  was  found  on  the  sixth  day  with  a  temperature  of 
106°  F.,  near  which  point  it  had  remained  for  three  days.  The  child 
was  being  suckled  at  a  breast  which  was  found  to  be  absolutely  dry. 
A  wet-nurse  was  procured,  the  temperature  fell  to  normal  in  a  few 
hours,  and  the  child,  which  when  first  seen  was  apparently  in  a  hopeless 
condition,  was  soon  perfectly  well. 

Since  that  time  very  extensive  observations,  extending  to  upward  of 
three  thousand  cases,  have  been  made  at  the  Sloane  Maternity  and  Nurs- 
ery and  Child's  Hospitals,  which  have  established  the  fact  that  a  rise  of 
temperature  to  102°  or  even  104°  F.  is  quite  common  in  newly-born 
infants  during  the  first  few  days.  This  fever  is  accompanied  by  no  evi- 
dences of  local  disease,  and  ceases  in  nursing  infants  with  the  establish- 
ment of  the  free  secretion  of  milk.  The  fall  in  temperature  is  often 
rapid,  dropping  to  the  normal  in  a  few  hours  after  having  continued 
for  three  or  four  days,  and  in  a  large  number  of  cases  it  does  not  rise 
again. 

The  following  case  is  a  fairly  typical  one  of  the  more  severe  form: 
The  patient  was  the  second  child,  the  first  having  died  at  the  age-  of 
ten  days,  from  no  disease,  it  was  said,  but  simply  from  exhaustion.  At 
birth  the  infant,  a  boy,  weighed  eight  and  a  quarter  pounds  and  was 
apparently  vigorous.  During  the  first  forty-eight  hours  his  loss  in 
weight  was  five  and  a  half  ounces  and  his  condition  good.  I  saw  him  on 
the  evening  of  the  third  day.  In  the  preceding  twenty-four  hours  he 
had  lost  eight  ounces  in  weight,  and  the  temperature  had  gradually 
risen,  until  at  the  time  of  my  visit  it  was  102.8°  F.  The  body  was  limp, 
the  child  making  no  resistance  to  examination.  He  cried  with  a  feeble 
whine;  the  restlessness  of  the  early  part  of  the  day  having  given  place 
to  complete  apathy.  The  lips  and  skin  were  very  dry,  the  fontanel 
sunken,  the  pulse  weak.  As  the  father,  a  physician,  expressed  it,  "  he 
had  been  wilting  through  the  day  like  a  flower  in  the  sun."  Although 
put  to  the  breast  regularly,  the  child  had  apparently  ol)tained  very  little. 
It  was,  in  fact,  impossible  to  squeeze  any  milk  from  the  mother's  breasts. 
"Water  was  freely  given  and  a  wet-nurse  secured  in  a  few  hours.  The 
first  milk  was  taken  from  the  wet-nurse  at  11  p.m.,  and  the  temperature, 
which  fell  gradually  during  the  night,  was  normal  the  next  morning 
and  did  not  rise  again.  (See  chart.  Fig.  21.)  During  the  succeeding 
four  days  the  child  gained  eighteen  ounces  in  weight,  and  at  the  end 
of  a  week  was  as  well  as  an  average  infant  of  his  age. 

The  symptoms  are  so  uniform  and  so  characteristic  that  they  make 
for  these  cases  of  fever  a  class  by  themselves.  The  frequency  with  which 
this  is  seen  is  shown  by  the  following  statistics :  Among  200  infants 
taken  successively  at  the  Nursery  and  Child's  Hospital,  20  had  fever 
during  the  first  five  days,  reaching  101°  F.  or  over,  which  was  not  ex- 
plained by  ordinary  causes  and  followed  the  course  above  described.    In 


120 


DISEASES  OF  THE   NEWLY   BORN. 


103' 


101° 


100 


' 

i 

3     1 

, 

5 

c 

- 

8     1 

1 

A 

/ 

/ 

' 

1 

<^ 

/ 

' 

J 

■% 

r 

s 

■^ 

"vj 

/v 

f 

>J 

Fig.  21. — Temperature  Chart. 
Fever. 


Inanition 


500  successive  children  born  at  the  Sloane  Maternity  Hospital,  there 
were  135  with  a  similar  fever.  It  was  seen  in  vigorous  infants  as  well 
as  in  those  who  were  delicate.     The  usual  duration  of  the  fever  was 

three  days,  the  temperature  gen- 
erally touching  the  highest  point 
upon  the  tliird  or  fourth  day  of 
life.  In  about  two-thirds  of  the 
cases  the  temperature  did  not  rise 
above  102°  F.;  in  9  it  was  104° 
r.  or  over,  the  highest  recorded 
being  106°  F.  The  fall  was  gen- 
erally quite  abrupt,  although  not 
always  so.  Daily  weighings,  which 
were  made  in  these  cases,  showed 
that  the  infants  continued  to  lose 
weight  while  the  fever  continued, 
and  that  the  loss  almost  invari- 
ably exceeded  by  several  ounces 
that  of  the  children  who  had  no 
fever.  The  maximum  loss  noted 
was  twenty-eight  ounces.  In  quite 
a  large  number  of  cases  it  ex- 
ceeded twenty  ounces.  As  a  rule  the  infants  began  to  gain  in  weight 
when  the  temperature  remained  at  the  normal  point,  but  not  until  then. 
The  symptoms  presented  by  these  infants  were  a  hot,  dry  skin, 
marked  restlessness,  dry  lips,  and  a  disposition  to  suck  vigorously  any- 
thing within  reach.  With  very  high  temperature  there  were  considerable 
prostration  and  weakened  pulse.  In  the  less  severe  cases  there  were  only 
crying  and  restlessness.  The  rapidity  with  which  the  symptoms  dis- 
appeared when  the  children  were  wet-nursed  or  properly  fed,  was  very 
striking. 

It  is  important  that  this  fever  should  be  recognised,  because  it  gives 
at  times  the  first  warning  of  a  condition  which  may  prove  fatal.  The 
extra  loss  of  ten  or  fifteen  ounces  in  the  first  week,  is  a  serious  handicap 
to  newly-born  infants,  the  effect  of  which  may  last  for  several  weeks. 
The  temperature  of  every  child  should  be  taken  during  the  first  week. 
All  the  usual  local  causes  of  fever  are  first  to  be  excluded  by  a  physical 
examination.  This  fever  can  hardly  be  confounded  with  that  due  to 
pyogenic  infection,  which  rarely  begins  before  the  fifth  or  sixth  day. 

The  treatment  is  simple,  viz.,  to  give  water  regularly  every  two  hours, 
in  quantities  up  to  an  ounce  at  a  time  if  required  by  the  thirst  of  the 
child.  This  should  be  done  in  every  case  where  the  temperature  reaches 
101°  F.  When  the  temperature  does  not  at  once  begin  to  fall,  the  infant 
should  be  put  upon  another  breast  or  artificial  feeding  should  be  begun. 


INANITION   FEVER.  121 

Examination  of  the  breasts  from  which  the  child  has  been  nursing  will 
usually  reveal  the  fact  that  the  secretion  of  milk  is  very  scanty  and  often 
entirely  absent. 

Such  a  fever  I  have  occasionally  seen  in  older  infants,  usually  in 
those  who  are  nursing  dry  breasts  or  where  fluid  food  and  water  have 
been  withheld  because  of  some  gastric  disturbance.  It  yields  as  promptly 
to  treatment  as  does  the  same  condition  in  the  newly  born. 


SECTION   II. 
NUTRITION. 

CHAPTER    I. 
INTRODUCTORY. 

Nutrition  in  its  broadest  sense  is  the  most  important  branch  of 
paediatrics.  In  no  other  field  and  at  no  other  time  of  life  does  prophy- 
laxis give  such  results  as  in  the  conditions  of  nutrition  in  infancy.  The 
largest  part  of  the  immense  mortality  of  the  first  year  is  traceable 
directly  to  disorders  of  nutrition.  The  importance  of  correct  ideas  re- 
garding this  subject  can  hardly  be  overestimated.  The  problem  is  not 
simply  to  save  life  during  the  perilous  first  year,  but  to  adopt  those 
means  which  shall  tend  to  healthy  growth  and  normal  development. 
The  child  must  be  fed  so  as  to  avoid  not  only  the  immediate  dangers  of 
acute  indigestion,  diarrlioea,  and  marasmus,  but  the  more  remote  ones  of 
chronic  indigestion,  rickets,  scurvy,  and  general  malnutrition,  since 
these  conditions  are  the  most  important  predisposing  causes  of  acute 
disease  in  early  life. 

One  of  the  difficulties  has  always  been  that  temporary  success  may 
mean  ultimate  failure.  If  the  injurious  effects  of  improper  feeding  were 
immediately  manifest,  there  would  be  very  much  less  of  it  than  exists 
at  the  present  time.  Many  things  are  valuable  as  temporary  foods, 
which  when  used  permanently  are  injurious.  No  better  illustration  of 
this  is  seen  than  in  the  too  exclusive  use  of  the  carbohydrate  foods.  In- 
fants fed  upon  many  of  the  proprietary  foods  often  grow  very  fat,  and 
for  the  time  appear  to  be  properly  nourished.  The  effect  of  the  absence 
from  the  diet  of  some  of  tiiose  elements  which  are  of  vital  importance 
may  not  be  evident  for  months.  Th(?  physiological  laws  regarding  the 
requirements  of  the  growing  organism  cannot  be  ignored  without  serious 
consequences,  which  will  sooner  or  later  be  evident.  Correct  ideas  of 
infant  feeding  are  based  upon  a  knowledge  of  these  laws.  An  accurate 
understanding  of  fundamental  principles  is  essential  to  success  and  the 
vast  majority  of  failures  may  be  ascribed  to  ignorance  or  disregard  of 
them. 

122 


THE  FOOD  CONSTITUENTS.  123 


THE  FOOD  CONSTITUENTS  AND  THE   PURPOSES  THEY  SUBSERVE 

IN    NUTRITION. 

In  infancy  and  childhood,  as  in  adult  life,  tho  elements  of  the  food 
are  five  in  number:  protein,  fat,  carbohydrates,  mineral  salts,  and  water. 
The  forms  in  which  they  must  be  furnished  to  the  child,  and  the  relative 
quantities  in  which  they  are  demanded,  are  different  from  those  required 
by  the  adult.  One  reason  for  this  difference  is  the  delicate  structure  of 
the  organs  of  digestion  in  infancy,  and  their  inability  to  assimilate  cer- 
tain forms  of  food.  Again,  provision  must  be  made  not  only  for  the 
natural  waste  of  the  body,  but  for  its  rapid  growth,  nearly  trebling  in 
size,  as  it  does,  during  the  first  twelve  months. 

Protein. — Protein  is  essential  to  life,  since  it  is  tlie  only  kind  of 
food  which  is  capable  of  replacing  the  continuous  nitrogenous  waste  of 
the  cells  of  the  body,  upon  which  health  depends.  Protein  is  also  in- 
dispensable for  the  growth  of  the  cells  of  the  body.  In  the  adult  only 
the  requirements  of  repair  are  to  be  supplied.  In  the  child  a  much 
larger  amount  is  demanded  to  provide  for  growth.  Protein  should  not 
be  called  upon  to  supply  animal  heat,  althougli  without  the  aid  either 
of  the  fats  or  the  carbohydrates,  protein  may  sustain  life  for  a  consider- 
able time ;  but  in  so  doing  a  great  excess  of  such  food  is  required.  Such 
a  diet  taxes  severely  the  digestive  organs  and  those  of  elimination. 
When,  however,  fats  and  carbohydrates  are  added  to  the  food,  only  one- 
half  or  one-third  as  much  protein  is  required  to  replace  the  nitrogenous 
waste,  as  in  the  case  of  an  exclusive  protein  diet. 

Of  all  the  forms  in  which  protein  food  may  be  furnished  to  the  body, 
in  proportion  to  its  nitrogen  content,  milk  taxes  the  digestive  organs 
least.  This  fact  is  of  the  greatest  importance  and  indicates  the  superior- 
ity of  milk  as  a  food,  not  only  for  the  first  year  but  throughout  child- 
hood. The  most  easily  digested  protein  is  that  of  woman's  milk.  Regard- 
ing the  protein  of  cow's  milk  there  is  no  doubt  that  the  view  formerly 
held  that  it  was  very  difficult  of  digestion  was  erroneous.  On  the 
contrary  under  most  conditions  it  is  digested  and  absorbed  with  facil- 
ity. During  the  first  year  milk  furnishes  all  the  protein  that  is  needed 
for  proper  nutrition.  During  the  second  year  meat,  eggs,  etc.,  may  be 
advantageously  added  to  the  diet. 

The  digestion  of  the  protein  is  begun  in  the  stomach  but  is  prin- 
cipally carried  on  in  the  intestines. 

The  protein  molecule  is  a  very  complex  one  when  compared  with  that 
of  the  fats  or  the  carbohydrates.  Growing  out  of  this  complexity  of 
structure  is  the  possibility  of  an  immense  number  of  side-products  which 
may  be  formed  by  the  splitting  up  of  the  protein  molecule  by  digestive 
ferments,  or  by  the  numbers  and  varieties  of  bacteria  found  in  the 
intestine.     While  the  products  of  decomposition  of  the  carbohydrates 


124  NUTRITION. 

are  often  irritating,  those  formed  from  the  protein  may  at  times  be 
toxic  and  may  be  the  cause  of  obscure  and  severe  clinical  conditions. 

The  prolonged  use  of  a  diet  in  which  the  protein  is  insufficient  in 
amount  or  of  an  unsuitable  form,  produces  a  certain  definite  group  of 
symptoms  which  are  not  always  referred  to  their  proper  cause.  In 
infants  the  most  striking  are  anaemia,  poor  circulation,  feeble  muscular 
power,  disinclination  to  exertion,  and  various  functional  nervous  dis- 
turbances. Such  children  are  often  very  fat.  The  vegetable  protein 
cannot  permanently  take  the  place  of  the  animal  protein  in  the  food 
of  young  infants. 

Fats. — Fats  are  the  most  important  source  of  animal  heat,  their 
caloric  value  being  a  little  more  than  twice  as  great  as  that  of  the  carbo- 
hydrates or  the  protein.  They  save  nitrogenous  waste.  The  fats  and 
carbohydrates  should  be  supplied  in  the  food  in  such  amount  that  the 
entire  energy  of  the  protein  may  be  utilized  for  the  growth  and  the 
nutrition  of  the  cells  of  the  body  without  being  drawn  upon  to  furnish 
animal  heat.  Fats  increase  the  body  weight.  The  large  amount  of  fat 
stored  up  in  the  subcutaneous  tissues  in  infancy  is  one  of  the  best  evi- 
dences of  healtli. 

The  fats  supply  important  elements  needed  for  the  normal  develop- 
ment of  the  nervous  system.  This  fact  is  probably  connected  with  the 
large  amount  of  fat  of  various  forms  which  the  nerve  structures  con- 
tain. It  is  a  familiar  clinical  fact  that  functional  nervous  disorders  are 
exceedingly  common  as  a  result  of  the  long-continued  use  of  foods  low 
in  fat.  Many  such  disturbances  commonly  seen  with  rickets  are  regarded 
by  some  as  a  consequence  of  fat-starvation. 

In  the  growth  of  bone  the  fats  play  an  important  role.  The  fatty 
acids  formed  in  the  intestine  by  the  splitting  up  of  the  neutral  fats  of 
the  food,  combine  with  the  insoluble  salts  of  lime  and  magnesium  and 
in  this  way,  chiefly,  these  substances  necessary  for  the  growth  of  the 
skeleton  are  absorbed.  Normal  bony  development,  therefore,  .suffers  if 
the  food  is  low  in  fat. 

The  unabsorbed  fats  have  a  distinct  value  in  preserving  the  proper 
consistency  of  the  faecal  mass.  While  neither  the  protein  of  milk  nor 
the  milk  sugar  appears  as  such  in  the  stools  of  the  nursing  infant,  fat  is 
abundant.  It  forms  normally  from  twenty  to  thirty  per  cent  of  the  dry 
substance  of  the  stool.  The  amount  furnished  to  the  infant  is,  there- 
fore, considerably  in  excess  of  the  needs  of  the  body  for  nutrition.  The 
use  of  this  excess  seems  to  be  to  increase  the  volume  of  the  stool  and  to 
keep  the  mass  so  soft  as  to  be  easily  expelled. 

The  amount  of  fat  required  in  infancy  is  relatively  much  greater 
than  in  adult  life.  A  well-nourished  nursing  infant  weighing  fifteen 
pounds  actually  receives  about  one-half  as  much  fat  as  is  allowed  in  a 
ration  for  an  adult  doing  moderate  work,  who  weighs  ten  times  as  much. 


THE  FOOD  CONSTITUENTS.  125 

The  form  in  which  fat  is  supplied  during  the  first  year  is  the  butter- 
fat  of  milk.  There  are  marked  differences  in  the  fats  of  woman's  and 
cow's  milk,  which  to  an  important  degree  affect  their  digestibility. 
These  are  more  fully  considered  later.  Fats  should  be  supplied  liberally 
throughout  childhood  in  the  form  of  cream,  eggs,  butter,  olive  or  cod- 
liver  oil. 

While  it  is  evident  from  the  foregoing  that  the  fat  requirements  of 
the  young  child  are  great,  it  must  also  be  remembered  that  in  certain 
conditions  even  the  normal  amount  of  fat  is  badly  borne  and  may  do 
positive  harm.  Fats  do  not  readily  form  products  injurious  to  the  econ- 
omy as  a  consequence  of  imperfect  digestion,  but  the  amount  given 
should  be  very  greatly  reduced  in  the  following  circumstances:  (1)  All 
wasting  conditions  depending  upon  disorders  of  digestion,  whether  due 
to  functional  derangement  of  the  stomach,  intestine,  liver,  or  pancreas, 
or  to  chronic  catarrhal  inflammations  of  the  stomach  or  intestine;  (2) 
all  acute  disorders  of  digestion  or  acute  inflammations  of  the  stomach 
or  intestines;  (3)  all  febrile  conditions,  no  matter  from  what  cause; 
(4)  during  periods  of  very  hot  weather.  A  failure  to  regard  these 
contraindications  is  a  constant  source  of  trouble  in  practice. 

In  the  conditions  just  enumerated  the  fats  must  largely  be  replaced 
by  the  carbohydrates,  as  these  substances  are  capable  for  the  time  being 
of  assuming  the  functions  of  the  fats,  and  besides  are  easily  digested  and 
assimilated.  Such  substitution  should  not  be  continued  too  long,  as 
serious  results  may  follow. 

Carbohydrates. — Although  these,  like  the  fats,  can  not  replace  the 
nitrogenous  waste  of  the  body,  they  are  important  aids  to  the  protein, 
and  in  this  respect  they  are  even  more  valuable  than  the  fats.  The 
carbohydrates  are  partly  converted  into  fats,  and  may  thus  increase  the 
body  weight.  They  are  capable  of  replacing  the  fat-waste  of  the  body. 
They  are  one  of  the  most  important  sources  of  animal  heat. 

Carbohydrates  are  the  most  abundant  of  the  solid  elements  of  the 
food,  although  they  form  a  smaller  percentage  of  the  entire  quantity 
of  food  in  infancy  than  in  adult  life.  The  soluble  carbohydrates  which 
are  used  as  foods  for  children  are  milk  sugar,  cane  sugar,  and  maltose. 
Since  all  of  these  are  converted  by  digestion  into  glucose  they  are  to  a 
certain  degree  interchangeable.  In  selecting  milk  sugar  as  the  chief 
carbohydrate  for  the  first  year,  we  are  following  Nature,  for  this  is 
what  is  furnished  in  the  milk  of  all  mammals.  Milk  sugar  has  a  decided 
advantage  in  not  fermenting  with  the  common  varieties  of  yeast  present 
in  the  stomach,  as  do  both  maltose  and  cane  sugar.  Like  the  other 
sugars,  however,  milk  sugar  does  readily  undergo  fermentation  in  the 
intestine  by  the  action  of  bacteria. 

The  ability  of  the  young  infant  to  digest  starches  is  relatively  feeble, 
although  this  power  does  exist  to  some  degree  from  birth ;  but  the  greater 


126  NUTRITION. 

part  of  the  carbohydrates  required  should  be  furnished  in  the  form  of 
sugars.  To  infants  of  four  months  and  over,  starches  may  at  times 
advantageously  be  added  to  the  diet,  and  after  eight  months  the  quantity 
may  be  considerably  increased.  But  in  whatever  form  or  quantity  used 
thorough  cooking  is  indispensable.  Insufficient  cooking  is  responsible 
for  much  of  the  starch  indigestion  seen  in  young  children. 

The  advantages  of  the  carbohydrates  as  foods  depend  upon  their  easy 
digestibility.  The  transformation  of  any  of  the  sugars  into  glucose  is  a 
relatively  slight  chemical  change,  when  compared  with  that  which  is 
necessary  in  the  fats  or  protein  before  they  can  be  absorbed. 

The  carbohydrates  are  at  a  great  disadvantage  on  account  of  the  readi- 
ness with  which  they  undergo  fermentation  in  different  parts  of  the 
alimentary  tract.  To  such  fermentation  are  due  many  of  the  symptoms 
seen  in  the  common  functional  disorders  of  digestion. 

A  diet  consisting  too  exclusively  of  carbohydrates  leads  often  to  a 
rapid  increase  in  weight,  but  it  is  not  accompanied  by  a  proportionate 
increase  in  strength.  Infants  so  fed  have  but  little  resistance,  and  many 
of  them  become  rachitic.  The  easy  digestion  of  foods  consisting  chiefly 
of  soluble  carbohydrates,  such  as  condensed  milk  and  the  proprietary 
infant  foods,  and  the  rapidity  with  which  children  so  fed  gain  in  weight, 
lead  to  a  great  misapprehension  in  regard  to  their  value  as  foods.  The 
ultimate  results  of  such  one-sided  feeding,  if  long  continued,  are  almost 
invariably  disastrous. 

In  building  up  the  cells  of  the  body  the  protein  is  first  in  impor- 
tance, the  carbohydrates  second,  and  the  fats  third.  In  the  production 
of  animal  heat  the  fats  come  first,  the  carbohydrates  second ;  practically 
the  protein  should  never  be  called  upon  for  this  purpose.  In  a  proper 
diet,  all  of  these  elements  are  represented. 

Mineral  Salts. — These  are  relatively  of  greater  importance  in  infancy 
than  in  later  life,  because  of  the  rapid  development  of  the  skeleton  dur- 
ing infancy  and  early  childhood.  The  most  important  for  this  purpose 
are  the  phosphates  of  lime  and  magnesium.  These  are  furnished  in 
abundance  both  in  woman's  and  cow's  milk;  but  are  deficient  in  prac- 
tically all  the  substitutes  for  milk.  Salts  are  necessary  for  cell  growth. 
They  furnish  the  elements  from  which  the  mineral  constituents  of  the 
blood  and  digestive  fluids  are  formed,  and  facilitate  absorption,  excretion, 
and  secretion.  In  fact,  no  function  of  the  body  is  possible  without  the 
presence  of  salts  in  their  proper  proportions. 

Water. — The  food  of  all  young  mammals  consists  of  from  eighty  to 
ninety  per  cent  of  water.  This  is  needed  for  the  solution  of  certain  parts 
of  the  food,  such  as  the  sugar,  the  salts,  and  some  of  the  protein,  and  for 
the  suspension  of  other  protein  and  the  emulsified  fat.  All  the  food 
is  thus  dissolved  or  very  finely  divided  so  as  to  be  more  readily  acted  upon 
by  the  delicate  digestive  organs  of  the  infant.     Water  is  needed  also  in 


WOMAN'S   MILK.  127 

large  quantities  for  the  rapid  elimingtion  of  the  waste  of  the  body.  In 
proportion  to  its  weight,  an  average  infant  during  the  first  year  requires 
about  five  times  as  much  water  as  an  adult.  During  tlie  time  when  the 
child  is  upon  an  entirely  fluid  diet,  tlie  addition  of  much  water  other 
than  that  supplied  by  the  food  is  unnecessary ;  l)ut  when  the  number  of 
feedings  becomes  less  frequent,  and  solid  food  is  given  in  larger  quanti- 
ties, water  should  be  given  freely  between  the  feedings  at  all  seasons,  but 
especially  in  the  summer. 

Caloric  Values. — The  different  foodstuffs  liave  different  caloric  values: 

One  gramme  of  fat  yields 9.3  calories 

"        "  carbohydrate  yields 4.1 

"  "        "  protein  yields 4.1        " 

It  is  important  that  these  caloric  values  should  be  considered  in  the 
dietary  of  the  child.  The  practical  application  of  the.se  facts  is  taken  up 
in  connection  with  the  subject  of  infant  feeding. 


CHAPTER    II. 
THE  INFANT'S  DIETARY. 

WOMAN'S   MILK. 

Woman's  milk  is  the  ideal  infant-food.  A  thorough  knowledge  of 
its  character,  exact  composition,  and  variations  is  indispensable,  for  upon 
this  knowledge  are  based  all  our  rules  for  the  preparation  of  foods  used 
as  substitutes  for  woman's  milk  when  this  can  not  be  obtained. 

Woman's  milk  is  a  secretion  of  the  mammary  glands  and  not  a  mere 
transudation  from  the  blood-vessels ;  although  under  abnormal  conditions 
it  may  partake  more  of  the  character  of  a  transudation  than  a  secretion. 
A  few  drops  may  be  squeezed  from  the  breasts  before  parturition ;  gen- 
erally speaking,  however,  it  is  only  present  after  delivery.  During  the 
first  two  days  the  secretion  is  scanty.  Usually  upon  the  third  or  fourth 
day  it  becomes  well  established,  although  it  may  be  delayed  several  days 
longer  and  yet  become  abundant.  During  the  period  of  lactation,  milk 
is  constantly  formed  in  the  mammary  glands,  but  the  process  is  more 
active  while  the  child  is  at  the  breast. 

Physical  Characters. — Woman's  milk  is  of  a  bluish-white  colour  and 
quite  sweet  to  the  taste.  When  freshly  drawn  its  reaction  is  ampho- 
teric to  litmus,  or  slightly  acid  to  phenolphthalein.  The  specific  gravity 
varies  between  1.026  and  1.036,  the  average  being  1.031  at  60°  F.  On 
the  addition  of  acetic  acid  only  a  slight  coagulation  is  seen,  this  being 
in  the  form  of  small  flocculi,  and  never  in  large  masses  as  is  the  case 


128 


NUTRITION. 


in  cow's  milk.  Microscopically,  there  are  seen  great  numbers  of  fat- 
globules  nearly  uniform  in  size  and  some  granular  matter.  Occasion- 
ally there  are  present  epithelial  cells  from  the  milk-ducts  or  from  the 
nipple. 

Colostnim. — The  secretion  of  the  first  three  or  four  days  differs  quite 
markedly  from  the  later  milk.  To  this  the  name  colostrum  has  been 
given.     It  is  of  a  deep  yellow  colour,  which  is  chiefly  due  to  the  colos- 


Fio.  22,  A. — Colostrum.     (Funke.)  Fig.  22,  B. — Woman's  Milk  at  a  Lath 

Period.     (Funke.) 

trum-corpuscles.  It  is  not  so  sweet  as  the  later  milk.  It  has  a  specific 
gravity  of  1 .  030  to  1 .  040,  a  strongly  alkaline  reaction,  and  is  coagulated 
into  solid  masses  by  heat,  and  sometimes  coagulates  spontaneously.  It  is 
very  rich  in  protein  and  in  salts.  Microscopically  the  fat-globules  are  of 
unequal  size,  and  there  are  present  large  numbers  of  granular  bodies 
known  as  colostrum-corpuscles  (Fig.  22,  A).  These  are  four  or  five 
times  the  size  of  the  milk-globules  (Fig.  22,  B),  and  they  are  probably 
leucocytes  in  which  are  contained  numerous  fat  granules.  They  are 
much  larger  than  ordinary  leucocytes  and  are  nucleated. 

Composition  of  Colostrum. 

Protein 5  .  71 

Fat 2.  04 

Sugar 3 .  74 

Salts 0.28 

Water 88.23 

100.00 

The  colostrum-corpuscles  are  very  abundant  during  the  first  few  days, 
but  under  normal  conditions  they  are  not  found  after  the  tenth  or 
twelfth  day. 

Daily  Quantity. — Exact  inforrtiation  upon  this  point  is  difficult  to 
obtain.     There  are  recorded,  however,  extended  observations  made  with 


WOMAN'S   MILK. 


129 


great  care  upon  eight  cases/  from  which  some  deductions  may  safely  be 
drawn.  All  were  healthy  infants,  nursing  exclusively  and  gaining  stead- 
ily in  weight. 

From  these  observations,  and  others  less  extended,  the  average  daily 


1  Haehner's  cases  (Jahrb.  f.  Kinderh.,  xv,  23;  xxi,  314).  Case  I.  Female;  birth- 
weight  7  pounds  14  ounces  (3,100  grammes).  First  week,  lost  H  ounce  (45  grammes) ; 
after  this  gained  steadily  during  the  twenty-three  weeks  of  observation;  from  second 
to  ninth  week,  average  weekly  gain  8  ounces  (241  grammes) ;  from  tenth  to  eighteenth 
week,  average  gain  4^  ounces  (138  grammes);  from  nineteenth  to  twenty-third  week, 
average  gain  4  ounces  (130  grammes);  weight  at  the  end  of  twenty-third  week,  14 
pounds  (6,690  grammes). 

Case  II.  Male;  birth-weight  6i  pounds  (2,950  grammes).  Lobs,  first  week,  3 
ounces  (90  grammes) ;  after  this  gained  steadily  during  the  eleven  weeks  of  observa- 
tion; from  second  to  eleventh  week,  average  weekly  gain  7i  ounces  (214  grammes); 
weight  at  end  of  eleventh  week,  11  pounds  2  ounces  (5,045  grammes). 

Case  III.  Female;  birth-weight  3  pounds  9  ounces  (1,620  grammes).  Gain,  first 
week,  li  ounce  (45  grammes) ;  during  the  succeeding  twenty-one  weeks  of  observation, 
average  weekly  gain  5  oimces  (141  grammes);  weight  at  the  end  of  twenty-second 
week,  10  pounds  3  ounces  (4,620  grammes). 

Laiu-e's  case  (These,  Paris,  1889).  Female;  birth-weight  8  pounds  13  ounces 
(4,000  grammes) ;  loss,  first  week,  8  ounces  (225  grammes) ;  after  this  gained  steadily 
during  the  nine  weeks  of  observation,  on  an  average  9i  ounces  (268  grammes)  weekly; 
at  the  end  of  ninth  week,  weight  13  pounds  Si  ounces  (6,000  grammes). 

Ahlf eld's  case  (Deutsch.  Ztschr.  f.  Prakt.  Med.,  1878).  Birth-weight  7  pounds  14 
ounces  (3,100  grammes).  Observations  continued  from  fourth  to  thirtieth  week. 
During  first  ten  weeks,  average  weekly  gain  5i  ounces  (161  grammes) ;  from  eleventh 
to  twentieth  week,  7i  ounces  (214  grammes);  from  twenty-first  to  thirtieth  week,  6 
ounces  (168  grammes);  at  the  end  of  the  thirtieth  week,  weight  18  pounds  9i  oimces 
(8,435  grammes). 

Feer  (Jahrb.  f.  Kinderh.,  xlii',  195).     Three  cases. 

In  all  these  cases  the  amoimt  of  milk  was  determined  by  weighing  the  infant  both 
before  and  after  every  nursing  during  the  entire  period  of  observation.  The  following 
table  gives  in  a  condensed  form  the  daily  quantity  of  milk  in  these  cases : 


Time. 


Ist  day 

2d  day 

3d  day 

4th  day 

5th  day 

6th  day 

7th  day 

Average  2d  week 

Average  3d  week 

Average  4th  week 

Average  5th  week 

Average  6th  week 

Average  7th  week 

Average  8th  week 

Average  9th  week 

Average  10th  to  13th  week. 
.\verage  14th  to  17th  week. 
Average  18th  to  23d  week.  . 
Average  24th  to  30th  week. 


Haehner's 
lat  case. 


Grsmmes. 

20 
176 
265 
420 
360 
374 
423 
497 
550 
594 
663 
740 
880 
835 
766 
796 
807 
870 


Haehner's 
2d  case. 


Grammea. 

75 
135 
325 
295 
290 
340 
350 
423 
468 
531 
561 
661 
681 
730 
665 


Haehner's 
3d  case. 


Grammes. 

20 
45 

70 

99 
124 
136 
156 
229 
314 
379 
447 
472 
525 
568 
584 
600 
673 
709 


Laure's 
case. 


125 

222 

400 

475 

500 

556 

730 

810 

944 

978 

1,038 

1,024 

1,085 


Ahlfeld's 
case. 


576 
655 
791 
811 
845 
810 
869 
983 
1,029 
1,145 


Feer'a 
3  cases. 
Average. 


256 

(average 
Ist  week) 


610 
667 
753 
802 
815 
820 
795 
845 
919 
1,002 


10 


130  NUTRITION. 

quantity  of  milk  secreted  under  normal  conditions  of  health  may  he 
assumed  to  be  pretty  nearly  as  follows : 

Approximately. 

At  the  end  of  the  first  week 10  to  16  oz.  (300  to     500  grm.). 

During  the  second  week 13  to  18  oz.  (400  to     550  grm.). 

During  the  third  week 14  to  24  oz.  (430  to     720  grm.). 

During  the  fourth  week 16  to  26  oz.  (500  to     800  grm.). 

From  the  fifth  to  the  thirteenth  week.  .20  to  34  oz.  (600  to  1,030  grm.). 
From  the  fourth  to  the  sixth  mfinth. .  .24  to  38  oz.  (720  to  1,150  grm.). 
From  the  sixth  to  the  ninth  month. ... 30  to  40  oz.  (900  to  1,220  grm.). 

It  will  be  noted  that  the  amount  increases  very  rapidly  up  to  about 
the  eighth  week,  and  after  this  much  more  slowly.  The  amount  of  milk 
varies  also  with  the  demands  of  the  child  in  a  very  striking  way.^  The 
quantities  mentioned  can  not  be  taken  as  an  absolute  guide  as  to  the 
amount  of  food  to  be  given  to  bottle-fed  infants.  Breast  milk  contains 
an  average  of  twelve  per  cent  solids;  while  the  modification  of  cow's 
milk  best  suited  to  the  early  months  seldom  has  more  than  from  nine 
to  eleven  per  cent  solids.  For  this  period,  therefore,  somewhat  larger 
quantities  are  needed  than  of  breast  milk. 

A  comparison  of  the  daily  amount  of  milk  taken  with  the  weight  of 
the  child  at  the  different  periods,  showed  that  both  during  the  early  and 
the  later  periods  the  larger  children  took  not  only  more  milk,  but  con- 
siderably more  in  proportion  to  their  body  weight  than  did  tlie  smaller 
ones.  This  harmonises  with  the  common  observation  that  small  children 
are  much  more  likely  to  be  overfed  than  large  ones. 

The  average  quantity  taken  at  one  nursing  by  five  of  the  children 
previously  mentioned  was  as  follows : 

Approximately. 

During  the  first  week |    to  li  oz.    (18  to    45  grm.). 

During  the  second  week 1    to  3    oz.    (30  to    90  grm.). 

During  the  third  week H  to  4    oz.    (45  to  120  grm.). 

During  the  fourth  week li  to  4i  oz.     (45  to  140  grm.). 

From  the  fifth  to  the  seventh  week 2    to  5    oz.    (64  to  150  grm.). 

From  the  eighth  to  the  eleventh  week 2i  to  5i  oz.    (75  to  160  grm.). 

During  the  fourth  month 3    to  6    oz.    (90  to  180  grm.). 

During  the  fifth  month 3i  to  6i  oz.  (110  to  200  grm.). 

During  the  sixth  month 4    to  7    oz.  (120  to  220  grm.). 

Between  the  limits  mentioned  the  greater  number  of  cases  will  un- 
doubtedly fall.  The  amount  taken  at  one  time  is,  however,  modified 
by  the  frequency  of  nursing,  and  is  therefore  not  so  good  a  guide  to  the 
amount  of  food  required,  as  is  the  quantity  taken  in  twenty-four  hours. 

•  There  are  a  number  of  recorded  instances  in  which  the  amount  of  milk  secreted 
has  been  quite  extraordinary— in  some  cases  as  much  as  four  quarts  daily.  Lacta- 
tion in  exceptional  instances  also  is  unduly  prolonged.  I  know  of  one  well  authenti- 
cated American  case  in  which  it  continued  for  seven  years.  Among  the  Japanese 
it  is  frequent  for  it  to  continue  up  to  three  or  four  years.  Among  the  Hottentots 
and  other  savage  races  lactation  may  be  prolonged  until  the  sixth  or  seventh  year. 


WOMAN'S  MILK. 


131 


Composition. — Many  of  the  older  analyses  of  milk  gave  erroneous  re- 
sults because  of  imperfect  methods  of  examination.  According  to  the 
more  recent  analyses  of  Pfeiffer,  Koenig,  Leeds,  Harrington,  Adriance, 
and  others,  the  composition  of  human  milk  is  as  follows : 


Normal  average. 

Common  healthy  variations. 

Fat 

Per  cent. 

3.50 
7.00 
1.25 
0.20 

88.05 

Per  cent. 

3  00  to    5  .  00 

Sugar 

Protein 

Salts... 

Water 

6.00  "     7.00 

1.00  "    2.25 

0.18  "    0.25 

89.82  "  85.50 

100.00 

100.00     100.00 

In  the  older  analyses,  the  percentage  of  protein  is  almost  invariably 
too  high  and  the  sugar  too  low. 

The  milk  varies  in  composition  somewhat  with  the  period  of  lacta- 
tion. That  of  the  colostrum  period  is  high  in  protein  and  salts  and 
low  in  sugar.  By  the  end  of  the  second  week  all  these  elements  have 
usually  reached  their  normal  averages.  After  this  time  until  near  the 
end  of  lactation  the  regular  variations  are  slight.  This  is  a  point  to  be 
borne  in  mind  in  the  selection  of  wet-nurses. 

Protein. — The  important  forms  of  protein  are  casein  and  lactalbumin ; 
several  others,  lactoglobulin,  lactoprotein,  and  nuclein  are  also  described. 
The  casein  is  in  suspension  by  virtue  of  the  presence  of  lime  phosphate  in 
the  milk,  with  which  it  is  probably  in  combination.  It  coagulates  only 
slightly  with  rennet,  while  acetic  acid  produces  a  loose  flocculent  precipitate. 
The  lactalbumin  resembles  the  serum-albumin  of  the  blood.  Chemists  are  by 
no  means  agreed  in  regard  to  the  proportion  of  the  different  forms  of  pro- 
tein present  in  milk.  Lactalbumin  exists  in  woman's  milk  in  much  larger 
amount  than  in  cow's  milk,  and  it  is  more  abundant  than  the  casein,  the 
proportion  of  the  two  being,  according  to  Koenig,  about  as  five  to  four. 

The  total  protein  of  normal  milk  is  usually  between  one  and  two  per 
cent.  In  abnormal  specimens  the  variations  are  from  0.7  to  4.5  per 
cent.  The  protein  is  highest  in  the  milk  of  the  first  few  days ;  after  the 
first  month  it  varies  but  little  until  toward  the  close  of  lactation,  when 
the  amount  falls  very  markedly. 

Fat. — This  exists  in  the  form  of  minute  globules,  which  are  held  in 
a  state  of  permanent  emulsion  by  the  albuminous  solution  in  which  they 
are  suspended.  The  fat  of  woman's  milk  is  chiefly  made  up  of  the  neu- 
tral fats — palmitine,  stearine,  and  oleine ;  the  last  mentioned  predominat- 
ing. There  are  also  small  quantities  of  the  fatty  acids,  but  these  are 
much  less  in  amount  than  in  cow's  milk.  In  woman's  milk  the  lower 
or  volatile  fatty  acids  are  most  abundant,  while  in  cow's  milk  it  is  the 
higher  fatty  acids.     Like  the  protein,  the  proportion  of  fat  is  subject 


132 


NUTRITION. 


to  wide  variations,  3 . 5  per  cent  being  taken  as  the  normal  average.  In  a 
series  of  thirty- four  analyses  made  for  me  the  fat  varied  between  1.12 
and  6.66  per  cent.  The  highest  percentage  I  have  known  was  10.91.  In 
forty-three  analyses- by  Leeds,  the  variations  were  between  2.11  and  6.89 
per  cent.  The  proportion  is  very  little  affected  by  the  period  of  lactation. 
Sugar. — The  sugar  is  in  solution.  Its  proportion  is  nearly  constant. 
The  ordinary  variations  are  usually  within  the  limits  of  6  and  7  per 
cent.  The  sugar  being  so  important  as  a  heat-producing  element.  Nature 
has  wisely  provided  that  this  shall  be  the  most  constant  ingredient  of 
the  milk.  The  amount  of  sugar  is  smallest  in  the  milk  of  the  first 
week;  after  the  first  month,  however,  the  variations  are  slight. 

Salts. — The  average  proportion  of  inorganic  salts  is  0.20  per  cent, 
or  a  little  more  than  one-fourth  that  of  cow's  milk.  The  proportion  of 
the  different  salts  is  given  in  a  subsequent  chapter. 

With  the  exception  of  calcium  phosphate  nearly  all  the  salts  are  in  so- 
lution.   The  milk  of  the  first  few  days  is  very  rich  in  salts ;  after  the  first 

month  the  variations  are  slight  but  show 
a  gradual  fall  in  tlie  quantity  present. 
The  Examination  of  Milk. — The 
exact  composition  of  human  milk  is 
to  be  determined  only  by  a  complete 
chemical  analysis.  There  are,  how- 
ever, many  variations  in  composition 
which  the  physician  may  readily  ascer- 
tain for  himself  by  simple  methods 
of  examination. 

The  quaniiiy  of  milk  secreted  by 
the  breasts  may  be  estimated  liy  the 
quantity  which  may  be  drawn  by  a 
breast-pump,  although  this  is  not  a 
very  reliable  test.  If  the  child  nurses 
habitually  thirty  or  forty  minutes,  the 
probabilities  are  very  strong  that  the 
quantity  of  milk  is  small.  If  the 
breasts  at  nursing  time  are  full,  hard, 
and  tense,  the  supply  is  probably 
abundant.  If  the  breasts  are  soft  and 
flabby,  and  appear  to  fill  only  while 
tlie  child  is  nursing,  it  is  almost  cer- 
tain that  the  quantity  is  small.  The 
most  reliable  of  all  tests  is  weighing 


1,010 


1,020 


1,030 


1,0«0- 


/ 


\ 


a 


=—50 


3» 


>  B 

Fia.  23. — Apparatus  for  Examination 
OF  Woman's  Milk.  The  author's  lac- 
tometer and  cream-gauge.^ 


'  The  author's  apparatus  may  be  obtained  from  Eimer  &  Amend,  Eighteenth 
Street  and  Third  Avenue,  New  York.  For  a  fuller  discussion  of  the  subject,  see 
Archives  of  Paediatrics,  March,  1893. 


WOMAN'S  MILK. 


133 


the  infant  before  and  after  nursing,  upon  an  accurate  pair  of  scales,  suf- 
ficiently sensitive  to  indicate  half-ounces.  Two  or  three  weighings  will  suf- 
fice to  show  conclusively  whether  an  infant  at  three  months,  for  instance, 
is  getting  habitually  four  or  five,  or  only  one  or  two  ounces  at  a  nursing. 

The  reaction  of  woman's  milk  even  when  freshly  drawn  is  rarely 
alkaline,  being  amphoteric  to  litmus,  or  slightly  acid  to  phenolphthalein. 

The  specific  gravity  may  be  taken  with  any  small  hydrometer  gradu- 
ated from  1.010  to  1.040  (Fig.  23,  A).  Tlie  specific  gravity  is  lowered 
by  the  fat,  but  increased  by  the  other  solids.  An  ordinary  urinometer 
will  answer  every  purpose,  the  only  difficulty  being  the  quantity  which 
is  required  to  float  the  instrument. 

Microscopical  Examination. — The  microscope  may  reveal  the  pres- 
ence of  fat  globules,  colostrum  corpuscles,  blood,  pus,  epithelium,  and 
granular  matter.  Colostrum  corpuscles  are  abnormal  after  the  twelfth 
day;  pus  and  blood  are  always  abnormal.  The  presence  of  any  of  these 
elements  necessitates  the  suspension  of  nursing,  at  least  temporarily. 
But  little  importance  can  be  attached  to  the  size  and  appearance  of  the 
fat  globules  as  affecting  the  nutritive  properties  of  the  milk. 

The  Determination  of  Fat. — The  simplest  method  is  by  the  cream- 
gauge  (Fig.  23,  B).  Its  results  are  only  approximate,  but  in  most  cases 
sufficiently  accurate  for  clinical  purposes.  The  tube  is  filled  to  the  zero 
mark  with  fresh  milk,  which  stands,  corked,  at  room  temperature  for 
twenty-four  hours,  when  the  percentage  of  cream  is  read  off.  The  ratio 
of  this  to  the  fat  is  approximately  five  to  three;  thus  5  per  cent  cream 
indicates  3  per  cent  fat,  etc. 

For  an  accurate  determination  the  best  ready  method  is  the  Babcock 
test,  which  requires  20  c.c.  of  milk,  or  the 
modification  by  Lewi  ^  of  the  Leffman  and 
Beam  test  for  cow's  milk.     This  requires 
special  tubes. 


^  Lewi's  method  is  as  follows: 

(1)  Place  in  the  milk  flask  2.92  c.c.  of  woman's 
milk  measured  in  a  special  graduated  pipette; 
(2)  carefully  rinse  the  pipette  and  add  the  same 
quantity  of  sulphuric  acid  C  P.  of  specific  gravity 
1.830.  The  acid  should  be  added  slowly,  and 
mixed  with  the  milk  by  gently  rotating  the  flask. 
The  colour  turns  to  a  very  dark  brown  from  the  oxi- 
dation of  the  sugar  and  protein;  (3)  now  add  0.6  c.c. 
of  a  mixture  of  equal  parts  of  fusel  oil  and  strong  hy- 
drochloric acid;  (4)  add  sufficient  of  a  mixttue  of 
the  same  sulphuric  acid  and  water,  equal  parts,  to 
bring  the  level  of  the  fluid  well  up  into  the  neck  of 
the  flask;  (5)  centrifuge  for  three  or  four  minutes. 
The  percentage  of  fat  is  now  read  off,  each  one- 
tenth  gradation  in  the  neck  of  the  flask  represent- 
ing 0.3  per  cent  of  fat  in  the  specimen  of  milk. 


Fig.   24.—  TUBES   FOR     DETERMINING   THE 

Fat  in  Milk,  a,  Babcock's  tube  lor 
cow's  milk;  B,  Lewi's  modification  for 
woman's  milk. 


134 


NUTRITION. 


Sugar. — The  proportion  of  sugar  is  so  nearly  constant  that  it  may  be 
ignored  in  clinical  examinations. 

Protein. — Clinical  methods  for  the  estimation  of  the  protein  are  not 
altogether  satisfactory.  The  one  giving  the  best  results  is  that  in  which 
the  protein  is  precipitated  by  a  solution  of  phosphotungstic  and  hydro- 
chloric acids  in  the  Esbach  tube,  the  percentages  being  read  of!  after 
standing  twenty-four  hours. ^  We  may  also  form  an  approximate  idea 
of  the  protein  from  a  knowledge  of  the  specific  gravity  and  the  per- 
centage of  fat,  if  we  regard  the  sugar  and  salts  as  constant,  or  so  nearly 
80  as  not  to  affect  the  specific  gravity.  We  may  thus  determine 
whether  it  is  greatly  in  excess  or  very  low,  which,  after  all,  is  the 
important  thing.  The  specific  gravity  will  then  vary  directly  with 
the  proportion  of  protein,  and  inversely  with  the  proportion  of  fat, 
i.  e.,  high  protein,  high  specific  gravity;  high  fat,  low  specific  grav- 
ity. The  application  of  this  principle  will  be  seen  by  reference  to  the 
accompanying  table. 

Woman's  Milk. 


Average 

Normal  variations. .  . 
Normal  variations. .  . 
Abnormal  variations. 
Abnormal  variations. 
Abnormal  variations. 
Abnormal  variations. 


Specific  gravity  70*  F.     Cream — 24  hours. 


1.031 
1.028-1.029 

1.032 
Low  (below  1.028) 
Low  (below  1.028) 
High  (above  1.032) 
High  (above  1.032) 


7% 

8%-12% 

5%-«% 

High(above  10%) 

Low  (below  5%) 

High 

Low 


Protein  (estimated). 


1.5% 

Normal  (rich  milk) 

Normal  (fair  milk) 

Normal  or  slightly  below 

Very  low  (very  poor  milk) 

Very  high  (very  rich  milk) 

Normal  (or  nearly  so) 


Any  specimen  taken  for  examination  should  be  either  the  mid- 
dle portion  of  the  milk — i.  e.,  after  nursing  two  or  three  minutes — 
or,  better,  the  entire  quantity  from  one  breast,  since  the  composi- 
tion of  the  milk  will  differ  very  much  according  to  the  time  when 
it  is  drawn.  The  first  milk  is  slightly  richer  in  protein  and  much 
poorer  in  fat.  The  last  drawn  from  the  breasts  is  low  in  protein 
and  high  in  fat.  The  following  analyses  from  Forster  illustrate  these 
differences : 


First  portion. 

Second  portion. 

Third  portion. 

Fat  

Per  oent. 

1.71 
1.13 

Per  cent. 

2.77 
0.94 

Per  cent. 

5.51 

Protein 

0.71 

Conditions  Affecting  the  Composition  of  Woman's  Milk. — The  Age  of 
the  Nurse. — This  has  no  constant  influence.     Other  things  being  equal. 

'  For    description    see 
October,  1906. 


Boggs,     Johns    Hopkins    Hospital  Bulletin,   No.   187, 


WOMAN'S  MILK. 


135 


the  milk  of  very  young  women,  and  also  of  those  over  thirty-five  years 
of  age,  is  likely  to  be  lower  in  fat  than  that  of  women  between  twenty 
and  thirty-five  years. 

Number  of  Pregnancies. — Adriance  found  that  the  average  milk  of 
23  primiparae  and  23  multiparas,  both  taken  at  the  third  month,  showed 
the  following  differences :  The  milk  of  the  primiparae  was  higher  in  fat 
(4.06  against  3.67)  and  in  protein  (1.61  against  1.35),  but  a  little 
lower  in  sugar  (6.52  against  6.85). 

Acute  Illness. — In  the  majority  of  cases  of  acute  illness  of  a  minor 
character  and  of  short  duration  there  is  no  perceptible  effect  upon  the 
milk.  In  the  acute  febrile  diseases  of  a  severe  type  the  quantity  of  milk 
is  reduced,  the  fat  is  low,  and  the  protein  is  apt  to  be  high.  In  septic 
conditions  bacteria  may  appear  in  the  milk. 

Menstruation. — The  effect  of  this  is  exceedingly  variable,  depending 
much  upon  the  individual  and  the  ease  of  menstruation. 

The  nature  of  the  changes  in  milk  sometimes  produced  by  menstrua- 
tion is  illustrated  by  the  following  case  taken  from  Eotch : 


Second  day  of  men- 
struation.    Child's 
stools  loose. 

Seven  days  after 
menstruation. 
Bowels  regular. 

Forty  days  later. 

Child  gaining 

rapidly. 

Fat 

Per  cent. 

1.37 

Per  cent. 

2.02 

Per  cent. 

2.74 

Sugar 

Protein 

6.10 

2.78 

6.55 
2.12 

6.35 
0.98 

Sahs 

0.15 

0.15 

0.14 

Water 

89.60 

89.16 

89.79 

From  observations  upon  685  cases,  Meyer  noted  disturbances  in  the 
child  in  over  one-half  the  number.  My  own  experience  accords  rather 
with  that  of  Pfeiffer  and  Schlichter,  who  consider  it  quite  exceptional 
for  the  child  to  be  visibly  affected.  Schlichter  made  observations  upon 
infants  during  233  menstrual  days,  noting  the  condition  of  the  stools 
and  digestion  both  before  and  after  menstruation.  In  ninety  ^er  cent  of 
the  cases  there  was  no  perceptible  influence.  In  only  eight  per  cent 
were  the  stools  bad,  and  in  only  three  per  cent  was  there  disturbance  of 
the  stomach  with  vomiting. 

At  the  present  time  sufficient  observations  have  not  been  made  to 
show  whether  the  differences  noted  in  the  case  cited  above — low  fat  and 
high  protein — are  the  rule  where  disturbances  are  produced  during 
menstruation.  Monti's  examinations  lead  him  to  the  conclusion  that  the 
fat  is  not  constantly  affected.  It  is  safe  to  say  that  the  changes  are  not 
uniform,  and  that  in  very  many  cases  none  of  importance  are  produced 
l)y  menstniation. 

Diet. — The  fat  and  the  protein  of  the  milk  are  much  influenced  by 
diet,  the  sugar  but  very  little.     The  fat  is  increased  by  overfeeding  es- 


136 


NUTRITION. 


pecially  with  fats  and  carbohydrates,  with  little  or  no  exercise;  it  is 
reduced  by  stopping  these  articles  and  substituting  vegetables  and  by 
increasing  the  amount  of  exercise.  The  protein  is  increased  by  over- 
feeding and  also  by  too  little  exercise.  Starvation  lowers  the  fat  and 
sometimes  also  the  protein.  All  fluids  tend  to  increase  the  quantity  of 
milk.  Alcohol  in  the  form  of  malted  drinks,  and  malt  extracts  increase 
the  quantity  of  milk  and  the  amount  of  fat.  The  effect  of  alcohol  upon 
the  protein  is  not  constant,  but  it  is  usually  increased.  The  following 
table  gives  the  result  of  analyses  of  the  milk  of  two  women  observed  in 
the  New  York  Infant  Asylum  before,  while  taking,  and  after  taking  an 
alcoholic  extract  of  malt : 


Case  I: 
Fat .  . . 
F*rotein 
Sugar . 
Salts . . 

Case  II: 
Fat .  . . 
Protein 
Sugar. 
Salts.. 


I. 

Without  malt. 


Per  cent 

1.74 
1.93 

7.02 
0.20 

1.12 
1.57 
7.11 
0.19 


II. 

After  taking  8  oz.  malt 
daily  for  10  days. 


Per  cent. 

3.8.3 
1.58 
7.43 
0.17 

2.75 
2.34 
6.77 
0.17 


III. 

No  malt  for  7  days. 


Per  cent. 

2.41 
2.95 
6.59 
0.19 

1.70 
1.26 
6.04 
0.18 


The  child  of  Case  I  gained  one  ounce  and  a  half  during  the  four  days 
preceding  the  first  analysis ;  that  of  Case  II  did  not  gain  at  all.  During 
the  ten  days  while  taking  the  malt,  the  first  child  gained  twelve  ounces, 
the  second  child  eight  ounces.  During  the  seven  days  after  the  malt 
was  discontinued,  the  first  child  gained  eight  ounces,  the  second  child 
one  ounce.  There  was  a  notable  increase  in  the  quantity  of  milk  in  both 
cases  while  taking  the  malt. 

The  nursing  woman  should  have  a  generous  diet  of  simple  food,  and 
should  dritfk  largely  of  milk  or  gruels  made  with  milk.  The  diet  should 
be  a  varied  one,  not  excessive  in  nitrogenous  food  nor  in  vegetables.  All 
salads,  pastry,  and  highly  seasoned  dishes  should  be  avoided,  not  so 
much  because  they  upset  the  child,  although  this  may  happen,  as  be- 
cause they  are  likely  to  disturb  the  digestion  of  the  nurse.  Nearly  all 
the  common  vegetables  and  sweet  fruits  in  season  may  be  allowed  in 
moderation.  Strong  tea  and  coffee  should  be  prohibited,  although  weak 
tea  or  coffee  may  be  allowed,  each  but  once  a  day.  Cocoa  is  not  ob- 
jectionable. In  addition  to  her  regular  meals  the  nurse  should  have 
milk  or  gruel  at  bedtime.  The  diet  should  in  all  cases  be  adapted  to  her 
digestion.  The  bowels  should  move  daily,  by  the  use  of  laxatives  if 
necessary.  Great  harm  often  results  from  overfeeding  with  its  conse- 
quent indigestion.    Alcoholic  beverages  should  be  forbidden. 


WOMAN'S   MILK.  137 

Drugs. — The  elimination  of  drugs  through  the  milk  is  somewhat  un- 
certain and  variable;  few  of  those  popularly  supposed  to  affect  the  child 
through-  the  milk  rgally  do  so.  Given  in  full  doses,  belladonna  regularly 
appears  in  the  milk.  Opium  does  not  do  so  constantly;  but  when  the 
milk  is  poor,  enough  may  be  excreted  to  produce  serious  symptoms.  The 
iodides  and  bromides  when  long  administered  may  be  eliminated  in 
sufficient  quantity  to  produce  their  constitutional  effects  in  the  child. 
Mercury  does  not  appear  regularly,  but  only  after  prolonged  use,  and 
then  in  variable  quantity.  Most  of  the  saline  cathartics,  arsenic,  and  the 
salicylates  are  occasionally  found  in  the  milk.  Alcohol  may  seriously 
disturb  the  child  if  taken  in  considerable  quantities  by  a  nurse,  although 
its  elimination  through  the  milk  is  doubtful. 

Pregnancy. — The  milk  of  pregnant  women  is  generally  scanty  and 
poor  in  quality,  especially  in  fat.     (See  Weaning.) 

Bacteria. — Under  normal  conditions  woman's  milk  may  contain  a 
few  bacteria.  They  are  chiefly  cocci  derived  from  the  external  milk  ducts 
and  are  of  no  importance.  In  suppurative  inflammation  of  the  mam- 
mary gland,  numerous  bacteria  may  be  found  in  the  milk;  also  in  some 
cases  of  puerperal  sepsis.  Tubercle  bacilli  have  been  demonstrated  by 
Eoger  and  Garnier  in  the  milk  of  a  woman  with  advanced  tuberculosis, 
but  ordinarily  they  are  not  present  unless  the  gland  is  the  seat  of  the 
disease. 

The  Elimination  of  Antitoxin  and  Other  Protective  Substances  by  the 
Milk. — The  immunity  of  nursing  infants  to  most  of  the  contagious  dis- 
eases has  long  been  noted,  but  until  recently  little  understood.  Animal 
experiments  have  demonstrated  the  constant  presence  of  diphtheria  an- 
titoxin in  the  milk  of  immunised  animals.  The  Widal  reaction  has  been 
obtained  with  the  milk  of  mothers  suffering  from  typhoid  and  with  the 
blood  of  their  healthy  nursing  infants. 

Nervous  Impressions. — The  effect  of  the  nervous  condition  of  a 
woman  upon  her  milk  secretion  is  very  striking,  and  much  more  im- 
portant than  the  diet.  Both  the  quantity  and  the  composition  of  the 
milk  are  markedly  changed  by  many  different  nervous  impressions. 
Fright,  grief,  passion,  excessive  sexual  indulgence,  or  any  great  excite- 
ment may  entirely  arrest  the  secretion,  or  if  not  arrested  the  milk  may 
be  so  altered  in  composition  as  to  make  the  child  acutely  ill.  Worry, 
anxiety,  fatigue,  intense  or  prolonged  nervous  strain  may  so  alter  the 
milk  as  to  cause  it  to  disagree  with  a  child  who  had  previously  thrived 
well  upon  it,  or  they  may  greatly  diminish  and  sometimes  even  arrest 
the  secretion.  It  is  the  nervous  condition  of  the  mother  more  than 
anything  else  which  determines  her  success  or  failure  as  a  nurse. 
If  a  mother  would  nurse  successfully,  she  must  have  plenty  of  rest 
and  sleep,  moderate  exercise,  keep  her  mind  free  from  unnecessary 
worries,  avoid  social  engagements,  and  lead  a  simple,  regular,  natural 


138  NUTRITION. 

life.     Unless  she  can  and  will  do  this  successful  nursing  can  hardly 
be  expected. 

The  nature  of  the  changes  produced  in  milk  by  nervous  disturbances 
in  the  mother  are  as  yet  little  understood.  Some  infants  are  so  pro- 
foundly affected  as  to  suggest  the  development  of  toxic  substances  in  the 
milk.  The  milk  of  the  tired  and  worried  mother  is  nearly  always  low 
in  fat,  while  the  protein  is  usually  high,  and  possibly  there  are  other 
changes  as  yet  unknown. 

COW'S  MILK. 

The  only  one  of  the  lower  animals  whose  milk  is  practically  available 
for  infant  feeding  is  the  cow.  Cow's  milk  being  our  main  reliance  in 
the  artificial  feeding  of  infants  and  the  staple  food  of  nearly  all  young 
children,  it  follows  that  everything  relating  to  its  production  and 
handling  is  important.  The  practising  physician  should  therefore 
familiarise  himself  with  the  main  facts  regarding  the  production  and 
handling  of  milk  according  to  modern  methods,  since  no  one  can  do  more 
than  he  to  educate  public  opinion  in  these  matters,  and  so  to  improve 
the  milk  supply  of  the  community.  Only  an  outline  of  the  subject  can 
be  presented  here.  For  more  minute  knowledge  the  reader  is  referred 
to  special  works  upon  the  subject.^ 

The  essential  conditions  to  be  fulfilled  in  cow's  milk  which  is  to 
be  used  as  a  food  for  infants  and  young  children  are :  ( 1 )  Freshness ; 
(2)  it  should  contain  no  preservatives;  (3)  it  should  be  from  healthy 
animals,  free  from  tuberculosis  or  other  taint;  (4)  it  should  be  clean; 
(5)  it  should  not  be  skimmed  or  otherwise  falsified;  (6)  it  should  con- 
tain no  pathogenic  organisms;  (7)  the  number  of  other  organisms  should 
not  be  excessive.  It  is  also  desirable  for  purposes  of  infant  feeding  that 
the  composition  of  the  milk,  particularly  the  percentage  of  fat,  should 
be  known,  and  that  the  milk  should  be  as  nearly  uniform  as  possible  from 
day  to  day  and  at  different  seasons  of  the  year.  Mixed  or  herd  milk  is 
therefore  to  be  preferred  to  that  from  a  single  animal,  since  it  is  subject 
to  fewer  variations.  The  common  varieties  or  "  grade  cows  "  should  be 
chosen  rather  than  highly  bred  animals,  if  for  no  other  reason,  because 
they  are  more  hardy,  less  subject  to  disease,  and  less  susceptible  to  other 
influences  which  might  affect  the  milk. 

As  ordinarily  handled,  milk  should  be  used  before  it  is  twenty-four 
hours  old;  after  this  time  changes  occur  very  rapidly,  and  such  milk 
can  not  in  summer  be  used  with  safety  for  young  children.     Milk  may 

•  Convpnient  works  for  a  physician's  use  are  Richmond's  Dairy  Chemistry; 
Aikman's  Milk,  Its  Nature  and  Composition,  Block,  London;  Russell's  Outlines  of 
Dairy  Bacteriology;  Belcher's  Clean  Milk,  Hardy  Publishing  Co.,  New  York;  Pear- 
sons' Jensen's  Milk  Hy^ene,  Lippincott  Co.;  Milk  and  Its  Relation  to  Public  Health, 
Bulletin  56,  U.  S.  Public  Health  and  Marine-Hospital  Service. 


COW'S  MILK.  139 

be  safe  when  more  than  twenty-four  hours  old  provided  special  pre- 
cautions are  taken  regarding  cleanliness  in  producing  and  handling  it, 
and  special  care  in  keeping  it  constantly  at  a  temperature  below  50°  F. 

Preservatives  are  very  often  added,  particularly  in  hot  weather,  by 
unscrupulous  dealers  to  retard  the  souring  of  milk,  in  order  thereby  to 
avoid  the  necessity  and  expense  of  proper  icing.  Formerly  boric  or  sali- 
cylic acid  was,  and  recently  formaldehyd  has  been  largely  employed  for 
this  purpose. 

Micro-organisms  in  Milk. — Most  of  the  common  bacteria  grow  read- 
ily in  milk,  and  the  conditions  under  which  it  is  produced  and  handled 
render  it  liable  to  contamination  in  many  ways. 

1.  Disease  in  the  Cow. — From  disease  of  the  udder  streptococci  or 
other  pyogenic  germs  may  enter  the  milk  in  such  numbers  as  to  excite 
acute  gastro-enteritis  in  a  child.  Other  diseases  which  may  be  com- 
municated from  the  cow  are  tuberculosis,  anthrax,  and  the  foot-and- 
mouth  disease.  In  the  State  of  New  York  it  is  estimated  that  7  per 
cent  of  the  coWs  are  tuberculous.  Pearson  and  Ravenel  estimate  the 
proportion  in  Pennsylvania  at  2  or  3  per  cent,  while  Marshall  states 
that  from  10  to  25  per  cent  of  the  Eastern  dairy  cattle  are  tuberculous. 
The  best  veterinarians  regard  tuberculosis  as  steadily  increasing  among 
cattle  in  the  United  States,  particularly  in  the  Eastern  States.  Of  the 
cattle  slaughtered  in  London,  25  per  cent  are  stated  to  be  tuberculous. 
Unless  the  process  is  advanced  or  the  udder  is  the  seat  of  disease,  very 
many  tuberculous  cows  do  not  have  tubercle  bacilli  in  their  milk. 
Nevertheless  tubercle  bacilli  are  frequently  found  in  ordinary  market 
milk.  In  107  unselected  specimens  of  milk  sold  from  cans  in  New  York 
City  Hess  found  tubercle  bacilli  in  17,  or  16  per  cent.  Eabinowitch  and 
Kempner  in  25  similar  examinations  in  Berlin  found  tubercle  bacilli  in 
7,  or  28  per  cent.  Macfadyen  in  London  found,  in  77  samples  of  milk, 
tubercle  bacilli  present  in  17,  or  22  per  cent.  These  figures  may  be 
taken  to  represent  average  conditions  in  large  cities.  But  the  dangers 
from  milk  are  not  quite  so  great  as  would  appear  from  these  findings, 
for  in  many  of  the  cases  the  number  of  bacilli  is  very  small  and  only 
discovered  by  animal  inoculations. 

For  reasons  given  elsewhere  (vide  Tuberculosis),  I  can  not  believe 
the  danger  of  acquiring  tuberculosis  through  milk  as  great  as  many 
have  represented.  For  the  present  milk  must  be  regarded  as  one  of  the 
possible  sources  of  tuberculous  infection.  The  sale  of  milk  from  cows 
showing  evidence  of  tuberculosis  upon  physical  examination,  and  from 
those  having  tuberculosis  of  the  udder  should  not  be  permitted.  Whether 
we  should  go  further  and  exclude  also  the  milk  of  every  cow  which 
reacts  to  the  tuberculin  test  is  still  an  open  question. 

2.  Specific  Pathogenic  Organisms  Accidentally  Gaining  Access  to 
Milk. — The  role  of  milk  in  the  spread  of  infectious  disease  may  be  ap- 


140  NUTRITION. 

predated  by  the  fact  that  in  1900  Kober  collected  records  of  330  out- 
breaks which  were  traced  to  it.  The  most  important  disease  communi- 
cated in  this  way  is  typhoid  fever.  In  the  reports  of  195  epidemics 
collected,  typhoid  existed  at  the  dairy  in  148  instances;  in  67  the  milk 
was  diluted  with  infected  well-water;  in  7  the  cows  probably  waded  in 
polluted  water;  in  24  cases  the  employees  acted  as  nurses  to  typhoid 
patients,  and  in  10  they  continued  at  work,  although  themselves  suffering 
from  the  disease;  in  one  case  it  was  found  that  the  milk-pans  were  washed 
with  cloths  used  about  patients. 

Next  to  typhoid  the  disease  most  often  spread  tliTough  milk  is  scar- 
let fever.  A  very  small  percentage  of  the  cases  of  scarlet  fever,  however, 
can  be  traced  to  contaminated  milk;  but  the  sudden  and  simultaneous 
development  of  a  considerable  number  of  cases  of  this  disease  in  a  com- 
munity should  lead  one  to  consider  the  milk  supply  as  a  possible  cause. 
Of  99  epidemics  of  scarlet  fever,  there  was  disease  at  the  farm  or  dairy 
in  68;  in  17,  employees  were  themselves  affected,  and  in  10  they  acted 
as  nurses;  in  6,  persons  connected  with  the  dairy  either  lodged  in  or 
had  visited  infected  houses;  in  3  infection  was  brought  by  cans  or 
bottles  from  the  houses  of  patients;  in  3  the  milk  was  stored  near  or 
in  the  sick-room;  in  one  case  milk-utensils  were  wiped  with  an  infected 
cloth. 

Very  infrequently  diphtheria  has  been  spread  through  milk.  Of  36 
outbreaks  of  diphtheria  collected,  there  was  disease  at  tlie  farm  or  dairy 
in  13;  in  3,  employees  themselves  were  ill.  Twelve  of  the  outbreaks 
included  in  this  series,  however,  were  of  very  doubtful  character.  Besides 
these  diseases  mentioned,  cholera,  dysentery,  and  certain  forms  of  diar- 
rhceal  diseases  may  probably  be  spread  by  milk. 

3.  Other  Bacteria  Found  in  Milk. — These  are  chiefly  derived  from 
the  dust  of  the  stable,  the  hands  and  clothing  of  the  milker,  and  from  the 
dirt  which  falls  from  the  udder,  belly,  and  tail  of  the  cow  into  the  pail 
during  milking;  very  many  come  from  the  cow's  excreta.  Freeman 
exposed  a  Petri  gelatin-plate  beneath  a  cow's  udder  for  one  minute  dur- 
ing milking  and  obtained  4,450  colonies.  The  varieties  of  bacteria  found 
in  fresh  milk  are  many  and  vary  with  locality.  Toward  the  souring 
point  the  great  majority  are  of  two  or  three  varieties  only;  fully  95 
per  cent  at  that  time  belong  to  the  lactic-acid-producing  group.  They 
cause  the  ordinary  souring  of  milk  by  acting  upon  the  milk  sugar.  Colon 
bacilli  are  very  common.  Other  bacteria  act  upon  the  milk  protein, 
inducing  various  putrefactive  changes;  and  still  others  have  a  peptonis- 
ing  power. 

Many  of  the  bacteria  are  no  doubt  harmless.  Others,  while  not, 
strictly  speaking,  pathogenic,  when  present  in  large  numbers  induce 
changes  in  milk  that  so  impair  its  nutritive  properties  as  to  render  it 
unfit  for  food,  and  in  susceptible  infants  may  cause  serious  illness.    The 


COW'S  MILK.  141 

effects  of  bacterial  contamination  of  milk  are  considered  in  the  intro- 
ductory chapter  upon  Diarrhoeal  Diseases. 

The  Number  of  Bacteria  in  Milk. — This  depends  upon  three  condi- 
tions: (1)  Cleanliness  in  handling;  (3)  temperature;  (3)  age  of  the 
milk.  Hence  the  bacterial  count  becomes  of  the  greatest  value  in  fur- 
nishing information  as  to  these  matters,  although  of  less  importance  in 
regard  to  the  production  of  disease  than  the  nature  of  the  organisms 
present.  The  influence  of  the  different  factors  may  be  illustrated  by 
the  following  experiments  made  at  the  laboratory  of  the  New  York 
Health  Department:  A  sample  of  milk  taken  under  good  conditions 
contained  immediately  after  milking  300  bacteria  in  each  drop.  It  was 
cooled  to  45°  ¥.,  and  kept  at  this  temperature.  After  twenty-four  hours 
it  contained  in  each  drop  only  200  bacteria ;  after  forty-eight  hours,  900 ; 
and  after  seventy-two  hours,  150,000.  The  milk  curdled  on  the  sixth 
day.  Another  sample,  taken  in  a  dirty  barn,  cooled  and  kept  at  52°  F., 
contained  at  first  2,000  bacteria  in  each  drop;  in  twenty- four  hours, 
6,000;  in  forty-eight  hours,  245,000;  in  seventy-two  hours,  16,500,000. 
The  milk  curdled  on  the  fourth  day.  The  influence  of  temperature  alone 
upon  the  multiplication  of  bacteria  in  milk  is  well  shown  by  the  follow- 
ing experiment:  Four  samples  of  the  same  milk  were  kept  at  different 
temperatures  for  twenty-four  hours  and  equal  quantities  were  then 
plated;  No.  I  was  kept  at  60°  F.  and  showed  134,340  colonies;  No.  II 
was  kept  at  55°  F.  and  showed  67,170;  No.  Ill  was  kept  at  50°  F.  and 
showed  1,362 ;  No.  IV  was  kept  at  45°  F.  and  showed  448. 

The  number  of  bacteria  in  bottled  milk  from  single  dairies  usually 
ranges  from  10,000  to  100,000  per  cubic  centimetre,  according  to  the 
season.  Milk  from  mixed  dairies  delivered  in  cases  ranges  from  100,000 
to  5,000,000,  the  latter  number  being  often  reached  in  very  hot  weather. 
There  seems,  however,  to  be  little  doubt  that  milk,  in  common  with  other 
animal  fluids,  possesses  certain  bactericidal  properties  which  render  it 
stable  for  a  limited  time,  which  are  soon  exhausted  if  the  temperature  is 
allowed  to  rise,  but  which  assist  materially  in  its  preservation  during  the 
first  twenty-four  hours. 

The  number  of  bacteria  in  cream  is  nearly  always  greater  than  in 
milk.  Freeman's  experiments  with  gravity  cream  showed  that  the  bac- 
teria were  300  times  as  numerous  in  the  cream  as  in  the  milk  left  be- 
hind, the  bacteria  being  apparently  carried  up  with  the  fat  globules. 
This  emphasises  the  necessity  of  the  greatest  care  with  reference  to 
cream  and  indicates  one  great  advantage  of  centrifugal  cream,  that  it 
can  be  marketed  at  least  twenty-four  hours  earlier  than  gravity  cream. 

A  Bacteriological  Standard  for  Pure  Milk. — There  has  been  much 
discussion  among  different  milk  commissions  regarding  some  such 
standard.  One  commission  requires  that  the  milk  shall  not  have  more 
than  10,000  bacteria  in  each  cubic  centimetre;  another  fixes  the  limit 


142  NUTRITION. 

at  30,000.  Methods  of  cultivating  and  counting  the  bacteria  of  milk  are 
by  no  means  uniform,  and  it  is  often  quite  impossible  to  compare  the 
figures  of  different  observers,  because  not  all  the  conditions  were  the 
same.  Too  much  stress  may  be  laid  upon  the  mere  number  of  bacteria ; 
their  character  must  also  be  considered.  A  milk  commission  should  be 
satisfied  if  all  pathogenic  organisms  have  been  excluded  and  if  the  num- 
ber of  other  organisms  is  below  30,000  per  cubic  centimetre.  There  is 
no  evidence  that  when  these  conditions  have  been  fulfilled  the  results 
in  infant  feeding  are  any  better  with  a  milk  containing  5,000  bacteria 
or  less,  than  with  one  containing  30,000.  Nor  is  there  any  proof  that 
milk  containing  30,000  bacteria  per  cubic  centimetre  is  for  this  reason 
injurious.  Emphasis  should  be  placed  rather  upon  tlie  hygienic  condi- 
tions under  which  the  milk  is  produced  and  the  exclusion  of  pathogenic 
organisms.  A  low  bacterial  count,  if  no  preservatives  have  been  used, 
may  be  taken  as  presumptive  evidence  at  least  that  the  milk  is  produced 
under  hygienic  conditions  and  carefully  handled,  and  under  such  cir- 
cumstances the  entrance  of  pathogenic  germs  is  extremely  improbable. 
It  is  quite  possible  to  produce  milk  which  is  practically  sterile;  but 
the  expense  entailed  is  so  great  as  to  make  the  commercial  produc- 
tion of  such  milk  impracticable.  For  milk  sold  in  cans  100,000  to 
the  cubic  centimetre  may  be  considered  good;  for  bottled  milk  any- 
thing under  30,000  is  good,  and  an  average  under  10,000  is  exceed- 
ingly good;  the  count  in  all  cases  being  made  at  the  time  the  milk  is 
offered  for  sale. 

The  reports  made  by  the  bacteriologist  of  one  of  the  New  York  milk 
commissions  show  that  by  the  most  careful  handling  the  number  of  bac- 
teria ^  can  be  kept  at  an  average  of  less  than  5,000  in  each  cubic  centi- 
metre at  the  time  when  it  is  delivered. 

The  Means  of  Excluding  Pathogenic  Bacteria,  and  of  Checking  the 
Spread  of  Contagious  Diseases  through  Milk. — Rules  are  readily  de- 
ducible  from  a  study  of  the  records  of  how  milk  has  usually  been  infected. 

1.  No  person  suffering  from,  or  in  contact  with  a  person  suffering 
from,  a  contagious  disease  should  enter  a  dairy  building  or  in  any  way 
come  in  contact  with  the  milk  or  milk-utensils;  especially  should  this 
rule  be  enforced  in  the  case  of  diphtheria,  scarlet  and  typhoid  fevers. 

*  To  accomplish  such  a  result  certain  special  precautions  are  observed;  the  most 
important  are  the  following:  The  stables  have  cement  floors  to  admit  of  ready  flushing 
with  a  hose;  no  hay,  straw,  or  fodder  is  kept  in  the  stables;  shavings  are  used  for 
bedding;  the  cows  are  carefully  groomed  every  day  and  not  fed  until  after  they  are 
milked;  a  few  minutes  before  milking  the  loose  dirt  is  removed  from  the  udders 
with  a  damp  cloth.  The  milkers  wear  sterilised  coats  and  caps,  and  wash  their 
hands  before  milking  each  cow;  all  bottles,  pails,  etc.,  are  sterilised  with  live  steam, 
the  pails  just  before  using.  The  milk  is  immediately  removed  to  the  milk-house, 
where  it  is  strained,  mixed,  cooled  to  38°  F.,  bottled  and  sealed — all  within  twenty 
minutes  from  the  time  it  leaves  the  cows. 


COW'S   MILK.  143 

Children,  domestic  animals,  and,  so  far  as  possible,  flies  should  be  ex- 
cluded from  rooms  where  milk  is  handled. 

2.  Milk  should  not  be  handled  in  or  near  dwellings,  privies,  or  sta- 
bles; cans  and  pails  should  be  washed  only  at  the  dairy,  and  after  ordi- 
nary cleansing  they  should  be  washed  in  boiling  water  or  sterilised  with 
live  steam.  Especial  attention  should  be  given  to  milk-bottles  which 
have  been  in  infected  rooms.  The  hands  of  the  milker  should  invariably 
be  carefully  washed  just  before  milking. 

3.  Dairies  should  be  subject  to  regular  city  or  state  inspection.  Milk 
from  cows  showing  physical  evidence  of  tuberculosis  should  be  excluded ; 
also  that  from  animals  which  are  in  any  way  sick  or  are  suffering  from 
disease  of  the  udder.  Milk  from  apparently  healthy  animals  who  re- 
spond to  the  tuberculin  test  should  not  be  used  for  food  in  a  raw  state. 

4.  In  any  epidemic  of  contagious  disease,  the  milk  supply  should 
be  carefully  investigated;  and  all  cases  of  such  diseases  in  the  families 
of  those  who  produce  or  handle  the  milk  should  be  immediately  re- 
ported and  supervised  by  the  authorities. 

Means  of  Reducing  the  Number  and  Lessening  the  Growth  of  Bac- 
teria in  Milk. — A  marked  diminution  in  the  number  of  germs  present  in 
milk,  as  it  is  now  handled,  may  be  brought  about  by  attention  to  two 
conditions — cleanliness  and  temperature — and  the  results  will  be  directly 
in  proportion  to  the  care  bestowed  upon  them. 

Cleanliness  must  have  reference,  in  the  first  place,  to  the  cows  them- 
selves. Since  most  of  the  germs  in  milk  come  from  the  cows,  it  is  im- 
portant that  the  belly,  udder,  and  tail  should  be  cleansed  before  milking, 
to  prevent  droppings  into  the  pail.  The  parts  should  be  wiped  with  a 
damp  cloth.  Milking  should  be  done  out  of  doors  or  in  a  clean,  special 
shed ;  if  in  the  stable,  this  should  be  clean.  No  dry  fodder  should  be  fed 
and  no  sweeping  done,  nor  anything  else  to  raise  a  dust,  just  before  milk- 
ing. The  milker's  hands  should  be  carefully  washed  and  dried,  not  moist- 
ened with  milk,  as  is  sometimes  done.  Milk  pails  and  cans  should  be 
washed,  as  stated  above,  and  always  dried  upside  down,  remaining  in  this 
position  until  used.  Pails  with  a  small  opening  partially  protected  by 
a  hood  should  be  used  to  lessen  the  contamination  with  dirt  from  the 
cows  during  milking.  All  sieves  and  straining  cloths  should  be  steril- 
ised before  each  using.  Milk  should  be  bottled  at  the  dairy,  and  so 
transported.  Every  time  milk  is  handled,  poured  from  one  vessel  into 
another,  or  in  any  way  manipulated,  the  danger  of  contamination  is 
increased. 

As  to  temperature,  no  point  in  the  care  of  milk  is  more  important 
than  the  rapid  first  cooling;  as  soon  as  possible  after  being  drawn  it 
should  be  cooled  to  at  least  50°  F.  Unless  the  milk  is  taken  at  once 
to  a  milk-house  and  some  of  the  special  forms  of  cooling  apparatus  em- 
ployed, the  cans  should  be  immersed  in  spring  water  having  a  tempera- 


144 


NUTRITION. 


ture  below  50°  F.  or  in  ice- water,  and  remain  at  least  one  hour.  If  a 
temperature  of  50°  F.  is  maintained  during  transportation,  which  is 
quite  possible  if  cans  and  bottles  are  properly  iced,  and  during  subse- 
quent storage,  the  growth  of  bacteria  may  be  so  retarded  that  milk  may 
be  a  safe  food  even  when  forty-eight  hours  old.  If  the  temperature  is 
not  kept  as  low  as  50°  F,  this  result  can  not  be  depended  upon,  and  with 
every  degree  above  that  point  the  increase  in  bacterial  growth  is  very 
marked.  Since  the  number  of  bacteria  increases  so  rapidly  witli  the  age 
of  the  milk  after  the  first  twenty-four  hours,  it  is  of  the  utmost  impor- 
tance that  milk  be  shipped  as  quickly  as  possible  after  it  is  collected. 

A  provision  of  the  Sanitary  Code  of  New  York  City  requires  that  no 
milk  shall  be  sold  having  a  temperature  above  50°  F.  This  ordinance 
has  done  more  than  anything  else  to  improve  the  milk  supply  of  the  city, 
especially  to  insure  proper  icing  during  transportation. 

The  desirable  results  indicated  above  are  to  be  secured,  in  the  first 
place,  by  educating  the  public  to  appreciate,  and  dealers  to  produce,  a 
better  and  cleaner  milkj  secondly,  by  giving  to  the  health  authorities 
of  city  and  state  greater  power  than  heretofore  in  the  matter  of  milk 
inspection ;  thirdly,  by  the  formation  of  milk  commissions,  through  which 
the  physicians  of  a  town  or  city  may  co-operate  to  secure  adequate  super- 
vision of  at  least  a  portion  of  the  milk  supply. 

Composition  of  Cow's  Milk. — Except  in  the  percentage  of  fat,  the 
composition  of  mixed  or  herd  milk  varies  but  little,  whatever  the  breed. 
The  fat  is  lowest  in  the  Holsteins,  and  highest  in  the  Jerseys. 


Composition  of  Cow^s 

Milk.' 

Jerseys. 

Holsteins. 

Average  good 
herd  milk. 

Fat 

5.61 
5.15 
3.91 
0.74 
84.59 

3.46 
4.84 
3.39 
0.74 

87.57 

4  00 

Sugar 

4  50 

Protein 

3  50 

Salts 

0  75 

Water 

87  25 

Total 

100.00 

100.00 

ion  on 

'  In  the  table  the  figures  for  Jersey  and  Holstein  herds  are  the  averages  given  by  the 
New  York  State  Experiment  Station.  The  legal  requirements  in  New  York  and 
most  of  the  States  are,  fat,  3  per  cent;  total  solids,  12  per  cent. 

The  figures  given  for  herd  milk  are  a  little  lower  for  the  protein 
and  a  little  higher  for  the  sugar  than  in  the  older  analyses.  It  is  with 
milk  of  such  composition  that  the  average  physician  has  to  do  in  infant 
feeding.  In  a  poor  milk  the  only  important  difference  to  be  considered 
is  that  the  fat  is  from  0.5  to  1  per  cent  lower  than  the  averages  given. 
In  a  rich  Jersey  milk  the  chief  difference  is  that  the  fat  is  1  to  1 . 5  per 
cent  higher  than  the  averages;  there  is  also  an  increase  in  the  protein 


COW'S  MILK.  145 

and  sugar  which  is  less  important,  but  should  not  be  ignored.  The  vari- 
ations in  the  fat  content  of  milk  are  those  which  are  of  most  practical 
importance  to  the  physician.  As  to  the  relative  advantages  of  the  dif- 
ferent breeds  for  this  purpose,  the  difference  does  not  seem  great,  pro- 
vided all  are  equally  healthy.  Jerseys  and  all  highly  bred  animals  are 
more  prone  to  disease  and  minor  disturbances  than  the  hardier  com- 
mon breeds. 

The  Examination  of  Cow's  Milk. — Tlie  application  of  heat  often 
causes  coagulation  in  milk  which  is  near  the  souring  point,  and  also 
in  colostrum  milk.  Both  are  unfit  for  use.  The  normal  reaction  of 
cow's  milk  is  amphoteric  or  slightly  acid.  If  strongly  acid  it  should 
not  be  used;  if  alkaline,  it  is  pretty  certain  that  something  has  been 
added  to  it. 

The  specific  gravity  is  from  1.028  to  1.033.  If  the  milk  has  been 
falsified  by  the  removal  of  cream,  the  specific  gravity  is  raised;  if  adul- 
terated by  the  addition  of  water,  the  specific  gravity  is  lowered. 

The  best  of  all  ready  methods  of  determining  fat  are  the  Leffman 
and  Beam  and  the  Babcock  tests.^  By  both,  the  fat  is  brought  to  the 
surface  by  the  centrifuge  after  the  addition  of  sulphuric  acid  and  other 
reagents.  These  tests  are  similar,  but  differ  in  the  reagents  used.  When 
carefully  made  they  are  very  accurate.  For  institutions  such  an  appa- 
ratus for  determining  the  fat  is  indispensable;  and  the  composition  of 
the  milk  and  the  cream  used  can  be  determined  each  day. 

The  cream-gauge  may  be  used  as  for  woman's  milk,  the  100  c.c.  size  to 
be  preferred;  but  it  is  not  to  be  relied  upon  unless  the  milk  is  put  into 
the  cylinder  soon  after  it  is  drawn  and  cooled  rapidly  by  being  placed 
in  ice-water.  Under  these  conditions,  if  the  reading  is  made  at  the  end 
of  eight  or  ten  hours  the  percentage  of  cream  to  that  of  fat  is  about 
three  to  one.  If  the  milk  has  been  first  cooled  and  afterward  handled 
two  or  three  times  before  the  test  is  made,  the  cream  does  not  rise  regu- 
larly, and  the  above  ratio  is  not  maintained. 

A  microscopical  examination  of  milk  is  of  considerable  importance, 
and  in  cases  where  the  character  of  the  supply  is  questionable  it  may 
give  valuable  information.  Both  the  cream  and  the  sediment  should  be 
examined.  Not  much  can  be  learned  from  a  study  of  the  fat  globules, 
but  among  them  may  be  found  colostrum  corpuscles,  which  are  usually 
present  for  nearly  a  week  after  calving.  The  sediment  is  best  studied 
after  centrifuging.  It  should  be  examined  for  pus  cells  and  blood,  and 
stained  for  bacteria.  A  few  leucocytes  are  almost  invariably  found  in 
normal  milk.  Stokes  and  Wegefarth  consider  that  an  average  of  more 
than  five  in  each  field  examined  with  an  oil-immersion  lens  should  be 

»  The  apparatus  can  be  obtained  of  D.  H.  Burrell  &  Co.,  Little  Falls,  N.  Y.     The 
one  sold  as  the  "Facile  Junior"  may  be  used  for  woman's  milk,  urine,  and  other 
fluids  as  well  as  for  cow's  milk,  and  is  very  convenient  for  physicians'  use.     Price,  $10. 
11 


146  NUTRITION. 

regarded  as  abnormal,  and  such  milk  excluded.  The  most  frequent 
source  of  pus  cells  in  numbers  is  inflammation  of  the  udder.  Pus  cells 
may  be  associated  with  a  stringy  mucus.  Blood  may  also  result  from 
inflammation  of  the  udder,  sometimes  from  traumatism. 

When  pus  cells  are  present  the  specimen  should  be  examined  for  bac- 
teria. Any  of  the  ordinary  pyogenic  cocci  may  be  found.  Streptococci 
were  found  by  Eastes  in  75  per  cent  of  186  specimens  examined,  although 
in  most  of  these  the  number  was  so  small  that  no  symptoms  were  pro- 
duced. He  cites  one  instance  where  symptoms  were  caused.  Woodward 
has  reported  a  striking  example  where  a  family  of  five  children  were 
all  made  seriously  ill  with  vomiting  and  collapse  after  taking  milk 
which  was  found  by  him  to  contain  large  numbers  of  streptococci.  The 
only  certain  way  of  demonstrating  the  presence  of  tubercle  bacilli  is  by 
animal  inoculation. 

Whenever  pus  cells,  blood,  or  streptococci  are  at  all  numerous,  the 
milk  should  be  regarded  as  unfit  for  food  and  a  thorough  inspection  of 
the  herd  should  be  made. 

The  Differences  between  Cow's  Milk  and  Woman's  Milk. — Cow's  milk 
is  more  opaque  than  woman's  milk,  although  the  latter  may  contain 
more  fat.  This  opacity  is  due  to  the  large  proportion  of  calcium  phos- 
phate with  which  the  casein  is  combined. 

The  reaction  of  cow's  milk  soon  after  it  is  drawn  becomes  acid.  It 
is  almost  invariably  so  found  unless  some  alkali  has  been  added.  Wom- 
an's milk  is  distinctly  less  acid. 

The  specific  gravity  and  total  solids  in  the  two  milks  are  about  the 
same. 

The  sugar  of  both  cow's  and  woman's  milk  is  lactose  in  solution. 
The  difference  in  amount  is  considerable.  Cow's  milk  usually  has  4.5 
per  cent,  while  woman's  milk  usually  has  from  6  to  7  per  cent. 

The  greater  part  of  the  fat  of  cow's  milk  is  neutral  fat,  as  in  woman's 
milk;  cow's  milk,  however,  contains  a  much  larger  proportion  of  the 
lower  or  volatile  fatty  acids  than  does  woman's  milk.  Woman's  milk 
on  the  contrary  contains  more  oleic  acid. 

The  protein  of  cow's  milk  is  two  and  a  half  times  as  abundant  as 
that  of  woman's  milk,  and  it  shows  marked  differences  in  character. 
Our  knowledge  of  the  protein  both  of  cow's  milk  and  woman's  milk 
is  still  imperfect.  The  separation  of  the  different  forms  of  protein  is 
diflBcult,  and  for  this  reason  chemists  are  by  no  means  agreed  as  to  the 
proportions  in  which  the  different  ones  are  present.  It  is  well  established 
that  in  woman's  milk  the  soluble  proteins — lactalbumin,  etc.,  are  in  ex- 
cess of  the  insoluble  casein,  Koenig  giving  the  proportion  as  5  to  4; 
in  cow's  milk,  on  the  other  hand,  the  proportion  of  the  soluble  protein 
is  much  smaller  than  the  insoluble,  the  latest  writers  giving  the  pro- 
portion as  1  to  3. 


COW'S   MILK. 


147 


The  casein  ^  of  cow's  milk  is  readily  coagulated  by  rennet  and  acids. 
The  curd  formed  by  the  gastric  juice  is  tough  and  firm  and  is  more 
slowly  dissolved  by  the  action  of  the  digestive  fluids.  The  casein  of 
woman's  milk  is  not  regularly  coagulated  by  rennet,  and  only  slightly 
and  with  difficulty  by  acids.  The  curd  formed  by  the  gastric  juice  is 
loose  and  flocculent,  and  is  readily  and  completely  dissolved. 

The  inorganic  salts  in  cow's  milk  are  a  little  more  than  three  times 
as  abundant  as  in  woman's  milk.  The  most  important  differences  in 
the  composition  of  these  salts  are  shown  in  the  following  analyses: 


Ash  in  100  Parts  of  Milk  {Bunge). 

Cow's. 

Woman's. 

Potassium  oxide 

.0703 
.0257 
.0343 
.0065 
.0006 
.0469 
.0445 

1760 

Sodium  oxide 

.1110 

Calcium  oxide 

.1590 

Magnesium  oxide-                

0210 

Ferric  oxide 

.0003 

Phosphoric  acid 

.1970 

Chlorine 

.1690 

Total 

.2288 

.7970 

Cow's  milk  contains  relatively  a  much  larger  amount  of  calcium 
phosphate  and  a  smaller  amount  of  potassium  salts  and  of  iron.  The 
ash  does  not  accurately  represent  the  mineral  constituents  of  milk. 
About  8  per  cent  of  the  phosphoric  acid  of  the  ash,  according  to  Eich- 
mond,  is  derived  from  the  phosphorus  of  the  casein;  while  the  traces  of 
sulphuric  and  carbonic  acid  found  are  not  true  mineral  constituents  of 
milk.  Most  of  the  more  recent  analyses  show  the  presence  of  citric  acid 
in  both  woman's  and  cow's  milk. 

Cow's  milk  always  contains  a  large  number  of  bacteria,  which  in- 
crease in  proportion  to  the  age  of  the  milk;  woman's  milk  is  either 
sterile  or  contains  but  a  few  cocci  from  the  milk  ducts. 

Cream. — A  great  misapprehension  exists  as  to  its  composition.  It  is 
often  spoken  of  as  if  it  were  entirely  different  from  milk.  It  should 
rather  be  regarded  as  milk  which  contains  an  excess  of  fat. 

Cream  was  formerly  obtained  by  skimming — the  gravity  process — at 
present,  almost  entirely  by  the  use  of  a  centrifugal  machine  known  as  a 
separator.     The  latter  process  has  the  advantage  in  point  of  time,  as 


*  By  Haliburton  and  some  other  chemists  the  term  caseinogen  is  given  to  this  pro- 
tein as  it  exists  in  milk.  When  this  is  acted  upon  by  rennet  it  splits  up  into  two 
substances:  One,  the  firm,  insoluble  coagulum  to  which  only  the  term  casein  is  applied; 
the  other,  a  soluble  protein  which  is  known  as  whey-protein;  this  is  present  in  but 
small  amount.  Those  who  use  the  term  casein  to  designate  the  protein  as  it  exists 
in  milk  refer  to  the  cujxi  formed  by  the  action  of  rennet  in  the  stomach  as  paracasein. 


148 


NUTRITION. 


centrifugal  cream  can  be  put  upon  the  market  from  twenty-four  to  thirty- 
six  hours  earlier  than  gravity  cream. 

The  following  table  gives  the  composition  of  an  average  milk  and  of 
centrifugal  cream  of  different  densities  removed  from  the  same  milk: 


Whole 
milk. 

Cream. 

I. 

ri. 

III. 

IV. 

V. 

Fat 

4.00 
4.50 
3.50 
0.75 

8.00 
4.50 
3.40 
0.70 

12.00 
4.20 
3.30 
0.65 

16.00 
4.05 
3.20 
0.60 

20.00 
3.90 
3.05 
0.55 

40  00 

Sugar 

3  00 

Protein 

2.20 

Salts 

0.45 

The  percentages  of  protein  and  sugar  in  the  8-  and  13-per-cent 
cream  are  but  little  lower  than  in  milk;  in  the  very  rich  creams  they 
are  reduced  by  about  one-third. 

It  is  unfortunate  that  no  general  standard  exists  as  to  what  shall  be 
sold  as  cream.  In  New  York  State  the  law  provides  that  cream  shall 
contain  at  least  18  per  cent  fat.  Very  rich,  centrifugal  cream  has  from 
35  to  40  per  cent  fat ;  "the  usual  centrifugal  cream  has  about  18  to  20 
per  cent.  Gravity  cream  has  generally  from  16  to  20  per  cent  fat.  It 
is  possible  to  obtain  from  milk  laboratories  cream  of  any  desired  fat 
percentage. 

None  of  the  methods  for  determining  the  fat  in  milk  is  applicable 
to  cream,  except  the  Babcock  test. 

Methods  of  Obtaining  Milk  Containing  Various  Proportions  of  Fat — 
Top-Milk,  Skimmed  Milk. — To  secure  a  milk  for  infant  feeding  which  is 
fresh  and  at  the  same  time  one  which  contains  a  larger  proportion  of 
fat  than  does  whole  milk,  the  practice  has  come  into  vogue  of  using  from 
milk  purchased  and  delivered  in  bottles,  only  a  certain  number  of 
ounces  removed  from  the  top.  To  this  the  term  "top-milk"  has  been 
given.  Different  percentages  of  fat,  which  are  sufficiently  accurate  for 
practical  purposes,  may  be  obtained  by  varying  the  amount  removed. 
Top-milk  and  thin  cream  are  practically  identical  in  composition.  If 
cow's  milk  is  put  into  bottles  soon  after  it  is  drawn  and  rapidly  cooled, 
it  will  be  found  that  after  four  hours  the  upper  fourth  will  contain 
nearly  all  the  fat  that  will  rise  as  cream,  and  the  top-milk  may  then  be 
removed.  It  is  therefore  unnecessary  to  allow  the  milk  to  stand  for  a 
longer  time.  Milk  bottled  at  dairies  and  then  transported  should  be 
allowed  to  stand  after  it  is  received  for  at  least  two  hours  before  remov- 
ing the  top-milk.  This  may  be  done  with  a  siphon,  spoon,  or  a  small 
special  dipper ;  pouring  off  is  not  so  accurate. 

Skimmed  milk,  or  milk  which  contains  a  smaller  proportion  of  fat 
than  does  whole  milk,  may  be  obtained  from  bottled  milk  by  removing  and 
rejecting  a  certain  number  of  ounces  from  the  top  of  the  quart  bottle  and 


COW'S  MILK.  149 

using  only  the  remainder.     The  amount  of  cream  removed  will  depend 
upon  the  proportion  of  fat  desired  in  the  skimmed  milk. 

It  is  unnecessary  in  practice  to  have  a  top-milk  which  contains  more 
than  7  per  cent  fat;  while  it  is  desirable  at  times  to  obtain  milk  which 
is  practically  fat-free.  These  two  extremes  and  all  intermediate  pro- 
portions of  fat  may  easily  be  obtained  from  bottled  milk  with  approxi- 
mate accuracy  by  the  method  given  below.  The  results  will  of  course 
not  be  the  same  with  all  milks,  but  will  vary  considerably  according  as 
the  supply  is  from  a  good  herd  of  selected  cattle  of  mixed  breeds  (aver- 
age 4  per  cent  fat),  or  from  a  Jersey  or  Alderney  herd.  It  is  therefore 
necessary  for  the  physician  to  know  with  M^hich  one  of  these  he  is  deal- 
ing, if  the  milk  is  to  be  used  for  infant  feeding. 

If  the  original  milk  contains  4  per  cent  fat;         If  it  contains  5  per  cent  fat; 

To  obtain  7%  fat,  use  upper  16  oz upper  20  oz.  from  1  quart. 

"        "     6%  "      "        "     20  " "     24  "       "      "     " 

"     5%  •'.     "        "     24  " all. 

"        "     4%  "      "    all remainder  after  skimming 

off  2  oz. 
"        "     3%  "      "    remainder  after  skimming  off  2  oz ..  remainder  after  skimming 

off  3  oz. 
"        "     2%  "      "  "  "  "  "  4  "  ..remainder  after  skimming 

off  5  oz. 
"        "     1%  "      "  "  "  "  "  8  "  ..remainder  after  skimming 

off  8  oz. 

Fat-free  milk  can  be  obtained  only  by  the  removal  of  the  cream  by  a 
separator. 

If  the  Jersey  milk  contains,  as  it  often  does,  5^  per  cent  of  fat,  24 
ounces  should  be  removed  from  a  quart  bottle  to  secure  a  7-per-cent  milk ; 
28  ounces  to  secure  a  6-per-cent  milk;  and  3,  5,  8,  and  10  ounces  respec- 
tively to  obtain  a  skimmed  milk  which  has  4,  3,  2,  and  1  per  cent  of  fat. 

The  physician  should  make  or  have  made  with  the  Babcock  appa- 
ratus several  fat  tests  of  a  given  milk  supply  in  order  to  obtain  a  basis 
upon  which  to  make  his  calculations.  In  general  it  is  wise  for  one  who 
has  much  to  do  with  infant  feeding  to  have  his  patients  take  milk  from 
the  same  supply  to  secure  uniformity  in  his  results. 

In  or  near  large  cities  it  is  possible  to  obtain  from  milk  laboratories 
milk  with  any  desired  percentage  of  fat.  This  of  course  greatly  sim- 
plifies the  whole  matter.  How  top-milk  and  skimmed  milk  of  different 
percentages  are  used  will  be  considered  in  the  chapter  on  Infant  Feeding. 

Milk  Sterilisation. — The  term  sterilisation  is  widely  and  rather 
loosely  used  to  signify  the  heating  of  milk  for  the  destruction  of  germs. 
It  should,  however,  be  borne  in  mind  that  none  of  the  methods  com- 
monly employed  renders  milk  sterile  in  the  bacteriological  sense  of  the 
word.  What  is  accomplished  is  the  destruction  of  such  pathogenic  germs 
as  may  be  present,  and  from  95  to  99  per  cent  of  the  other  bacteria,  so 


150  NUTRITION. 

as  to  retard  for  a  considerable  time  the  ordinary  fermentative  changes. 
The  preservation  of  milk  for  infant  feeding,  by  boiling  it  in  small  bottles, 
was  advocated  by  Jacobi  many  years  ago. 

The  advantages  of  sterilising  milk  are  obvious.  When  we  consider 
the  enormous  number  of  bacteria  present  in  cow's  milk  with  the  usual 
methods  of  handling,  and  that  none  of  these,  so  far  as  is  now  known, 
are  advantageous,  but  that  they  are  frequently  the  cause  of  disease,  it  is 
not  strange  that  after  its  introduction  by  Soxhlet  in  1886  the  practice 
of  heating  milk  used  for  infant  feeding  was  rapidly  adopted  all  over  the 
M'orld.  Following  him,  the  earlier  experiments  in  sterilisation  were  made 
at  312*  F.,  usually  continued  for  an  hour  and  a  half,  and  this  tempera- 
ture is  still  largely  employed  on  the  Continent  of  Europe.  Even  this 
does  not  render  milk  safe  for  very  long.  Spores  are  not  destroyed,  and 
at  ordinary  room  temperatures  spore-bearing  bacteria  may  soon  develop 
in  such  numbers  as  to  make  the  milk  dangerous.  Since  some  of  these 
bacteria  act  upon  the  milk-protein  and  not  upon  the  sugar,  such  milk 
may  not  be  sour,  and  hence  its  danger  may  not  be  recognised. 

There  are  disadvantages  in  heating  milk.  The  change  in  taste  and 
the  constipating  effects  of  sterilised  milk  were  soon  noticed ;  other  altera- 
tions were  not  so  evident  and  have  more  recently  come  to  be  appreciated, 
although  many  of  these  are  not  yet  fully  explained.  Some  of  the  lactose 
is  converted  into  caramel,  causing  a  slight  change  in  colour;  the  lactal- 
bumin  is  partially  coagulated,  this  beginning  at  160°  F.  (70°  C);  the 
casein  is  rendered  less  coagulable  by  rennet,  and  appears  to  be  acted  upon 
more  slowly  both  by  pepsin  and  trypsin;  Rettger  has  shown  that  when 
milk  is  heated  above  185°  F.  (85°  C.)  a  volatile  sulphide  is  liberated, 
conclusive  evidence  of  a  change  in  the  protein;  the  organic  phosphorus 
is  changed  into  an  inorganic  phosphate;  the  citric  acid  is  partially  pre- 
cipitated as  calcium  citrate,  and  some  lime  salts,  which  are  usually  solu- 
ble, are  converted  into  insoluble  compounds.  Some  changes  also  occur  in 
the  fat.  Moreover,  certain  natural  ferments  in  fresh  milk,  believed  to  be 
of  value  in  digestion,  are  destroyed  by  heat. 

Many  of  these  changes  are  but  imperfectly  understood,  and  some  of 
them  are  doubtless  without  any  injurious  effect  upon  nutrition.  There 
is,  however,  one  important  clinical  reason  for  believing  that  the  nutritive 
properties  of  milk  are  impaired  by  heating  to  212°  F. — viz.,  the  occur- 
rence of  scurvy  in  infants  who  are  fed  upon  such  milk  for  a  long  time. 
Of  379  cases  of  infantile  scurvy  brought  together  in  the  Eeport  of  the 
American  Paediatric  Society  in  1898,  sterilised  milk  was  the  previous 
diet  in  107.  At  least  a  score  of  such  cases  have  come  under  my  own 
notice.  Again  and  again  cases  of  scurvy  have  been  cured  by  simply  ceas- 
ing to  sterilise  the  milk. 

Heating  at  Lower  Temperatures — Pasteurising  Milk. — To  obviate  the 
disadvantages  above  referred  to,  the  practice  has  come  largely  into  use 


COW'S   MILK.  151 

in  America  of  employing  much  lower  temperatures  for  milk  sterilisa- 
tion, owing  chiefly  to  the  work  of  Freeman  (New  York)  and  Russell 
(Wisconsin). 

At  first  167°  F.  (75°  C.)  was  used;  subsequently,  however,  a  lower 
temperature  was  found  sufficient,  and  150°  to  155°  F.  (65°  to  68°  C.) 
are  the  temperatures  which  are  now  generally  employed.  These  tempera- 
tures are  maintained  from  twenty  to  tliirty  minutes.  This  is  sufficient 
to  kill  the  bacilli  of  tuberculosis,  diphtheria,  and  typhoid  fever,  and 
from  98  to  99.8  per  cent  of  all  other  bacteria  in  milk.  Nearly 
all  of  the  objectionable  changes  produced  in  sterilised  milk  are  avoided 
when  the  temperature  is  raised  only  to  150°  F.  (65°  C),  while  it  accom- 
plishes the  purpose  for  which  milk  is  heated.  The  advantages  of  this 
form  of  heating  are  therefore  obvious.  But  spores  are  not  destroyed, 
and  such  milk  requires  special  handling.  It  should  always  be  rapidly 
cooled  and  kept  at  a  low  temperature.  Pasteurised  milk  should  be  used 
within  a  few  hours  after  heating;  no  attempt  should  be  made  to  keep  it 
more  than  twenty-four  hours,  even  upon  ice.^ 

Pasteurisation  vs.  Sterilisation. — From  what  has  already  been  said 
it  would  appear  that  the  argument  is  altogether  in  favour  of  pasteurisa- 
tion. The  lowest  temperature  and  the  shortest  time  that  will  surely 
destroy  the  objectionable  bacteria  in  milk  would  seem  to  merit  general 

'  Quite  distinct  from  the  process  ju.st  described  is  that  known  as  commercial 
pasteurisation.  In  this,  by  passing  milk  through  hot  pipes,  it  is  heated  to  tempera- 
tures ranging  from  140°  F.  for  several  minutes  to  160°  F.  for  a  very  brief  period, 
usually  for  5  to  30  seconds.  Such  heating  destroys  from  90  to  99  per  cent  of  the 
bacteria  ordinarily  found  in  milk.  According  to  the  experiments  made  in  the  labora- 
tory of  the  New  York  Health  Department,  a  temperature  of  160°  F.  maintained  for 
30  seconds  under  usual  conditions  kills  tj^phoid,  diphtheria,  and  colon  bacilli.  In  a 
email  percentage  of  experiments  about  1  in  100,000  of  these  bacteria  withstood  this 
exposure. 

By  this  treatment  (160°  F.  for  30  seconds)  the  great  majority  of  tubercle  bacilli, 
which  are  the  most  resistant  of  the  bacteria  exciting  disease  that  are  found  in  milk, 
are  either  killed  or  so  injured  that  they  can  not  infect.  On  the  average  about  one- 
tenth  of  1  per  cent  survive;  160°  F.  for  one  minute  usually  kills  all. 

The  pasteurised  milk  of  commerce  which  is  extensively  sold  in  many  large  cities  is 
chiefly  milk  that  has  been  heated  for  from  5  to  30  seconds  in  the  manner  described. 
The  destruction  of  pathogenic  organisms  is  a  great  advantage.  The  killing  of  the 
bacteria  which  produce  the  souring  of  milk  makes  it  possible  to  keep  milk  in  warm 
weather  a  much  longer  time  before  souring  occurs.  It  is  therefore  a  great  advantage 
to  the  dealer,  and  he  is  likely  to  depend  upon  it  rather  than  upon  adequate  icing 
and  cleanUness  in  handling  his  milk.  There  are  some  serious  objections  to  com- 
mercial pasteurisation.  Milk  so  heated  should  be  quickly  cooled,  should  be  received 
into  sterilised  vessels  and  kept  at  a  low  temperature  (below  50°  F.).  If  these  pre- 
cautions are  not  taken  bacteria  develop  rapidly  and  the  milk  may  after  24  hours  be 
more  dangerous  than  if  it  had  not  been  heated  at  all;  since,  unlike  raw  milk,  it  does 
not  usually  sour  and  reveal  its  contaminated  condition.  Commercial  pasteurisation 
should  be  permitted  only  under  the  most  careful  restrictions,  and  the  can  or  bottle 
containing  pasteurised  milk  should  indicate  the  degree  and  time  of  heating. 


152 


NUTRITION. 


adoption.  Pasteurisation,  however,  requires  considerable  care,  intelli- 
gence, and  special  apparatus ;  if  not  properly  done  it  may  be  worse  than 
nothing.  Moreover,  pasteurised  milk  can  not,  in  very  hot  weather,  be 
kept  without  ice  as  long  as  it  may  be  necessary  to  keep  milk.  Steril- 
isation at  212°  F.  (100°  C.)  is  much  simpler;  it  may  be  done  with  many 
simple  and  inexpensive  forms  of  apparatus  or  even  without  any  special 
apparatus.  Where  no  ice  is  available,  it  is  certainly  safer  in  hot  weather 
than  pasteurisation.  Among  the  poor  of  our  large  cities,  in  summer, 
heating  to  212°  for  an  hour  is  to  be  advised  as  the  most  satisfactory,  and 
indeed  the  only  efficient,  method  of  sterilisation.  It  should  not  be  for- 
gotten that  the  use  of  such  milk  as  the  sole  diet  for  a  long  time  is  at- 
tended with  a  certain  amount  of  risk ;  and  one  should  always  be  on  the 
watch  for  the  soreness  of  the  legs  and  the  spongy  gums  that  indicate  the 
beginning  of  scurvy,  as  well  as  for  the  more  general  symptoms  of  mal- 
nutrition. Heating  to  212°  F.  on  two  successive  days  is  also  to  be  recom- 
mended where  milk  must  be  kept  for  one  or  two  weeks,  as  upon  ocean 
journeys. 

Methods  of  Heating  Milk. — Milk  should  be  sterilised  preferably  in 
small  bottles,  each  one  of  which  contains  a  sufficient  quantity  for  one 
feeding.  These  bottles  may  be  plugged  with  cotton  or  corks,  or  special 
stoppers  may  be  used.  Soxhlet's  apparatus  may  be  employed,  or  Ar- 
nold's, or  any  one  of  a  half  dozen  others  sold  in  the  shops.  All  that  is 
really  necessary  is  to  expose  the  bottles  on  all  sides  to  live  steam  in  a 
closed  vessel.  It  can  be  done  effectively  in  any  tin  vessel  which  has  a 
closely  fitting  cover  and  a  perforated  bottom,  and  which  can  be  placed 


Fio.  25. — Freeman's  Pasteuriser. 
A,  Bottles  in  position  for  heating;    B,  method  of  cooling. 


over  a  pot  of  boiling  water.  Sterilisation  at  212°  F.  is  usually  continued 
for  one  hour.  The  bottles  should  then  be  cooled  in  water  as  quickly  as 
possible  and  placed  upon  ice  or  in  the  coolest  place  available. 

A  simple  apparatus  for  pasteurising  milk  has  been  devised  by  Free- 
man (Fig.  25).    In  this  the  temperature  is  raised  to  155°  F.  (68°  C.) 


COW'S   MILK.  153 

by  hot  water.^  Another  useful  form  of  apparatus  is  that  of  the  Walker- 
Gordon  Laboratory  Company,  which  contains  a  thermometer  so  that  any 
desired  temperature  can  be  secured.  An  essential  step  in  pasteurising 
milk  is  rapid  cooling.  After  forty-five  minutes  the  bottles  should  be 
removed  from  the  pasteuriser  and  placed  in  tepid  water  and  afterward 
in  ice-water,  where  they  should  remain  half  an  hour  before  being  placed 
in  the  cold  room  or  ice  chest. 

Limitations  of  Milk  Sterilisation. — While  pasteurising  or  sterilising 
milk  kills  nearly  all  the  living  organisms,  it  destroys  few  of  the  spores, 
and  probably  but  a  small  proportion,  if  any,  of  the  toxins.  Before  sterili- 
sation milk  may  contain  the  products  of  bacterial  growth  in  such  quan- 
tity and  of  such  a  character  as  to  render  it  unfit  for  food.  Again,  the 
fewer  the  spores  and  spore-bearing  bacteria  which  the  milk  contains,  the 
more  effective  the  sterilisation.  The  cleaner  the  milk  the  better  will 
be  the  result. 

Sterilised  milk  requires  the  same  modification  for  infant  feeding  as 
raw  milk.  There  is  no  evidence  to  show  that  its  digestibility  is  en- 
hanced by  the  process  of  heating. 

The  sterilisation  of  milk  is  useful,  first,  for  the  destruction  of 
pathogenic  germs,  particularly  typhoid  and  tubercle  bacilli;  secondly, 
for  the  destruction  of  the  bacteria  causing  fermentation,  thus  enabling 
one  to  feed  with  safety  milk  in  which,  though  it  may  be  forty-eight  hours 
old,  no  important  fermentative  changes  have  occurred.  As  a  therapeutic 
measure  sterilised  milk  is  useful  in  various  forms  of  gastric  or  intestinal 
infection  such  as  typhoid  fever,  dysentery,  diarrhoea,  etc.  In  certain 
of  these  conditions  no  milk  is  admissible;  at  other  times  sterilised  milk 
may  be  given  when  raw  milk  would  be  harmful. 

Shall  all  Milk  used  for  Infant  Feeding  be  Sterilised  ? — In  summer  only 
the  cleanest  milk  which  has  been  handled  in  the  best  manner  can  safely 
be  used  without  heating.  In  winter,  the  heating  of  milk  is  not  neces- 
sary, provided  the  source  of  supply  is  known  to  be  good.     So  long  as 

'  Freeman'.s  apparatus  is  used  as  follows:  The  pail  is  filled  to  the  groove  with 
water,  which  is  then  raised  to  the  boiling  point.  The  bottles  of  milk  are  dropped  into 
their  places  in  the  cylindrical  cups,  sufficient  water  being  poured  into  each  cup  to 
surround  the  bottle,  this  water  acting  as  the  conductor  of  heat.  The  pail  is  now 
removed  from  the  stove  and  placed  upon  a  board  or  other  non-conductor,  and  the 
receptacle  containing  the  bottles  of  milk  is  set  inside  and  the  cover  replaced.  The 
volumes  of  milk  and  water  have  been  so  calculated  that  in  ten  minutes  they  are  both 
at  a  temperature  of  155°  F.  The  water  contains  heat  enough  to  maintain  this,  with 
very  slight  variations,  for  twenty  minutes.  In  half  an  hour  the  bottles  of  milk  are 
removed  and  cooled  rapidly  by  being  placed  in  a  water-bath,  the  water  being  changed 
once  or  twice;  or,  better,  by  setting  the  pail  in  a  sink  and  allowing  the  cold  water  to 
nin  from  a  faucet  through  a  piece  of  rubber  pipe  into  the  pail,  overflowing  into  the 
sink.  This  rapid  cooling  is  very  important.  The  bottles  are  then  put  in  the  refrigera- 
tor. This  apparatus  may  be  obtained  from  James  Dougherty,  411  West  Fifty-ninth 
Street,  New  York. 


154  NUTRITION. 

milk  is  produced  and  handled  as  the  bulk  of  it  is  at  present,  not  being 
delivered  in  large  cities  until  it  is  considerably  over  twenty-four  hours 
old,  and  not  consumed  until  over  forty-eight  hours  old,  some  form  of 
heating  should  invariably  be  practised  in  hot  weather ;  also,  where  there 
is  any  doubt  about  the  dairy  hygiene  or  the  health  of  the  cows;  and 
finally,  during  epidemics  of  typhoid  fever,  diphtheria,  and  scarlet  fever. 

It  is  quite  possible  to  produce  milk  which  does  not  need  sterilisation ; 
the  conditions  to  be  fulfilled  have  been  already  detailed.  There  are 
special  dairies  supplying  such  certified  milk  to  many  of  our  large  cities, 
and  their  number  may  be  very  greatly  increased  if  the  medical  profession 
will  use  its  influence  in  this  direction.  My  preference  for  infant  feeding 
is  a  milk  so  clean  and  fresh  that  it  may  be  safely  given  without  heating, 
feeling  as  I  do  that  all  forms  of  sterilisation  do  impair,  though  possibly 
only  to  a  slight  degree,  its  nutritive  properties.  It  should,  however,  be 
borne  in  mind  that  there  are  some  delicate  infants  with  feeble  digestion 
who  thrive  better  upon  sterilised  milk  than  upon  raw  milk  in  which  the 
bacterial  content  is  quite  low;  for,  even  though  not  numerous,  bacteria 
may  yet  do  harm  to  such  children.  Healthy  infants  with  good  digestion 
may  do  well  upon  raw  milk  even  though  the  number  of  bacteria  is  quite 
large,  i.  e.,  100,000-1,000,000  per  c.c. ;  while  delicate  infants  or  those 
with  digestive  disturbances  may  be  seriously  affected  by  such  milk.  In 
the  country  where  milk  is  obtained  fresh  and  used  before  it  is  twenty-four 
hours  old,  sterilising  is  usually  unnecessary  if  the  cows  are  healthy  and 
the  milk  properly  handled. 

Peptonised  Milk. — Milk  is  peptonised  through  the  agency  of  a  sub- 
stance derived  from  the  pancreas,  usually  that  of  the  pig.  This  is  known 
in  the  market  as  "  extractum  pancreatis,"  the  active  ferment  being  the 
trypsin.  As  this  acts  only  in  an  alkaline  medium,  bicarbonate  of  soda 
should  first  be  added  to  the  milk.  The  purpose  of  peptonising  is  to 
secure  a  partial  digestion  of  the  protein  of  milk  before  feeding. 

Milk  which  has  been  peptonised  ten  minutes  is  not  altered  in  taste; 
if,  however,  the  process  is  continued  for  twenty  minutes,  a  slightly  bitter 
taste  is  noticed.  This  increases  with  the  duration  of  the  process.  Pep- 
tonising may  be  arrested  at  any  stage  by  raising  the  milk  to  the  boiling 
point ;  but  if  the  milk  is  to  be  fed  at  once  this  is  not  necessary. 
^^n  Peptonised  milk  is  to  be  modified  according  to  the  child's  age  and 
digestion.  It  is  useful  only  where  there  is  feeble  protein  digestion,  and 
during  attacks  of  acute  gastric  indigestion  in  infancy.  It  is  not  advis- 
able to  continue  its  use  indefinitely,  for  in  this  case  the  stomach  grad- 
ually becomes  less  and  less  able  to  do  its  work.  Its  prolonged  use  is 
sometimes  followed  by  scurvy. 

,.  «>,?Condensed  Milk. — This  is  prepared  by  heating  fresh  cow's  milk  to 
218"  P.  for  twenty  minutes  for  sterilisation,  and  tlien  evaporating  in 
vacuo,  so  that  one  part  of  condensed  milk  represents  about  two  and  a 


COW'S  MILK. 


155 


half  parts  of  the  original  milk.  It  is  preserved  in  tin  cans,  with  the 
addition  of  cane  sugar  in  the  proportion  of  nearly  seven  ounces  to  a 
pint.  The  changes,  therefore,  to  which  the  milk  has  been  subjected  are : 
evaporation  of  a  part  of  the  water,  sterilisation,  and  the  addition  of 
cane  sugar.  Fresh  or  unsweetened  condensed  milk  is  to  be  obtained  in 
many  large  cities. 

The  composition  of  condensed  milk  is  shown  in  the  following  table; 
also  the  results  obtained  when  it  is  diluted  with  six,  twelve,  and  eighteen 
parts  of  water. 


Condensed 
Lmilk.' 

With  6  parts 
of  water 
added. 

With  12  parts 
water. 

With  18  parts 
of  water. 

Fat 

Per  cent. 

9.61 
8.01 

54.94 

1.78 
25.66 

Per  cent. 

1.37 
1.14 

7.89 

0.25 
89.35 

Per  cent. 

0.73 
0.61 

4.75 

0.13 
94.28 

Per  cent. 

0.50 

Protein          

0.42 

Q„„o.  J  Cane,  42.91  ) 
Sugar  j  ^m^'  J2.03  J 

Salts • 

2.90 
0.09 

Water 

96.09 

'  Analysis  of  Borden's  Eagle-Brand  condensed  milk. 


The  reasons  both  for  the  success  and  for  the  failure  of  condensed 
milk  as  an  infant-food  are  apparent  from  a  study  of  its  composition.  As 
a  temporary  food  it  is  often  useful,  first  because  it  has  been  sterilised, 
but  chiefly  because  both  the  fat  and  the  protein  of  cow's  milk  have  been 
reduced  by  the  usual  dilution  to  a  point  at  which  an  infant  with  a  very 
weak  digestion  can  manage  them,  while  it  furnishes  an  abundance  of 
sugar.  Infants  fed  upon  condensed  milk  are  often  fat,  but  have,  as  a 
rule,  feeble  resistance,  and  when  attacked  by  acute  disease,  especially  of 
the  intestinal  tract,  they  succumb  more  readily  than  do  those  reared  in 
almost  any  other  way.  It  is  rare  to  see  a  child  reared  on  condensed 
milk  who  does  not  show  to  some  degree  evidence  of  rickets.  The  pro- 
longed use  of  condensed  milk  is  a  frequent  cause  of  scurvy.  Condensed 
milk  fails  as  a  permanent  food  because  it  consists  too  largely  of  -carbo- 
hydrates, and  is  lacking  in  fat.  It  is  admissible  for  temporary  use  dur- 
ing attacks  of  indigestion,  for  infants  with  feeble  digestion,  especially 
in  summer,  for  very  young  infants  during  the  first  two  or  three  months, 
or  among  the  very  poor,  when  the  cow's  milk  which  is  available  is, still 
more  objectionable.  It  should  not  be  used  as  a  permanent  food  where 
good,  fresh  cow's  milk  can  be  obtained.  In  travelling  it  is  often  the 
most  convenient  as  well  as  the  safest  food  to  use.  It  should  be  diluted 
twelve  times  for  an  infant  under  one  month,  and  from  six  to  ten  trme& 
for  those  who  are  older. 

To  fresh  condensed  milk  no  addition  of  cane  sugar  has  been  made. 
It  requires  essentially  the  same  modification  as  ordinary  cow's  milk.    For 


156  NUTRITION. 

routine  use  it  should  be  diluted  with  from  eight  to  twelve  parts  of 
water,  and  sugar  added. 

Dried  Milk. — Dried  milk  sold  under  various  names  has  recently  been 
put  upon  the  market.  It  is  prepared  either  from  whole  milk  or  from 
skimmed  milk.  The  process  of  manufacture  most  extensively  employed 
is  that  of  spraying  the  milk  upon  hot  revolving  cylinders  by  which  means 
the  water  is  driven  off  almost  instantaneously.  Dried  milk  is  a  sterile 
white  powder  and  in  sealed  cans  keeps  indefinitely.  ^\nien  eight  parts 
by  volume  of  water  are  added  (one  level  teaspoonful  to  the  ounce)  it 
approximates  in  composition  the  original  milk.  It  may  be  further 
modified  if  desired.  Its  application  is  similar  to  that  of  condensed  milk 
over  which  it  presents  obvious  advantages  in  travelling ;  it  is  open  to  the 
same  objections  as  a  permanent  food,  and  should  not  be  advised  when 
fresh  milk  can  be  obtained. 

Buttermilk  and  Other  Forms  of  Fermented  Milk. — Various  forms  of 
fermented  milk  are  in  use  which  differ  according  to  the  milk  used  and 
the  process  followed.  They  resemble  each  other  in  that  the  fermentation 
is  excited  by  some  of  the  varieties  of  lactic  acid  organisms,  in  some  cases 
with  the  addition  of  yeast,  which  ferment  a  portion  of  the  milk  sugar. 
The  ordinary  buttermilk  of  commerce  is  sometimes  made  from  sweet, 
but  usually  from  sour  cream.  If  from  the  latter,  it  resembles  the  fer- 
mented milks  in  that  it  contains  little  or  no  fat  but  a  certain  amount 
of  lactic  acid,  the  result  of  fermentation.  It  differs  from  them  in  that 
the  fermentation  in  buttermilk  is  due  to  a  great  variety  of  lactic  acid 
organisms;  besides,  it  contains  many  other  forms  of  bacteria  than  those 
concerned  in  the  process  of  fermentation.  Buttermilk  should  be  made 
with  care  or  it  may  be  grossly  contaminated.  It,  therefore,  varies 
greatly  in  taste  and  considerably  in  composition  at  different  times  and 
under  different  conditions. 

BtUtermilk  (Vieth).  *                  I 

Fat 0.50 

Milk  sugar 4 .  06 

Lactic  acid 0 .  80 

Protein 3 .  60 

Inorganic  salts 0 .  75 

Water 90.29 

100.00 

When  used  as  an  infant  food  it  is  usually  sterilised  by  boiling  so 
that  the  living  organisms  are  not  given.  Its  low  sugar  content  is  over- 
come by  the  addition  of  milk  sugar  or  cane  sugar,  sometimes  also  by 
barley  flour  or  other  farinaceous  food,  in  any  proportion  desired.  A 
formula  much  used  in  Europe  is:  buttermilk,  one  quart;  barley  flour, 
two  even  tablespoonf uls ;  water,  four  ounces.  Cook  slowly,  constantly 
stirring,  for  twenty  minutes;  then  add  two  teaspoonfuls  of  cane  sugar. 
The  advantages  of  buttermilk  as  an  infant  food  are  chiefly  due  to  its 


COW'S   MILK.  157 

low  fat  content  and  the  small  amount  of  lactic  acid  which  it  contains. 
Its  cheapness  is  an  important  consideration  and  makes  it  available  for 
the  very  poor. 

Other  fermented  milks,  sometimes  called  buttermilk,  are  known  also 
as  lactic  acid  milk,  lactobacilline,  lactobacillary  milk,  lactone  buttermilk, 
etc.  They  are  sometimes  made  from  whole  milk  but  chiefly  from  skimmed 
milk.  This  is  usually  first  sterilised  and  then  the  ferment  added  in  the 
form  of  tablet,  mixture  or  culture  from  some  previously  fermented  milk. 
The  ferment  consists  of  different  varieties  of  lactic  acid  organisms;  the 
one  most  frequently  employed  is  known  as  the  Bulgaricus.  The  prod- 
uct differs  according  to  the  exact  varieties  or  combinations  used,  also 
according  to  the  temperature  maintained  and  the  duration  of  the  fer- 
mentation. A  temperature  of  80°  to  85°  F.  is  usually  employed  and  this 
is  continued  from  twelve  to  twenty-four  hours  according  to  the  degree 
of  acidity  desired.  The  milk  is  then  bottled  and  put  on  ice,  where  a 
slight  change  continues,  although  the  milk  alters  but  little  for  several 
days.  The  taste  is  rather  pleasant  unless  the  acidity  is  too  pronounced. 
The  product  always  contains  a  considerable  amount  of  lactic  acid;  it 
should  not  contain  alcohol  or  acetic  acid.  These .  fermented  milks  are 
sometimes  used  in  acute  disease,  but  chiefly  in  chronic  intestinal  con- 
ditions.    They  are  not  adapted  to  continuous  use  in  infant  feeding. 

Kumyss  has  been  made  by  the  Tartars  for  centuries  from  mare's 
milk.  It  is  made  in  this  country  from  cow's  milk,  sometimes  skimmed, 
but  usually  from  the  whole  milk.  The  fermentation  is  generally  started 
with  yeast  and  is  continued  in  corked  bottles  usually  for  several  days, 
with  frequent  agitation.  Kumyss  contains  carbon  dioxide,  lactic  acid, 
alcohol  and  traces  of  butyric  and  acetic  acid.  The  acidity  and  the  taste 
depend  upon  the  duration  of  the  process. 

Zoolak  or  matzoon  is  made  from  whole  milk  which  is  first  sterilised 
and  then  has  added  to  it  a  ferment  which  contains  some  form  of  yeast. 
It  differs  from  kumyss  chiefly  in  that  the  process  is  carried  on  in  open 
vessels  and  the  carbon  dioxide  allowed  to  escape.  It  is  a  thick  smooth 
liquid  and  has  a  taste  resembling  that  of  sour  cream. 

Both  kumyss  and  zoolak  are  better  adapted  for  use  with  older  chil- 
dren than  with  infants;  they  are  chiefly  valuable  in  cases  of  chronic 
intestinal  indigestion.  For  infants  they  should  be  diluted  with  water 
and  often  given  with  a  spoon  since  they  are  too  thick  to  go  through  the 
ordinary  nipple. 

Protein  Milk  (Eiweiss  Milch  of  Finkelstein). — The  object  of  this 
preparation  is  to  secure  a  milk  for  infant  feeding  which  is  low  in  sugar, 
high  in  protein  with  a  moderate  amount  of  fat.  It  is  made  as  follows: 
To  one  quart  of  whole  milk  is  added  half  an  ounce  of  rennet  or  enough 
to  coagulate  the  casein.  The  whey  is  strained  off  through  muslin,  by 
suspending  the  curd  for  an  hour.     The  curd  is  then  rubbed  through  a 


158 


NUTRITION. 


fine  wire  sieve.  One  pint  of  fermented  milk  (buttermilk  or  any  of  those 
mentioned  above  may  be  used)  is  now  added,  also  one  pint  of  water. 
The  finely  divided  curd  is  so  held  in  suspension  in  the  mixture  that  it 
will  pass  through  a  nipple  with  a  moderately  large  opening.  It  is 
easier  to  rub  the  curd  through  the  sieve  if  the  fermented  milk  is 
gradually  added  during  the  process.  The  average  composition  of  pro- 
tein milk  is:  fat,  2.5  per  cent;  sugar,  1.5  per  cent;  protein,  3  per 
cent ;  salts,  0.5  per  cent.  The  other  ingredients  are  pretty  uniform ;  but 
the  fat  percentage  varies  considerably,  according  to  the  amount  present 
in  the  original  milk  and  in  the  fermented  milk.  Under  certain  condi- 
tions it  is  desirable  to  vary  the  fat  percentage.  For  acute  conditions 
protein  milk  is  used  without  additional  carbohydrates;  for  prolonged 
use  as  an  infant  food,  sugar,  preferably  maltose,  should  be  added. 

Junket  or  Curds  and  Whey. — Junket  is  made  as  follows:  To  one 
pint  of  fresh  lukewarm  cow's  milk  are  added  two  teaspoonfuls  of  essence 
of  pepsin,  liquid  rennet,  or  a  junket  tablet.  It  is  stirred  for  a  moment 
and  then  allowed  to  stand  at  the  room  temperature  until  firmly  coag- 
ulated. Junket  is  useful  in  the  feeding  of  older  children,  but  should 
not  be  given  to  infants. 

Whey. — The  milk  is  coagulated  with  rennet  as  above,  the  curd  is 
then  broken  up,  and  the  whey  strained  through  muslin  by  suspension. 
The  composition  of  whey  varies  somewhat,  depending  upon  the  way 
in  which  it  is  prepared.  If  it  is  desired  to  have  as  little  fat  as  possible, 
skimmed  or  fat-free  milk  should  be  used,  and  the  whey  should  be 
strained  through  fine  muslin  without  pressure.  If  it  is  desired  to  retain 
some  of  the  fat,  whole  milk  may  be  used,  cheesecloth,  and  more  pressure. 
The  protein  of  whey  is  chiefly  lactalbumin. 

Whey  is  useful  particularly  in  the  feeding  of  very  young  infants.  It 
has  been  made  the  basis  of  milk  modifications,  the  purpose  of  which 
is  to  give  a  larger  proportion  of  lactalbumin  and  a  smaller  proportion 
of  casein  than  exist  in  any  dilution  of  cow's  milk. 

Wfwy. 


Average 
46  analyses 
(Koenig). 

From 
whole  milk 
(Adriance) . 

From 
fat-free  milk 
(Adriance). 

Protein 

0.86 
0.32 
4.79 
0.65 
93.38 

0.94 
0.96 
5.49 
0.48 
92.13 

1.17 

Fat 

0  04 

Sugar 

5  36 

Salts 

0  52 

Water 

92  91 

Total 

100.00 

100.00 

100.00 

Wine  whey  is  made  by  simply  adding  sherry  wine  to  whey  prepared 
in  the  usual  manner,  in  the  proportion  of  one  part  to  four  of  whey,  or 


BEEF  PREPARATIONS. 


159 


possibly  better  by  using  the  wine  to  coagulate  the  milk  (Still).  The 
wine  (cooking  sherry  preferred)  is  added  to  the  milk  in  the  proportion 
mentioned  and  the  mixture  slowly  brought  to  the  boiling  point.  After 
standing  off  the  fire  for  three  or  four  minutes  it  is  strained  through  two 
layers  of  coarse  muslin,  or  cheesecloth.  >Sherry  whey  is  useful  as  an 
emergency  food  for  short  periods  in  acute  illness  for  children  who  will 
take  very  little  food;  it  is  seldom  given  alone,  but  alternating  with 
some  other  food. 

BEEF  PREPARATIONS. 

The  nutrient  value  of  these  preparations  is  to  be  measured  by  the 
amount  of  albumin  they  contain — their  stimulant  properties  by  the  pro- 
portion of  extractives. 

Beef  Juice. — Expressed  beef  juice  is  made  as  follows:  A  piece  of 
round  steak  is  slightly  broiled,  and  the  juice  pressed  out  by  a  meat-press 
or  a  lemon-squeezer.  Two  or  three  ounces  can  ordinarily  be  obtained 
from  one  pound  of  steak.  This  is  seasoned  with  salt  and  given  cold  or 
warm,  but  not  heated  sufficiently  to  coagulate  the  albumin  in  solution. 

An  excellent  method  of  making  beef  juice  without  cooking  is 
by  taking  one  pound  of  finely  chopped  lean  beef  and  eight  ounces  of 
water  and  allowing  this  to  stand  in  a  covered  jar  upon  ice  from 
six  to  twelve  hours.  The  meat  is  then  squeezed  by  twisting  in  coarse 
muslin.  It  is  seasoned  with  salt  and  given  as  above.  This  is  not  quite 
so  palatable  as  that  obtained  by  the  first  method,  because  it  contains  a 
much  smaller  proportion  of  extractives,  but  it  is  much  more  economical. 
If  the  raw  juice  is  added  to  milk  in  the  proportion  of  two  or  three  tea- 
spoonfuls  to  each  feeding,  the  taste  will  not  be  noticed.  The  milk  should 
not  be  warmed  above  100°  F.  before  the  addition  of  the  juice. 

The  composition  of  the  two  products  is  given  below. 

Patients  should  be  encouraged  to  use  beef  juice  freshly  prepared 
from  meat  when  the  latter  can  be  obtained,  rather  than  the  beef  prepara- 
tions of  the  shops. 

Beef  Juiced 


' 

I. 

Expressed  juice 
from  1  lb.,  warm 
j)rocess;  quan- 
tity, 2M  oz. 

II. 
Cold  process, 
1  lb.  beef,  8  oz. 
water;    quan- 
tity, 8J^  oz. 

Protein 

2.90 
0.60 
3.40 
0.20 
92.90 

3.00 

Fat 

Extractives 

Salts 

1.90 
0.20 

Water 

94.90 

100.00 

100.00 

Analysis  made  for  the  author  by  E.  E.  Smith,-  Ph.D.,  M.D. 


160  NUTRITION. 

Beef  extracts  are  not  to  be  considered  in  any  sense  as  foods.  Kem- 
merich  has  shown  that  animals  receiving  nothing  else  died  of  starvation, 
and  sooner  even  than  when  everything  was  withheld.  According  to 
Chittenden,  they  contain  no  nitrogen  in  the  form  of  protein,  but  only  in 
combination  with  the  soluble  extractives.  They  are  stimulants,  but  as 
such  are  often  useful. 

Eare  scraped  beef  is  easily  digested  by  most  young  children.  There 
are  many  conditions  in  which  other  forms  of  protein  are  not  well  borne, 
where  children  even  as  young  as  twelve  months  appear  to  digest  this 
beef-pulp  without  difficulty.  It  should  be  made  from  very  rare  or  raw 
steak,  finely  scraped  and  well  salted.  A  tablespoonful  may  be  given  at 
one  feeding  to  a  child  of  eighteen  months.  In  nutrient  properties  this 
far  exceeds  the  beef  preparations  in  the  market.  The  alleged  danger  of 
tapeworm  from  the  use  of  rare  scraped  beef  or  beef  juice  is  in  this  coun- 
try so  slight  that  it  may  be  disregarded. 

Broths. — Animal  broths  may  be  made  from  mutton,  veal,  chicken,  or 
beef.  A  good  formula  for  general  use  is  the  following:  One  pound  of 
lean  meat,  one  pint  of  water;  stand  for  two  hours,  then  cook  over  a  slow 
fire  for  two  hours  down  to  half  a  pint.  After  it  has  cooled,  skim  off  the 
fat  and  strain  through  a  cloth.  The  composition  of  a  broth  so  made  is 
given  by  Cheadle  as  follows : 

Beef  Broth. 

Protein 1 .02 

Extractives 1 .  82 

Fat 0.00 

Salts 0.88 

Water 96.28 

100.00 

From  their  composition  it  will  be  seen  that  broths  are  not  very  nutri- 
tious ;  they  are,  however,  quite  stimulating,  and  are  at  times  useful,  par- 
ticularly where  milk  must  be  temporarily  withheld.  They  are,  however, 
not  adapted  to  prolonged  use  alone.  Broths  which  have  been  thickened 
with  either  barley  or  rice  flour  are  useful  for  infants  and  older  children. 

Albtunin  Water. — This  is  prepared  as  follows:  The  white  of  one 
fresh  Qgg  is  mixed  witli  a  pint  of  cold  water,  a  little  salt,  and  a  tea- 
spoonful  of  brandy  added.  It  should  be  given  cold.  Albumin  water 
is  useful  in  a  variety  of  conditions  attended  by  gastric  irritability.  The 
nutritive  value  of  this  preparation,  it  should  be  borne  in  mind,  is  very 
small. 

CEREALS. 

Barley  Water. — This  may  be  made  either  from  the  grains  or  from 
the  barley  flour.  When  the  grains  are  used,  the  following  is  the  formula 
which  I  have  been  accustomed  to  employ :  To  two  tablespoonf  uls  of  pearl 


INFANT  FOODS.  161 

barley,  add  one  quart  of  water  and  a  pinch  of  salt,  and  boil  continuously 
for  six  hours,  keeping  the  quantity  up  to  a  quart  by  the  addition  of 
water;  strain  through  coarse  muslin.  It  is  an  advantage  to  soak  the 
barley  for  a  few  hours  before  cooking.  The  water  in  which  it  is  soaked 
is  not  used.  When  cold  this  preparation  makes  a  rather  thin  jelly. 
Its  composition  by  analysis  is  as  follows : 

Barley  Water. 

Starch 1 .63 

Fat 0.05 

Protein 0.09 

Inorganic  Salts 0 .  03 

Water 98 .20 

100.00 

Almost  an  identical  product  may  be  obtained  in  an  easier  way  by 
using  prepared  barley  flour,  one  even  tablespoonful  to  each  twelve  ounces 
of  water,  and  cooking  for  twenty  minutes.  A  thicker  jelly  when  desired 
can  be  made  by  using  twice  as  much  of  the  barley. 

Bice,  Wheat,  or  Oatmeal  Water,  etc. — These  may  be  made  in  the 
same  manner  as  the  barley  water,  using  the  same  proportions  either  of 
the  flour  or  the  grains.  These  are  useful  as  additions  to  milk  for  healthy 
infants  who  have  reached  the  age  of  five  or  six  months;  they  may  also 
be  given  in  many  cases  of  acute  or  chronic  indigestion  where  milk 
must  be  omitted  or  given  in  small  quantities.  When  there  is  a  tendency 
to  constipation  oatmeal  is  preferred ;  when  to  looseness,  barley,  wheat,  or 
rice  water. 

INFANT    FOODS. 

It  is  not  possible,  nor  even  desirable,  for  a  physician  to  know  all  about 
the  infant  foods  with  which  the  market  is  flooded.  He  should,  however, 
know  at  least  that  they  are  not  perfect  substitutes  for  breast-milk,  that 
as  permanent  foods  they  are  greatly  inferior  to  properly  modified  cow's 
milk,  and  that  they  are  capable  of  doing  and  have  done  much  positive 
harm.  Rickets  and  scurvy  have  so  frequently  followed  their  prolonged 
use,  when  given  without  the  addition  of  fresh  milk,  and  sometimes  even 
when  they  have  been  given  with  it,  that  there  can  be  no  escaping  the 
conclusion  that  they  were  the  active  cause.  Their  general  use  is  con- 
demned with  practical  unanimity  by  authorities  on  infant  feeding.  Yet 
by  industrious  and  skilful  advertising  they  are  forced  upon  public  at- 
tention, and  are  extensively  used  by  the  laity  and  even  by  the  medical 
profession.  They  are  expensive.  They  add  little  or  nothing  to  our  re- 
sources in  infant  dietetics;  in  fact,  they  tend  to  retard  rather  than  ad- 
vance our  knowledge  of  this  subject. 

There  are,  however,  a  few  occasions  when  some  of  these  preparations 
12 


162 


NUTRITION. 


may  be  useful  as  temporary  expedients  or  when  nothing  better  can  be 
obtained.  They  should  be  used  only  with  a  very  definite  knowledge  of 
exactly  what  they  do  and  what  they  do  not  contain.  Their  name  is 
legion;  but  those  most  commonly  employed  in  this  country  may  be 
grouped  as  follows: 

1.  The  Milk  Foods. — Nestle's  food  is  perhaps  the  most  widely  known. 
The  others  closely  resembling  it  in  composition  are  the  Anglo-Swiss,  the 
Franco-Swiss,  the  American-Swiss,  and  Gerber's  food.  These  foods  are 
essentially  sweetened  condensed  milk  evaporated  to  dryness,  with  the 
addition  of  some  form  of  flour  which  has  been  dextrinised;  they  all 
contain  a  considerable  proportion  of  unchanged  starch, 

2.  The  Liebig  or  Malted  Foods. — Mellin's  food  may  be  taken  as  a 
type  of  the  class.  Others  which  resemble  it  more  or  less  closely  are 
Liebig's,  Horlick's  malted  milk,  and  cereal  milk.  Mellin's  food  is  com- 
posed principally  (80  per  cent)  of  soluble  carboh3^drates.  They  are  de- 
rived from  malted  wheat  and  barley  flour,  and  are  composed  chiefly  of 
a  mixture  of  dextrin,  dextrose,  and  maltose. 

3.  The  Farinaceous  Foods. — These  are  imperial  granum.  Ridge's 
food,  Hubbell's  prepared  wheat,  and  Robinson's  patent  barley.  The  first 
consists  of  wheat  flour  previously  prepared  by  baking,  by  which  a  small 
proportion  of  the  starch — from  one  to  six  per  cent — has  been  converted 
into  sugar.  In  chemical  composition  these  four  foods  are  very  similar, 
consisting  mainly  of  unchanged  starch  which  forms  from  seventy-five  to 
eighty  per  cent  of  their  solid  constituents. 

4.  Miscellaneous  Foods. — Under  this  head  may  be  mentioned  Carn- 
rick's  soluble  food  and  Eskay's  food.  The  composition  of  these  is  given 
in  the  following  table : 


The  Composition 

of  Infant-Foods.^ 

Nestle's 
food. 

Mellin's 
food. 

Eskay's 
food. 

Malted 
milk. 

Ridge's 
food. 

Imperial 
granum. 

Carn- 
rick's 
food. 

Fat . 

Protein 

Percent. 

5.60 

14.34 

25.00 

[27.36 

58.93 

15.39 
2.03 
3.81 

Per  cent. 

0.24 
11.50 

60 'so 
19.20 

80.00 
4.73 

Per  cent. 

1.16 

5.82 

j  53.46'' 

67.81 

21.21 
1.30 
2.70 

Per  cent. 

8.78 
16.35 

1  49.15' 
18.80 

67.95 

s'.m 

3.06 

Per  cent. 
1.11 

11.81 
'Q.tj2 

1/28 

1.80 

76.21 
0.49 

8.58 

Per  cent. 

1.04 
14.00 

0^42 

1^38 

1.80 

73.54 
0.39 
9.23 

Per  cent. 

7.45 
10.25 

Cane  sugar 

Dextrose 

Lactose  (milk  sugar). . 
Maltose 

Dextrins 

Total   Soluble   carbo- 
hydrates   

27.08 

37.37 

4.42 
3.42 

Insoluble        carbohy- 
drates (Starch)  .... 

Inorganic  salts 

Moisture 

*  With  the  exception  of  Nestl6's  food  and  Carnrick's  soluble  food,  these  analyses 
were  made  for  the  author  by  E.  E.  Smith,  Ph.D.,  M.D.,  of  samples  purchased  in  the 
open  market.  '  Chiefly  lactose.  '  Largely  maltose. 


PLATE   III. 


WOMAN'S  MILK. 

1=1 


JMy.i,jiWMiw.-  i»  g 


COW'S   MILK. 


Proteim. 

F*T 

SoLutLt  Carbohvomates  Uva**|. 

Salts 

Insoluble  Carbohydrates  UT«acn> 


B 


CANNED  CONDENSED  MILK. 


MELLIN'S  FOOD. 


P 


MALTED   MILK. 


P 


NESTLE'S  FOOD. 


CARNRICK'S  SOLUBLE  FOOD 


ii^^ttM 


IMPERIAL  GRANUM. 


f 


i 


Chart  showing  the  solid  ingredients  of  various  infant  foods 
as  comp«red  with  those  of  wonnan's  milk. 


CHOICE  OF   METHODS  OF  FEEDING.  163 

A  better  idea  of  the  composition  of  these  foods  can  be  obtained  by  a 
study  of  the  accompanying  chart  (Plate  III),  which  shows  their  solid  con- 
stituents as  compared  with  those  of  woman's  milk.  The  essential  features 
of  the  foods  are  seen  at  a  glance — i.  e.,  they  are  all  composed  principally  of 
carbohydrates  and  are  lacking  in  fat.  Some  of  them  contain  a  large  pro- 
portion of  unchanged  starch.  Furthermore,  their  protein,  though  often 
sufficient  in  amount,  is  chiefly  vegetable,  not  animal  protein.  No  one  of 
them  can  be  regarded  in  any  sense  as  a  proper  substitute  for  breast-milk. 

Some  of  these  foods — Xestle's  and  other  milk  foods,  malted  milk, 
cereal  milk,  and  Carnrick's  food,  and  even  some  of  the  farinaceous  foods, 
like  imperial  granum — are  advertised  as  substitutes  for  breast-milk 
and  recommended  for  use  alone.  Others,  such  as  Mellin's,  Liebig's,  and 
Eskay's  foods,  are  intended  to  be  used  with  milk.  The  use  of  any  of 
the  commercial  foods  alone  is  admissible  only  for  short  periods  during 
derangements  of  digestion,  when  we  wish  to  withhold  for  the  time  all 
fat  and  milk  protein.  Their  prolonged  use  almost  invariably  produces 
some  grave  disorder  of  nutrition,  most  frequently  rickets  or  scurvy. 
Those  foods  which  require  in  their  preparation  the  addition  of  milk 
are  open  to  less  serious  objections,  but  are  not  necessary  or  even  desir- 
able. They  should  never  be  used  with  condensed  milk.  When  added  to 
fresh  milk  they  may  furnish  the  additional  carbohydrates  required  by  an 
infant  fed  upon  a  diluted  cow's  milk.  In  such  a  case  they  take  the 
place  of  milk  sugar  or  cane  sugar  in  the  milk  modification.  There  is 
no  proof  to  sustain  the  claim  that  they  increase  the  digestibility  of  cow's 
milk.  Farinaceous  foods  may  be  used  as  an  addition  to  milk  after  the 
sixth  or  seventh  month  and  during  the  second  year. 


CHAPTEE    III. 
INFANT  FEEDING. 

CHOICE   OF   METHODS  OF  FEEDING. 

The  different  methods  of  feeding  which  are  available  are : 

1.  Breast-feeding,  either  by  the  mother  or  by  a  wet-nurse. 

2.  Mixed  feeding,  or  a  combination  of  nursing  and  artificial  feeding. 

3.  Artificial  feeding  exclusively. 

In  deciding  by  which  one  of  these  methods  a  child  shall  be  fed,  many 
circumstances  must  be  taken  into  consideration :  the  vigour  of  the  child, 
the  health  of  the  mother,  and  especially  the  surroundings,  since  these 
determine  very  largely  the  success  or  failure  of  any  method  employed. 

Maternal  Nursing. — This  is  the  natural  and  the  ideal  method  of 
infant  feeding.  Every  mother  should  nurse  her  infant  unless  there  are 
some  very  weighty  reasons  to  the  contrary.     The  physician  should  do  all 


164  NUTRITION. 

in  his  power  to  encourage  maternal  nursing  and  to  promote  its  success. 
He  should  explain  to  the  mother  how  imj^ortant  breast-milk  is  for  the 
child;  that  fully  four-fifths  of  the  deaths  under  one  year  are  in  infants 
who  are  artificially  fed.  He  should  also  make  clear  the  conditions  by 
which  alone  successful  nursing  can  be  accomplished;  viz.,  proper 
diet,  regular  habits  of  sleep  and  exercise,  and  a  simple  life,  in  so  far  as 
possible  free  from  causes  of  nervous  excitement,  fatigue,  over-work,  or 
worry.  Social  engagements  should  be  avoided.  Nursing  may  be  fur- 
thered by  proper  care  of  the  nipples  before  delivery,  and  by  attention 
to  them  during  the  early  days  of  nursing  to  prevent  fissures  and  mastitis, 
which  so  often  interrupt  successful  nursing. 

In  spite  of  all  efforts  to  the  contrary,  it  is  nevertheless  a  fact  that 
the  capacity  for  maternal  nursing  is  steadily  diminishing  in  this  coun- 
try, chiefly  in  the  cities,  but  to  a  considerable  degree  in  the  rural  districts 
as  well.  Among  the  well-to-do  classes  in  New  York  and  its  suburbs, 
of  those  who  have  earnestly  and  intelligently  attempted  to  nurse,  less 
than  25  per  cent,  in  my  experience,  have  been  able  to  continue  satis- 
factorily for  as  long  as  six  months.  An  average  city  mother  who  is  able 
to  nurse  her  child  successfully  for  the  entire  first  year  is  almost  a  phe- 
nomenon. Among  the  poorer  classes  in  our  cities  a  decline  in  nursing 
ability  is  also  seen,  although  not  yet  to  the  same  degree  as  in  the  higher 
social  scale.  These  are  facts  that  must  be  taken  into  account  in  decid- 
ing the  question  of  feeding.  While  nothing  is  so  good  as  good  maternal 
nursing,  no  method  of  feeding  gives  much  worse  results  than  poor  nurs- 
ing. Among  the  classes  of  society  where  most  of  the  maternal  nursing 
is  very  poor,  but  where  every  facility  can  be  afforded  for  the  best 
artificial  feeding,  one  should  not  be  slow  to  adopt  the  latter  in  cases  of 
doubt.  Among  the  poor  and  ignorant,  however,  where  artificial  feeding 
can  not  be  carried  on  with  anything  like  the  same  chances  of  success,  all 
possible  efforts  should  be  made  to  increase  maternal  nursing  as  the  most 
effective  means  of  reducing  infant  mortality. 

When  Maternal  Nursing  should  not  be  Attempted. —  (1)  No  mother 
who  is  the  subject  of  tuberculosis  in  any  form,  whether  latent  or  active, 
should  nurse  her  infant;  it  can  only  hasten  the  progress  of  the  disease 
in  herself,  while  at  the  same  time  it  exposes  the  infant  to  the  danger  of 
infection.  (2)  Nursing  should  seldom  be  allowed  where  serious  com- 
plications have  been  connected  with  parturition,  such  as  severe  haemor- 
rhage, puerperal  convulsions,  nephritis,  or  puerperal  septicaemia.  (3)  If 
the  mother  is  epileptic.  (4)  If  the  mother  is  suffering  from  any  serious 
chronic  disease  or  is  very  delicate,  since  great  harm  may  be  done  to  her 
without  any  corresponding  benefit  to  the  child.  (5)  Where  experience 
on  two  previous  occasions  under  favourable  conditions  has  shown  her 
inability  to  nurse  her  child.  (6)  When  no  milk  is  secreted.  With  ref- 
erence to  the  fourth  and  fifth  conditions,  an  absolute  opinion  can  not 


CHOICE   OF   METHODS  OF   FEEDING. 


165 


always  be  given  at  the  outset.  As  a  rule,  mothers  are  more  likely  to 
succeed  in  nursing  first  or  second  children  than  subsequent  ones.  My 
own  statistics  indicate  that  in  general  the  capacity  for  lactation  dimin- 


WEEK  OF 

AGE    1         3        5         7         9       11       13      15      17      19      21      23      25      27      29     31      33      35      37    3£ 

22 

21 
20 
19 
18 
17 
1G 

^ 

y 

H 

.J 

^ 

■A 

1. 

-' 

- 

2. 

/ 

^ 

ui 

^ 

'> 

^ 

^ 

- 

•- 

— 

^ 

k 

,' 

/ 

^ 

^y 

--< 

^ 

-^ 

_, 

^ 

. 

y 

/ 

^ 

■^ 

•' 

^ 

.- 

^' 

'  .^ 

^ 

^i 

4 

^ 

^ 

^<^ 

y 

, 

13 

, 

^"/,. 

^> 

, 

*. 

^ 

, 

fA 

% 

r 

•\^ 

^t 

p 

/ 

V 

y 

•^' 

/ 

V 

11 

10 

9 

8 

7 

•  1 

•^i 

/ 

/ 

/ 

/ 

'/ 

/ 

y 

/ 

/ 

/ 

/ 

/ 

J 

/ 

\ 

f 

/ 

/ 

/ 

V 

•/ 

_J 

Fig.  26. — Weight  Curve  of  Nursing  and  Artificial  Feeding  Compared.  Both  in- 
fants were  strong,  well  nourished,  and  in  good  surroundings.  The  bottle-fed  infant 
was  never  once  put  to  the  breast;  fed  from  the  milk  laboratory.  First  formula:  Fat 
1  per  cent,  sugar  5  per  cent,  protein  0.5  per  cent.  At  six  weeks  taking:  Fat  3  per 
cent,  sugar  7  per  cent,  protein  1.25  per  cent.  It  will  be  observed  that  the  nursing 
infant  made  more  rapid  progress  during  the  first  few  weeks,  while  the  bottle-fed  in- 
fant more  than  made  up  for  this  between  the  fifth  and  ninth  month,  for  weaning  be- 
came necessary  in  the  other  child  owing  to  the  gradual  failure  of  the  mother's  milk. 
The  stationary  weight  was  the  result  of  this  condition,  and  the  irregular  subsequent 
gain  was  incident  to  the  change  of  food. 


ishes  with  each  successive  pregnancy.  My  inclination  as  a  result  of 
increasing  experience  is  not  to  allow  nursing  in  either  of  these  con- 
ditions, provided  the  means  for  proper  artificial  feeding  can  be  com- 
manded. The  chances  of  success  are  so  small  and  the  difficulties  are  so 
increased  by  even  a  few  weeks  of  bad  nursing  that  I  prefer  not  to  put 
the  child  to  the  breast  at  all,  even  for  the  first  two  or  three  days.  The 
breasts  are  bound  up  at  once  and  kept  bandaged.  When  one  begins  with 
healthy  digestive  organs  the  difficulties  with  artificial  feeding  are  rela- 
tively few,  and  it  is  usually  successful. 

Artificial  Feeding  vs.  Wet-Nursing. — When  maternal  nursing  is  im- 
possible or  undesirable,  the  milk  of  another  woman  would  seem  to  be 


166  NUTRITION. 

the  most  natural  and  best  substitute.  While  this  is  theoretically  true, 
the  practical  obstacles  are  so  many  as  to  put  wet-nursing  out  of  the 
question  as  a  general  method  of  feeding.  We  have  in  America  no  peasant 
class  like  that  of  Europe  to  draw  upon;  and  in  the  class  which  furnishes 
most  of  our  wet-nurses  the  capacity  to  nurse  has  steadily  diminished. 
The  expense  of  a'  wet-nurse — twenty-five  to  thirty-five  dollars  a  month 
in  New  York — the  danger  of  transmitting  contagious  disease,  and  the 
diflBculty  of  obtaining  proper  care  for  her  own  infant,  are  all  very  seri- 
ous objections  to  wet-nursing.  The  recent  advances  in  artificial  feeding 
have  placed  it  now  on  quite  a  different  footing  from  that  which  it  for- 
merly occupied.  While  it  is  true  that  good  breast-milk  is  unquestionably 
the  best  food,  it  is  equally  true  that  properly  modified  cow's  milk  is  a  far 
better  food  than  the  milk  of  many  wet-nurses  who  are  employed.  These 
facts  added  to  the  constantly  increasing  difficulty  of  obtaining  good 
ones  have  caused  wet-nurses  to  be  pretty  generally  discarded,  even  in 
our  large  cities,  where  formerly  no  other  substitute  for  maternal  nursing 
was  considered. 

There  are,  however,  some  conditions  in  which  they  are  necessary, 
even  indispensable.  Some  infants,  usually  those  who  have  been  badly 
started,  can  not  be  made  to  thrive  upon  any  form  of  artificial  feeding. 
There  are  also  premature  infants  and  other  very  delicate  ones  whose 
powers  of  assimilation  are  so  feeble  that  they  are  reared  under  any  cir- 
cumstances only  with  the  greatest  difficulty,  but  whose  chances  of  life 
are  much  increased  by  a  good  wet-nurse.  Again,  in  young  infants  who 
have  been  suffering  for  some  time  from  chronic  indigestion  and  failing 
nutrition,  the  symptoms  of  acute  inanition  sometimes  develop  with  great 
rapidity  and  severity.  From  such  a  condition,  apparently  hopeless,  in- 
fants may  sometimes  be  rescued  by  the  timely  assistance  of  a  good 
wet-nurse. 

The  difficulties  in  the  way  of  successful  infant  feeding  in  foundling 
asylums  and  other  institutions  for  young  infants  are  such  that  in  them 
partial  wet-nursing  at  least  should  be  employed  whenever  possible. 

Mixed  Feeding. — Mixed  feeding,  or  a  combination  of  nursing  and 
artificial  feeding,  may  be  employed  whenever  the  supply  of  the  nurse  is 
insufficient.  The  use  of  one  or  two  feedings  a  day  from  the  bottle  after 
the  third  or  fourth  month  may  do  much  to  relieve  the  mother  from  the 
strain  of  nursing  entirely  without  disturbing  the  infant's  progress. 
During  the  later  months  more  feedings  may  be  introduced  for  the  pur- 
pose of  gradual  weaning. 

BREAST-FEEDING. 

Caxe  of  the  Breasts  during  Lactation. — For  the  safety  of  both  mother 
and  child  it  is  essential  that  the  most  scrupulous  attention  be  given  to 
cleanliness.    The  nipples,  and  the  breasts  as  well,  should  always  be  care- 


BREAST-FEEDING.  167 

fully  washed  after  each  nursing.     Usually  plain  water  is  sufficient,  or  a 
weak  boric-acid  solution  may  be  employed. 

Nursing  during  the  First  Days  of  Life. — This  is  necessary,  to  accus- 
tom the  child  and  the  mother  to  the  procedure,  and  to  empty  the  breasts 
of  the  colostrum ;  it  probably  also  promotes  uterine  contractions.  All 
these  results  can  be  attained  by  putting  the  child  to  the  breast  on  the 
first  day  once  in  six  hours,  on  the  second  day  once  in  four  hours.  The 
child  gets  from  the  breast  only  from  four  to  six  ounces  a  day  during 
the  first  two  days.  Did  it  require  more  nourishment  before  the  milk- 
flow  is  fully  established,  we  may  be  sure  that  Nature  would  not  have 
been  so  late  with  her  supply.  The  common  practice  of  administering 
to  an  infant  a  few  hours  old  all  sorts  of  decoctions,  with  the  idea  that 
because  it  cries  it  is  suffering  from  colic,  can  not  be  too  strongly  con- 
demned. A  certain  amount  of  crying  is  necessary.  In  exceptional  cir- 
cumstances, when  an  infant  is  unusually  large  and  strong  and  cries 
excessively,  it. may  be  necessary  to  give  food  even  on  the  first  day;  but 
this  is  not  to  be  the  rule.  A  little  warm  water  should  first  be  given; 
from  two  to  four  teaspoonfuls  at  a  time  are  sufficient.  If  this  doe's  not 
satisfy  the  child,  regular  feeding  should  be  begun  on  the  second  day. 
Should  the  milk  be  delayed  beyond  the  second  day,  the  child  should 
be  put  to  the  breast  at  regular  intervals,  but  only  for  two  or  three  min- 
utes, and  then  given  the  bottle  thereafter  if  still  hungry.  It  is  impor- 
tant not  to  cease  in  our  efforts  to  induce  a  secretion  for  several  days 
longer,  and  the  best  of  all  means  is  the  stimulation  of  the  child's  sucking. 

Nursing  Habits. — Good  habits  of  nursing  and  sleep  are  almost  as 
easily  formed  as  bad  ones,  provided  one  begins  at  the  outset.  A  vast  deal 
of  the  wear  and  tear  incident  to  the  nursing  period  may  be  avoided  if 
the  child  is  trained  to  regular  habits.  Attention  to  these  minor  points 
often  makes  all  the  difference  between  successful  and  unsuccessful  nurs- 
ing. After  the  third  day,  ten  nursings  in  the  twenty-four  hours  are  quite 
sufficient  for  the  first  weeks,  and  no  more  should  be  allowed.  An  infant 
at  this  age  can  usually  be  depended  upon  to  take  at  least  one  long  sleep 
of  from  four  to  five  hours  in  the  twenty-four.  For  the  rest  of  the  day 
the  child  should  be  awakened,  if  necessary,  at  the  regular  nursing  time, 
and  put  to  the  breast;  this  plan  being  continued  until  nine  o'clock  at 
night.  He  should  then  be  allowed  to  sleep  as  long  as  he  will,  and  but 
two  nursings  given  between  this  hour  and  seven  in  the  morning.  In  the 
course  of  two  or  three  weeks  a  healthy  infant  can  usually  be  trained  to 
nurse  and  sleep  with  almost  perfect  regularity,  frequently,  when  a  month 
old,  going  six  hours  regularly  at  night  without  feeding.  A  trained  nurse 
of  my  acquaintance  states  that  out  of  thirty-three  infants  of  which  she 
had  the  care  from  birth,  thirty-one  were  trained  without  difficulty  in  the 
manner  stated.  Of  course,  success  in  training  must  rest  almost  entirely 
with  the  nurse;  but  the  physician  should  at  least  appreciate  the  impor- 


168 


NUTRITION. 


tance  of  proper  training  and  lend  it  his  support.  So  far  as  the  child 
is  concerned,  regular  habits  of  feeding  and  sleep,  and  regular  evacua- 
tions from  the  bowels,  which  nearly  always  go  with  them,  are  most 
important  factors  in  infant  hygiene. 

Schedule  for  Br  east-Feeding. 


AOK. 


Number  of 
nursinga  in 
24  hours. 


Interval  during 
the  day. 


Night  nursings 

between  9  p.m. 

and  7  a.m. 


First  day 

Second  day 

Third  to  twentieth  day 
Third  to  ninth  week  .  . 
Third  to  fifth  month  .  . 
After  the  fifth  month  .  . 


4 

6 

10 

8 
7 
6 


6 
4 

2 

3 
3 


Relieving  the  mother  of  night-nursing  after  the  child  is  five  months 
old  is  of  the  greatest  value,  and  will  often  enable  her  to  continue  lacta- 
tion, when  otherwise  it  would  be  brought  to  an  abrupt  termination.  On 
no  account  should  the  child  be  allowed  to  sleep  upon  the  mother's  breast, 
nor  in  the  same  bed  with  the  mother.  The  temptation  to  frequent  nurs- 
ing is  thus  largely  removed.  No  mere  sentiment  in  regard  to  these  mat- 
ters should  be  allowed  to  interfere  with  the  plain  dictates  of  reason  and 
experience. 

Symptoms  of  Unsuccessful  Nursing  during  the  Early  Weeks. — At- 
tempts at  maternal  nursing  so  often  result  in  failure,  jeopardising  the 
health,  and  even  endangering  the  life  of  the  child,  that  it  becomes  a 
matter  of  the  greatest  importance  to  decide  this  question  of  nursing 
aright,  and  as  early  as  possible.  On  the  one  hand,  one  should  not  hastily 
wean  a  child  on  account  of  symptoms  which  may  have  no  connection 
with  the  food,  nor  should  one  advise  weaning  when  the  indigestion  from 
which  the  infant  is  suffering  is  due  to  causes  which  are  temporary  and 
remediable.  On  the  other  hand,  nursing  should  not  be  continued  simply 
because  a  conscientious  mother  desires  it,  when  every  indication  points  to 
failure.  If  artificial  feeding  is  to  be  employed  the  difficulties  are  fewer 
when  it  is  begun  early  than  after  the  digestive  organs  have  been  deranged 
by  several  weeks  of  poor  nursing.  These  cases  form  a  very  large  group 
and  present  peculiar  difficulties  in  practice.  While  a  decision  is  being 
reached  as  to  the  ability  of  the  mother  to  nurse,  there  is  required  close 
observation  and  a  careful  study  of  all  the  conditions,  and  even  then  the 
physician  is  liable  to  make  mistakes  in  judgment  the  results  of  which 
may  be  serious. 

The  body-weight  gives  valuable  information.  The  child  does  not 
gain  or  continues  to  lose  after  the  usual  initial  loss  of  the  first  three 
or  four  days.     Observations  on  the  weight  at  least  twice  a  week  are 


BREAST-FEEDING.  169 

necessary,  and  in  cases  presenting  special  difficulties  the  weight  should 
be  taken  daily. 

At  times  there  may  be  no  vomiting,  diarrhoea,  or  even  severe  colic, 
yet  the  child  may  fret  and  worry  continually,  sleep  but  little,  and  show 
a  general  discomfort.  In  other  cases  definite  symptoms  of  gastric  indi- 
gestion may  be  present,  usually  vomiting  or  frequent  regurgitation  of 
small  amounts  of  undigested  milk,  later  mixed  with  mucus;  eructations 
of  gas  with  or  without  vomiting  may  occur,  and  distention  of  the  stom- 
ach with  gas  and  gastric  colic  may  follow. 

More  often  the  symptoms  of  indigestion  are  intestinal.  Occasionally 
there  is  constipation,  but  as  a  rule  the  stools  are  frequent,  thin  and 
green,  containing  flaky  masses  of  undigested  milk,  and,  after  a  short 
time,  mucus  which  is  frequently  in  large  amount.  The  odour  of  the 
discharges  may  be  slightly  sour  or  there  may  be  none  at  all.  At  times 
there  is  much  gas  and  the  stools  are  sour  and  irritating.  If  constipation 
is  present  there  is  apt  to  be  severe  colic  and  abdominal  distention.  The 
almost  uniform  absence  of  any  elevation  of  temperature  in  these  cases 
points  strongly  against  the  existence  of  an  intestinal  infection,  which  is 
further  indicated  by  the  prompt  recovery  under  appropriate  treatment. 

Before  considering  the  case  one  of  inadequate  nursing,  or  simple  indi- 
gestion in  a  nursing  infant,  one  should  be  careful  to  exclude  organic 
conditions  in  the  child,  particularly  hypertrophic  stenosis  of  the  pylorus. 
The  diagnosis  of  unsuccessful  nursing  should  include  the  changes  in  the 
milk  and  if  possible  the  causes  of  these  changes. 

As  the  first  step  one  should  endeavour  to  gain  some  idea  as  to  the 
quantity  of  milk  secreted.  During  the  first  week,  particularly  from  the 
second  to  the  fourth  day,  the  temperature  may  be  elevated  quite  apart 
from  septic  or  inflammatory  conditions  or  even  evidences  of  indigestion. 
This  is  particularly  seen  where  the  breasts  secrete  almost  nothing  (see 
Inanition  Fever).  Often  when  the  milk  is  very  scanty  something  may 
be  learned  from  the  manner  in  which  the  child  takes  the  breast.  Where 
the  milk  is  abundant,  five  or  six  minutes  are  often  sufficient.  If  the  milk 
is  very  scanty,  an  infant  will  frequently  nurse  half  or  three-quarters  of 
an  hour  and  then  stop,  more  because  he  is  exhausted  than  because  he  is 
satisfied.  Sometimes,  when  the  breasts  are  practically  empty,  the  child 
will  seize  the  nipple  and  nurse  vigorously  for  a  few  moments,  then  drop 
it  in  apparent  disgust  and  refuse  to  make  any  further  efforts.  The  only 
satisfactory  way  of  determining  the  quantity  of  milk  secreted  is  to  weigh 
the  infant  before  and  after  each  nursing.  If  the  milk  is  merely  scanty, 
but  not  otherwise  abnormal,  the  infant  does  not  gain,  but  shows  no  symp- 
toms of  indigestion,  such  as  vomiting,  colic,  or  undigested  stools,  and 
he  frets  and  cries  from  hunger  only. 

An  excessively  rich  milk  is  usually  found  under  the  following  con- 
ditions: The  mother  is  in  good  health,  has  large  breasts  which  are  full 


170 


NUTRITION. 


and  tense  at  nursing  time.  In  most  cases  she  is  upon  a  very  abundant 
diet,  getting  little  or  no  exercise,  and  frequently  taking  some  alcoholic 
beverage  with  the  notion  that  because  the  child  is  not  thriving  the  milk 
is  poor.  The  child  may  be  colicky,  sleepless,  and  uncomfortable,  may 
vomit,  may  have  frequent  stools  containing  much  undigested  food,  and 
may  be  losing  in  vs^eight.  A  similar  condition  is  often  seen  when  a  wet- 
nurse  makes  a  change  from  the  simple  life  and  habits  of  her  own  home 
to  the  more  luxurious  life  and  diet  of  the  family  to  which  she  goes. 
The  milk  then  has  usually  a  high  specific  gravity,  is  high  in  fat  and  high 
in  protein.  The  following  analyses  from  Eotch  illustrate  the  point : 
No,  I  shows  milk  of  a  healthy  but  under-fed  wet-nurse  two  days  before 
change  of  food ;  II,  the  milk  of  the  same  nurse  after  one  month  of  rich 
food  with  very  little  exercise ;  III,  milk  of  the  same  nurse,  the  food  and 
exercise  being  regulated.  The  effect  of  the  exercise  and  the  change  in 
diet  is  seen  in  a  very  marked  reduction  in  the  protein. 


I. 

II. 

III. 

Per  cent. 

Per  cent. 

Per  cent. 

Fat 

0.72 

5.44 

5.5U 

Sugar 

6.75 

6.25 

6.60 

Protein 

2.53 

4.61 

2.90 

Salts 

0.22 

0.20 

0.14 

A  scanty  milk  of  a  poor  quality  is  most  often  seen  when  the  mother 
is  delicate  or  anaemic,  or  perhaps  has  had  a  difficult  or  complicated 
labour,  and  who  besides  is  anxious  and  careworn.  It  is  often  with  the 
greatest  difficulty  that  one  can  secure  the  necessary  half  ounce  required 
for  examination.  The  milk  is  usually  low  in  total  solids  and  very  low 
in  fat.  The  specific  gravity  may  be  only  1.024  to  1.027,  and  the  fat 
only  one  per  cent  or  less. 

A  disturbed  or  disordered  milk  secretion  is  sometimes  seen  when  the 
milk  is  scanty,  often  when  it  is  very  abundant.  Like  the  group  of  cases 
just  mentioned,  this  is  frequently  met  with  when  the  mother's  general 
health  is  below  the  normal,  but  particularly  is  it  influenced  by  her 
nervous  condition.  It  is  the  highly  nervous,  emotional,  worried  woman 
whose  milk  we  are  now  considering.  During  the  first  week  or  two  the 
secretion  may  be  excessive  and  then  rapidly  diminish;  or,  though  the 
milk  continues  abundant,  the  infant  shows  no  improvement.  It  is  most 
frequently  found  on  examination  that  the  milk  is  low  in  fat  (0.50  to 
1  per  cent),  while  it  may  be  high  in  protein  (1.75  to  3.50  per  cent). 
The  cliild's  symptoms  are  usually  those  of  intestinal  indigestion-^severe 
colic,  flatulence,  and  frequent,  green,  undigested  stools.  Very  similar 
symptoms  are  sometimes  seen  when  the  milk  is  high  in  fat. 

Management. — The  cause  of  tlie  symptoms  being  in  the  food  and  not 
in  the  child,  the  futility  of  all  medical  treatment  will  be  at  once  appar- 


BREAST-FEEDING.  171 

ent.  He  who  expects  to  relieve  the  symptoms  of  indigestion  by  the  use  of 
digestive  ferments,  by  giving  something  before  the  nursing  to  dilute  the 
milk,  or  to  check  frequent  intestinal  discharges  by  opium  or  astringents, 
will  be  disappointed.  Temporary  benefit  often  follows  a  dose  of  castor 
oil,  but  unless  the  milk  can  be  materially  changed  in  composition  no 
permanent  improvement  in  the  child  is  to  be  looked  for.  The  question 
usually  to  be  decided  relates  to  the  continuance  of  nursing.  We  have  a 
choice  of  four  courses :  ( 1 )  To  continue  nursing,  endeavouring  to  correct 
the  milk  through  treatment  of  the  mother;  (2)  to  partly  nurse  and 
partly  feed  from  the  bottle;  (3)  to  stop  all  nursing  temporarily,  pump- 
ing the  breasts  meanwhile  to  keep  up  the  secretion  while  we  attempt  to 
improve  its  character;  (4)  to  wean  at  once  and  entirely.  In  deciding 
which  of  these  courses  is  to  be  adopted  we  must  take  into  consideration 
the  condition  of  the  child,  the  severity  and  duration  of  his  symptoms, 
the  findings  of  the  milk  examination,  and  the  condition  of  the  mother. 

WTiile  the  analysis  of  the  milk  is  of  some  value  in  determining  the 
course  to  be  pursued,  and  should,  if  possible,  be  made,  it  is  of  much  less 
importance  than  the  child's  symptoms.  We  must  be  guided  not  by  what 
the  milk  contains,  but  by  how  seriously  it  disagrees.  The  chemical  ex- 
amination may  show  the  milk  to  be  of  normal  average  in  the  proportion 
of  its  different  ingredients  and  yet  the  child  be  seriously  upset  by  it; 
on  the  other  hand,  a  child  may  be  doing  admirably  upon  a  milk  which 
shows  proportions  which  differ  very  greatly  from  the  normal  average. 
The  question  always  concerns  the  effect  of  the  particular  milk  upon  the 
particular  child. 

When  the  symptoms  of  indigestion  are  severe  or  have  been  prolonged 
it  is  usually  a  mistake  to  attempt  to  relieve  the  condition  by  simply 
substituting  solne  other  food  for  part  of  the  nursings.  This  seldom 
leads  to  any  material  improvement  in  the  symptoms,  while  it  does  con- 
fuse the  result,  since  we  can  not  now  tell  whether  it  is  the  breast  or  the 
bottle  feeding  which  disagrees.  A  better  plan  is  to  stop  nursing  en- 
tirely for  a  time  and  try  the  bottle  alone.  If  the  symptoms  are  at  once 
relieved  the  weaning  should  be  permanent. 

When  symptoms  point  to  a  scanty  milk,  but  of  fair  quality — i.  e., 
infant  not  gaining  but  without  any  particular  symptoms  of  indigestion 
— one  is  often  able  to  overcome  the  difficulties  and  continue  the  nursing 
to  advantage.  Until  a  decided  increase  in  the  milk  has  occurred  the 
child  should  have  supplementary  feedings  from  the  bottle  in  sufficient 
number  to  insure  his  being  properly  nourished.  Only  one  or  two  a  day 
may  be  required,  or  it  may  be  desirable  to  nurse  and  give  the  bottle  al- 
ternately. If  the  latter  plan  is  followed,  both  breasts  should  be  given  at 
each  nursing  period  for  the  stimulating  effect  upon  the  secretion. 

In  the  treatment  of  the  mother  the  first  thing  is  to  secure  for  her  an 
undisturbed  rest  at  night.    If  possible,  she  should  be  entirely  relieved  of 


172  NUTRITION. 

the  care  of  the  infant  at  this  time,  and  if  feeding  is  necessary  the  bottle 
should  be  given.  She  should  have  a  certain  amount  of  fresh  air  every 
day,  driving  if  possible,  or  walking  as  soon  as  she  is  able  to  take  more 
active  exercise.  Gentle  massage  of  the  breasts  is  often  useful  in  stimu- 
lating secretion.  It  should  be  done  with  care  and  with  every  precaution 
against  infection,  and  may  be  repeated  two  or  three  times  a  day  for  ten 
minutes.  The  diet  should  be  abundant,  with  a  large  allowance  of  milk 
and  meat,  especially  beef.  If  there  is  anaemia,  iron  should  be  given. 
Every  means  should  be  taken  to  improve  the  general  nutrition,  for  what- 
ever benefits  this  improves  the  milk.  If  the  conditions  present  are  in- 
cident to  the  confinement  or  the  convalescence,  the  prognosis  is  good; 
and  in  the  course  of  a  week  or  two  very  marked  improvement  may  be 
evident,  and  lactation  may  be  successfully  continued.  If,  however,  the 
conditions  depend  upon  constitutional  debility,  the  prognosis  is  much 
worse.  Temporary  improvement  may  take  place,  but  it  soon  becomes 
evident  that  the  nursing  is  a  failure. 

When  the  symptoms  are  found  to  be  associated  with  an  over-rich 
milk  the  prospects  for  continuing  nursing  are  much  better  than  when 
the  milk  is  poor.  Unless  the  infant's  digestion  is  very  feeble  or  has  been 
seriously  upset  either  with  vomiting  or  diarrhoea,  one  can  usually  so 
alter  the  milk  by  treating  the  mother  as  to  make  it  possible  to  keep  the 
baby  at  the  breast.  Alcohol  should  be  prohibited;  the  diet,  especially 
the  amount  of  solid  food,  should  be  reduced,  and  the  mother  required  to 
take  daily  exercise  in  the  open  air,  particularly  by  walking.  The  in- 
tervals between  nursings  should  be  lengthened,  usually  to  three  hours. 
In  many  cases  there  is  an  advantage  in  diluting  the  milk  by  allowing  the 
child  to  take  water  before  putting  it  to  the  breast.  The  improvement 
following  such  a  change  in  regimen  is  often  immediate,  and  with  in- 
creasing age  and  weight  the  child  gradually  becomes  accustomed  to  and  is 
able  to  digest  the  rich  milk.  If,  however,  the  child's  symptoms  of  in- 
digestion are  of  an  aggravated  type,  whether  gastric  or  intestinal,  it 
will  be  necessary,  even  though  the  weight  is  increasing  normally,  to  stop 
nursing  entirely  for  a  time.  The  breasts  should  be  pumped  at  regular 
intervals  and  the  child  placed  upon  some  other  food  until  the  symptoms 
are  relieved,  and  then  brought  back  gradually  to  breast-feeding.  Should 
the  infant's  digestion  be  seriously  upset  a  second  time  as  soon  as  the 
breast  is  resumed,  the  child  should  be  partially  or  entirely  weaned. 

If  the  examination  shows  the  milk  to  be  of  very  poor  quality  (i.  e., 
low  in  fat,  low  in  total  solids),  whether  scanty  or  abundant,  the  outlook 
is  not  good.  It  is  seldom  that  the  conditions  affecting  the  mother  to 
which  such  a  milk  is  due  can  be  removed. 

When  we  see  a  fretful,  colicky,  sleepless  infant  with  either  no  gain 
in  weight  or  a  loss  of  a  few  ounces  a  week,  and  with  stools  which  never 
approach  the  normal,  and  these  conditions  have  lasted  for  three  or  four 


BREAST-FEEDING. 


173 


weeks,  we  are  justified  in  taking  the  child  from  the  breast  at  once  (Fig. 
27).  When  the  symptoms  are  less  pronounced,  and  especially  when,  in 
spite  of  all  discomfort  and  indigestion,  the  infant  is  gaining  in  weight, 


OF  AGE  2       4       6        8       10      12     14     16      18     20      22     24    26 

19 
18 

17 
16 
16 

14 

a> 
OI3 

z 

3 

OI2 

a. 

1  1 

10 

9 

8 

7 
6 

y' 

y 

/ 

y 

/> 

y 



/ 

/ 

/ 

^ 

/ 

/ 

' 

y 

^ 

/ 

/ 

1 

fy 

/ 

y 

> 

1 

/ 

/ 

y 

/ 

/ 

/ 

/ 

^ 



U 

-X 

r 

\N 

EC 

7 

^ 

/ 

/ 

/ 

_ 

L 

Fio.  27. — Weight  Curve  showing  the  Effect  of  Bad  Nursing  and  Good  Feeding. 
Maternal  nursing  for  seven  weeks;  continued  symptoms  of  indigestion;  colic,  fre- 
quent green  passages,  constant  discomfort,  etc. ;  other  treatment  without  avail.  Im- 
mediate improvement  when  weaned  and  put  on  modified  milk  from  the  laboratory. 
Formula:  Fat  1.5  per  cent,  sugar  6  per  cent,  protein  0.75  per  cent.  All  symptoms  of 
indigestionsrapidly  disappeared,  the  percentages  were  gradually  increased,  and  a  steady 
gain  in  weight  followed. 


even  though  not  rapidly,  further  efforts  may  be  made  before  weaning 
is  ordered. 

Summary. — Poor  milk  is  usually  low  in  fat  and  scanty  in  quantity, 
while  the  protein  may  be  either  high  or  low.  Very  rich  millc  is  usually 
high  both  in  fat  and  protein.  Very  poor  milk  can  seldom  be  perma- 
nently improved  unless  the  causes  are  very  definite  and  of  a  temporary 
character.  Over-rich  milk  can  often  be  improved  if  the  true  explanation 
for  it  can  be  reached.  Eesults  are  to  be  judged  not  so  much  by  the 
change  in  the  composition  of  the  milk  as  by  improvement  in  the  infant's 
symptoms.  Since  good  feeding  gives  so  much  better  results  than  poor 
nursing,  if  circumstances  are  such  that  artificial  feeding  can  be  properly 
done,  I  am  inclined  to  stop  nursing  after  a  fair  trial — e.  g.,  of  two  to 
three  weeks — has  been  made,  rather  than  waste  time  in  prolonged  efforts 
to  improve  the  breast-milk. 


174  NUTRITION. 

Wet-Nursing. — In  the  selection  of  a  wet-nurse,  it  is  by  no  means 
so  essential  as  has  generally  been  supposed,  that  her  child  shall  be  oi 
about  the  same  age  as  the  child  she  is  to  nurse,  for,  after  the  first  month, 
the  changes  in  the  composition  of  breast-milk  are  insignificant.  It  is 
always  desirable  that  the  wet-nurse  shall  have  nursed  her  own  infant 
long  enough  to  demonstrate  the  fact  that  she  has  an  abundance  of  good 
milk ;  hence,  taking  a  wet-nurse  at  the  end  of  the  first  or  second  week  is 
always  fraught  with  considerable  uncertainty.  It  is  the  quality  of  the 
milk,  not  its  age,  which  determines  whether  or  not  it  will  agree.  For 
an  infant  over  one  month  old,  a  good  wet-nurse  whose  milk  is  anywhere 
between  one  and  six  months  old  will  usually  answer  perfectly  well;  and 
even  for  premature  infants  such  a  milk  may  be  used  without  hesitation, 
but  it  should  at  first  be  diluted. 

A  good  nurse  must,  first  of  all,  be  a  healthy  woman,  free  from 
syphilitic  or  tuberculous  taint,  and  her  throat,  teeth,  skin,  glands,  scalp, 
and  legs  should  be  carefully  inspected.  She  must  have  good  mammary 
glandular  development.  The  breasts  should  be  full  and  hard  three  hours 
after  nursing.  They  may  be  very  large  and  yet  supply  very  little  milk, 
being  then  composed  almost  entirely  of  fat.  On  the  other  hand,  some 
smaller  breasts  may  be  almost  all  glandular  tissue  and  secrete  an  abun- 
dance of  milk.  The  difference  in  the  size  of  a  breast  before  and  after 
nursing  is  one  of  the  best  guides  as  to  the  amount  of  milk  it  is  secreting. 
The  nipples  should  be  free  from  erosions  or  fissures,  and  long  enough 
for  the  needs  of  the  child.  Preferably  a  wet-nurse  should  be  of  a  phleg- 
matic temperament,  and  of  a  good  moral  character.  This  is  desirable 
for  personal  reasons,  although  there  is  no  evidence  of  moral  qualities 
being  transmitted  through  the  milk.  It  is  desirable  that  she  should 
be  between  twenty  and  thirty  years  of  age,  although  much  more  depends 
upon  the  individual  than  upon  the  age.  Other  things  being  equal,  a 
primipara  should  be  chosen.  An  examination  of  the  milk  may  be  of 
some  assistance  in  selecting  a  nurse ;  but  the  best  evidence  to  be  obtained 
of  the  character  of  a  woman's  milk  is  the  condition  of  her  own  child, 
which  should  always  be  seen  before  she  is  accepted.  It  often  happens 
that  a  woman  who  has  had  an  abundant  supply  of  milk  for  her  own 
infant  has  very  little  for  another  infant  for  the  first  few  days  in  her 
new  surroundings.  This  is  usually  the  result  of  the  nervous  disturbance 
connected  with  parting  from  her  own  child,  going  to  a  new  place,  being 
carefully  watched,  etc.  In  such  a  case  it  should  not  be  too  readily  de- 
cided that  she  is  incompetent  as  a  nurse,  for,  under  most  circumstances, 
with  proper  treatment  the  regular  flow  of  milk  will  be  re-established. 

Weaning. — Weaning  should  always  be  done  gradually,  when  pos- 
sible, for  the  sake  of  both  mother  and  child.  Sudden  weaning  is  apt  to 
be  followed  by  an  attack  of  acute  indigestion  in  the  infant.  This,  how- 
ever, is  not  a  necessary  result,  and  usually  depends  upon  the  fact  that 


BREAST-FEEDING. 


175 


the  cliild  is  given  cow's  milk  without  sufficient  dilution.  Weaning  in  hot 
weather  is  usually  to  be  avoided,  but  the  harm  from  this  is  not  nearly  so 
great  as  sometimes  results  where  lactation  is  unduly  prolonged  because 
of  a  prejudice  against  a  change  of  food  at  this  time.  While  there  are 
many  women  of  the  lower  classes  who  are  able  to  nurse  their  children  to 
advantage  for  the  entire  first  year,  the  number  of  such  among  the  bet- 
ter classes  is  certainly  very  small.  By  the  latter,  nursing  can  rarely  be 
continued  beyond  the  ninth,  and  often  not  beyond  the  sixth  month, 
without  unduly  draining  the  vitality  of  the  mother  and  at  the  same  time 
harming  the  child.  The  late  months  of  lactation,  like  the  early  months, 
require  close  watching.  It  is  a  common  mistake  to  continue  both  ma- 
ternal and  wet-nursing  too  long,  owing  to  a  dislike  of  making  a  change 
when  things  are  going  tolerably.  If  it  has  not  been  done  before  for 
reasons  previously  considered,  breast-feeding  sliould  be  supplemented 
by  other  food  by  the  ninth  or  tenth  month  in  any  case.  The  child's 
weight  is  a  good  guide  as  to  time  and  amount  to  be  given.  In  the  ab- 
sence of  evident  signs  of  disease,  a  stationary  weight  for  several  weeks 
makes  weaning  advisable ;  a  steady  loss  makes  it  imperative. 


MONTH  OF  AGE.                                                           I 

CMS. 

LBS. 

1         2         3         4         5          6          7          8         9        10        11      1?1 

8530 
9070 
8620 
81G0 
7710 
7260 
6800 
6350 
5900 
5iV) 
1990 
4540 
4080 
SSSO 
3180 
2720 
2270 

21 

20 
19 
18 
17 
16 
15 
U 
13 
12 
11 
10 
9 
8 
7 
6 
5 

■>; 

lN 

In 

tl 

e 

H 

>r- 

irn 

t 

^ 

^ 

' 

/ 

'' 

^ 

/ 

, 

/ 

/ 

^ 

■^ 

/ 

— 

^ 

/ 

V 

^ 

\ 

/ 

V 

M<! 

L* 

' 

c 

p, 

Ic 

r| 

/ 

■" 

' 

^ 

^ 

/ 

/ 

^ 

■^ 

/ 

y 

> 

/ 

- 

/ 

' 

^ 

/ 

/ 

/ 

} 

/ 

' 

/ 

J 

/ 

/ 

/ 

/ 

\, 

/ 

1 

y 

/ 

V 

1 

Fig.  28. — Chart  showing  the  Effect  of  Pregnancy  Upon  the  Weight  of  a  Nurs- 
ing Infant.  The  upper  line  is  that  of  the  patient;  the  lower  one  is  the  average  line 
for  tlie  first  year. 


The  accompanying  weight-chart  (Fig.  28)  illustrates  this  point.  The 
infant  did  unusually  well  until  the  sixth  month.  As  it  did  not  seem  ill, 
the  parents  were  not  disturbed  until  the  loss  had  reached  three  pounds. 
Feeding  was  at  once  begun,  and  the  child  gradually  regained  its  lost 
weight.     It  was  subsequently  discovered  that  the  mother  was  pregnant. 


176 


NUTRITION. 


When  a  nursing  infant  has  been  accustomed  from  birth  to  take  one 
feeding  a  day  from  the  bottle,  always  a  great  convenience  to  a  nursing 
mother,  gradual  weaning  is  generally  an  easy  matter;  otherwise  it  is 
sometimes  an  impossibility,  the  child  refusing  all  food  except  the  breast 
80  long  as  this  is  given,  and  nothing  but  starvation  inducing  it  to  take 
food  either  from  a  bottle  or  a  spoon. 

Sudden  weaning  may  be  required  at  any  time  from  the  development 
in  the  mother  of  acute  disease  of  a  serious  nature,  such  as  typhoid  fever 
or  pneumonia,  of  grave  chronic  disease,  such  as  tuberculosis  or  nephritis, 
from  the  intercurrence  of  pregnancy,  or  from  disease  of  the  mammary 
gland.  An  infant  should  not  be  suckled  at  a  breast  which  is  the  seat 
of  acute  inflammation.  Through  many  of  the  minor  ills — mild  attacks 
of  bronchitis,  pharyngitis,  indigestion,  and  even  malarial  fever — mothers 
frequently  nurse  their  children  without  any  seeming  detriment  to  them 
or  to  themselves.  In  acute  illness  of  short  duration,  if  severe,  it  is 
usually  better,  unless  we  decide  to  w^ean  altogether,  to  feed  the  cliild 
from  the  bottle  and  to  maintain  the  flow  of  milk  by  the  use  of  the  breast- 
pump  three  or  four  times  a  day  rather  than  to  allow  it  to  dry  up. 


WEEK 

OF  AGE  28      30     32      34     36     38     40     42     44     46      48      50     52 

26 

26 

24 

23 

to22 
Q 

§21 

O 

"■20 

1  9 

' 

/ 

^ 

/ 

/ 

/ 

-^ 

/ 

5| 

r 

k 

MEt 

) 

/' 

v 

^ 

^ 

S 

__ 

y' 

^ 

v' 

^ 

/ 

18 
17 
16 

- 

^ 

^ 

^ 

Fig. 


29. — Weight  Curve  op  a  Child  Properly  Weaned.  Abrupt  weaning  at  eight 
months;  loss  of  weight  for  the  first  week  due  to  the  child'.s  being  put  upon  cow's  milk 
with  low  percentages.  Formula:  Fat  l.G  per  cent,  sugar  6  per  cent,  protein  0.80  per 
cent.  Percentages  were  graduallj'  increased,  with  subsequent  steady  and  regular 
gain  in  weight.  Weaning  accomplished  without  the  slightest  symptom  of  indiges- 
tion.    The  lower  is  the  average  line. 


In  eases  of  sudden  weaning,  the  food  should  in  the  beginning  be  very 
much  weaker  than  for  an  artificially  fed  child  of  the  same  age.  The 
change  can  then  be  made  without  causing  much  disturbance  (Fig.  29). 


MIXED   FEEDING.  177 

When  the  infant  has  become  somewhat  accustomed  to  cow's  milk  the 
strength  of  the  food  may  be  gradually  increased. 

The  difficulties  in  weaning  a  child  who  up  to  nine  or  ten  months  has 
had  no  food  but  the  breast  are  sometimes  great.  Much  time  and  tact 
are  necessary  on  the  part  of  both  physician  and  nurse  in  these  cases.  To 
try  to  teach  older  infants  to  take  the  bottle  is  unwise ;  feeding  from 
cup  or  spoon  is  usually  quite  as  easy.  Continued  coaxing  of  food  is 
objectionable;  forcing  is  much  worse  and  prolongs  the  struggle.  In 
my  experience  I  have  found  the  best  way  to  offer  food  at  regular  in- 
tervals and  to  take  it  away  at  once  if  refused.  This  is  repeated  every 
three  or  four  hours.  A  variety  of  things  may  be  offered — modified  cow's 
milk,  thick  gruels,  beef  juice,  broths,  bread  and  milk,  etc.  The  nature 
of  the  food  seems  to  make  very  little  difference.  A  strong-willed  child 
will  often  hold  out  for  twenty-four  or  thirty-six  hours,  and  occasionally 
a  very  stubborn  one  is  found  who  will  do  so  for  forty-eight  hours.  At 
the  end  of  this  time  the  pangs  of  hunger  are  generally  so  acute  that  he 
capitulates.  Serious  symptoms  from  withholding  food  under  such  cir- 
cumstances I  have  never  seen. 


MIXED  FEEDING. 

By  mixed  feeding  is  meant  a  combination  of  nursing  and  artificial 
feeding.  There  are  no  objections  to  this  practice ;  on  the  contrary,  there 
are  great  advantages  in  giving  an  infant  only  a  few  breast-feedings  a 
day  when  more  are  impossible.  This  may  frequently  be  done  in  hospital 
practice,  and  thus  a  single  wet-nurse  may  assist  in  the  feeding  of  several 
infants.  Mixed  feeding  may  be  resorted  to  whenever  the  milk  supply 
of  the  mother  is  insufficient.  If  at  any  time  the  mother's  health  begins 
to  suffer,  she  may  be  relieved  of  night  nursing  or  of  one  or  more  nurs- 
ings during  the  day,  and  the  bottle  substituted.  In  this  way  she  may 
be  enabled  to  continue  lactation  for  some  time  longer  than  would  other- 
wise be  possible.  Mixed  feeding  is  often  necessary  during  the  first  few 
weeks,  while  the  mother's  milk  is  insufficient  in  consequence  of  some- 
thing which  has  retarded  her  convalescence.  For  the  advantage  of  the 
stimulation  to  secretion  -afforded  by  the  child's  nursing,  it  is  usually 
better,  rather  than  alternate  the  breast  and  the  bottle,  to  put  the  child 
at  first  to  the  breasts.  After  he  has  emptied  them,  additional  food  may 
be  given  from  the  bottle  if  the  baby  is  still  hungry.  The  milk  may  be- 
come abundant  and  of  good  quality  as  soon  as  the  mother  is  well  enough 
to  be  up  and  out  of  doors,  although  it  was  previously  scanty  and  of  in- 
ferior quality.  Two  or  three  feedings  a  day  from  the  bottle  help  to 
bridge  over  this  period  and  prevent  the  child's  nutrition  from  suffering. 
But  before  allowing  a  mother  partly  to  nurse  and  partly  to  feed  her 
infant,  one  should  be  sure  that  the  quality  of  her  milk  is  good. 
13 


178  NUTRITION. 

It  is  well  from  the  very  outset  to  accustom  the  infant  to  take  one 
feeding  from  a  bottle  each  day.  In  maternal  nursing,  the  occasional 
feeding  which  is  usually  necessary  becomes  then  a  simple  matter.  If 
the  child  is  being  wet-nursed,  the  same  plan  is  advisable,  for  it  is  then 
easy  to  put  an  infant  upon  the  bottle  entirely  in  the  event  of  the  wet- 
nurse  leaving  suddenly — a  not  uncommon  occurrence. 

ARTIFICIAL  FEEDING. 

There  are  a  few  fundamental  principles  regarding  wliich  nearly  all 
paediatrists  are  agreed. 

Woman's  milk  is  not  only  the  best,  it  is  the  ideal  infant  food. 

Any  substitute  should  furnish  the  same  constituents — fat,  carbohy- 
drates, protein,  salts,  and  water,  and  in  sufficient  quantities  to  supply 
the  needs  of  the  body  for  its  nutrition  and  growth ;  ^  furthermore,  they 
should  be  in  about  the  same  proportion  as  they  exist  in  a  good  sample 
of  woman's  milk. 

The  different  constituents  should  resemble  those  of  woman's  milk 
as  nearly  as  possible  both  in  their  chemical  composition  and  in  their 
behaviour  toward  the  digestive  fluids. 

'  From  numerous  observations,  the  nutritive  needs  of  the  average  infant  in  health 
have  been  shown  to  be  about  100  calories  for  each  kilo,  of  body  weight  from  the  third 
week  to  the  sixth  month.  These  gradually  diminish  until  at  the  end  of  the  first  year 
they  reach  about  75  to  80  calories  per  kilo.  The  caloric  requirements  are  greater 
for  very  active  infants  on  accoimt  of  their  more  rapid  metabolism ;  also,  for  premature 
infants  or  those  much  below  average  weight,  on  accoimt  of  their  relatively  larger 
body  surface  to  radiate  heat.  For  such  infants  from  125  to  150  calories  per  kilo. 
may  be  necessary. 

An  infant  weighing  7  kilos.  (15  pounds)  requires  about  700  calories  daily.  As  the 
caloric  value  of  a  good  average  specimen  of  woman's  milk  is  about  650  calories  per 
litre,  the  requirements  would  be  supplied  by  a  little  over  one  litre  of  woman's  milk. 

The  practical  application  of  these  facts  in  infant-feeding  is  that  one  should  be 
careful  to  furnish  to  an  infant  who  is  artificially  fed  what  is  needed,  but  no  con- 
siderable excess.  A  food  much  below  the  normal  caloric  requirements,  or  one  much 
above  them,  may  be  equally  improper  and  therefore  unsuccessful.  The  physician 
should  be  able  to  calculate  the  caloric  value  of  the  food  given,  to  see  if  possible  where 
the  mistake  lies,  when  infants  are  not  triving. 

The  caloric  value  of  any  modification  of  cow's  milk  of  known  percentages  may  be 
calculated  as  follows :  An  infant  is  taking  six  feedings  of  6  ounces,  or  36  ounces  daily 
of  a  milk  containing,  fat  3.5  per  cent,  sugar  7  per  cent,  protein  1.75  per  cent. 

.035    (fat  %)  X  9.3  (cal.  val.  o'"  fat)         -  .325  cal.  val.  of  fat  in  1  grm.  food. 

.07      (sugar     %)  X  4.1  ( sugar)      -  .287    "      "     "  sugar      "  1     " 

.0175  (protein  %)  X  4.1  ("      "     "  protein)   =  .072    "      "      "  protein  "  1    " 

.684  caloric  value  of  1  gram  of  food. 

.684  X  1000  =  684  (caloric  value  1  litre  food). 

36ounces  =  1.06  litres:  1.06  X  684  =  725  <No.  of  calories  in  food  taken  daily). 

Such  calculations  may  be  applied  to  any  milk  formula  of  known  percentage,  but 
are  rather  laborious.     A  simpler  way  of  arriving  at  the  same  result  is  to  multiply  the 


ARTIFICIAL  FEEDING. 


179 


No  food  except  fresh  milk  from  some  other  animal  meets  the  re- 
quirements even  approximately. 

In  the  artificial  feeding  of  infants,  cow's  milk  is  selected  as  being 
the  only  milk  available  for  general  use.  Although  it  furnishes  all  the 
constituents  required,  they  are  not  present  in  the  proportions  suited  to 
young  infants,  and  the  constituents  are  not  identical  with  those  in 
woman's  milk.  Cow's  milk,  therefore,  can  not  be  fed  to  most  infants 
without  some  changes.  These  changes  are  technically  known  as  the 
modification  of  cow's  milk.  To  make  these  changes  properly  it  is  neces- 
sary to  know  what  are  the  difficulties  in  the  digestion  of  cow's  milk  and 
how  these  may  be  overcome. 

The  earliest  milk  modification  was  simply  dilution  with  water  and 
the  addition  of  enough  cane  sugar  to  make  it  taste  like  breast-milk. 
The  only  change  made  with  the  age  of  the  child  was  simply  to  vary  the 
amount  of  water.  Instead  of  water  as  a  diluent  many  preferred  to  use 
gruels  made  from  different  cereals,  believing  that  thereby  the  casein  was 
rendered  more  digestible.  Upon  such  simple  modifications  as  these  many 
children  have  done,  and  many  still  do,  very  well,  when  the  matter  of 
dilution  is  judiciously  managed.  But  it  is  equally  true  that  present 
knowledge  enables,  us  to  do  something  better.  There  are,  however,  cir- 
cumstances in  which  an}'thing  more  complex  is  impossible  in  the  way 
of  milk  modification. 

Later,  when  the  composition  of  woman's  milk  came  to  be  better 
understood,  it  was  thought  that  all  that  was  necessary  in  modified  milk 
was  to  secure  the  exact  percentages  of  fat,  protein,  sugar,  and  salts 
which  exist  in  a  good  sample  of  woman's  milk,  and  that  this  combina- 
tion would  be  the  best  possible  substitute  for  it.     Out  of  this  came  the 


caloric  values  of  the  different  ingredients  used  in  making  up  the  food  by  the  amount 
of  each  one  that  is  taken.     These  values  are  approximately  as  follows: 
ounce  7  per  cent  milk 
"      6    "       " 

"     5    "      " 

"     3    "      " 

tl         o      ('  '< 

tl  1       <i  u 

"     fat-free 

"      whey 

"      milk  sugar  by  weight 
"       "  volume 
even  tablespoonful  of  milk  sugar 
ounce  barley  flour  by  weight 

'*  '■      water  (1  tablespoonful  to  a  pint) 

"      malt-soup  extract 

"      condensed  milk 

"     olive  oil  by  volume 


has 

a  caloric  value  of    27.5 

(1 

" 

'    25.0 

It 

(( 

'    22.5 

it 

(( 

'    20.0 

It 

(( 

'     17.5 

It 

tt 

'     15.0 

tl 

tt 

'     12.5 

tt 

tt 

'     10.0 

tt 

tt 

'    10.0 

tt 

tt 

'  116.0 

tt 
tt 

It 

It 

'  72.0 
'    44.0 

It 

It 
tl 

'  100.0 
'  2.0 
'  80.0 
'  132.0 

<< 

tl 

'  245.0 

180  NUTRITION. 

various  mixtures  of  milk,  cream,  sugar,  etc.,  which  aimed  to  reproduce, 
according  to  the  views  of  different  writers,  the  exact  proportions  of 
woman's  milk.  This  was  a  step  in  advance,  in  that  some  proper  relation 
between  the  different  food  constituents  was  maintained.  Experience, 
however,  has  shown  that  no  single  milk-formula  can  serve  as  a  substitute 
for  woman's  milk;  and  intelligent  students  of  the  problem  have  ceased 
to  search  for  one. 

In  the  percentage  method  of  infant-feeding  one  considers  the  differ- 
ent elements  of  the  food  separately  and  tries  to  adapt  their  proportions 
to  the  child's  digestion.  While  it  is  based  upon  the  percentage  com- 
position of  woman's  milk,  it  recognises  that  there  are  differences  in  the 
digestibility  of  cow's  milk  and  woman's  milk.  It  aims  to  discover  the 
proper  proportions  of  fat,  sugar,  and  protein,  and  the  best  methods  of 
gradational  increase  for  healthy  infants  with  normal  digestion;  and 
also  to  discover  for  those  with  abnormal  or  feeble  digestion,  the  com- 
binations best  suited  to  the  individual  conditions.  Percentages  are 
simply  a  method  of  stating  definitely 'the  composition  of  the  food  which 
we  are  giving.  There  is,  therefore,  strictly  speaking,  no  such  thing  as 
the  percentage  method  of  feeding;  it  is  merely  a  method  of  statement. 

For  the  fundamental  work  along  this  line  we  are  indebted  to 
Prof.  T.  M.  Rotch,  of  Harvard,  and  Mr.  C.  E.  Gordon,  of  the  Walker- 
Gordon  Laboratory  Company. 

The  calculation  of  food  requirements  of  an  infant  in  terms  of  calories 
is  at  present  much  employed.  The  requirements  are  assumed  to  be 
fairly  uniform  for  an  infant  of  a  given  weight  (the  figures  are  givqn 
on  a  previous  page),  and  for  healthy,  well-nourished  children  this  is 
approximately  correct.  But  the  calculation  is  not  correct  for  those  who 
are  below  the  average  weight  for  their  ages.  For  such  children  the  food 
requirements  measured  in  calories  are  considerably  greater  than  those 
allowed  by  the  theoretical  calculation.  A  comparison  of  the  physiological 
requirements  as  calculated,  with  the  calories  furnished  by  the  food  given, 
is  a  useful  method  of  control  in  the  feeding  of  children  who  are  not 
thriving  or  whose  nutrition  is  especially  difficult.  It  enables  one  to 
see  whether  he  is  feeding  far  above  or  far  below  physiological  require- 
ments, and  also  to  appreciate  the  necessity  of  increasing  some  elements 
in  the  food  if  others  are  reduced.  It  may  be  regarded  as  a  basis  of  cal- 
culating food  requirements,  but  nothing  more.  Like  the  percentage 
method,  it  is  a  method  of  statement;  the  two  are  not  in  contrast  or  op- 
position, and  both  are  valuable. 

The  Modification  of  Cow's  Milk  for  Healthy  Infants  during  the  First 
Year. — It  is  absolutely  necessary  to  consider  separately  the  changes  re- 
quired by  healthy  infants  with  normal  digestion,  those  required  by  in- 
fants with  feeble  digestion,  and  those  required  by  infants  suffering  from 
more  or  less  indigestion.    From  a  failure  to  make  this  distinction,  much 


ARTIFICIAL   FEEDING. 


181 


confusion  has  arisen.  The  digestion  of  all  healthy  infants  is  very  much 
alike,  and  they  can  all  be  fed  in  much  the  same  way ;  while,  on  the  con- 
trary, the  variations  afforded  by  unhealthy  infants  are  almost  endless, 
and  each  case  must  be  considered  by  itself.  If  it  is  only  healthy  infants 
that  can  be  fed  by  rule,  it  is  equally  true  that  if  fed  from  the  beginning 
by  proper  rules  most  infants  will  remain  healthy. 

In  adapting  cow's  milk  for  infant-feeding  we  must  realise  at  the 
outset  that,  no  matter  how  we  may  alter  it,  cow's  milk  is  not  a  perfect 
substitute  for  woman's  milk.  It  sliould  not  be  lost  sight  of  that  there 
are  inherent  differences  which  will  never  l)e  altogether  removed.  The 
following  table  gives  the  proportions  of  the  various  elements  which  make 
up  the  two  milks: 


Woman's  milk, 
average. 

Cow's  milk, 
average. 

Fat ; 

Sugar 

Protein 

Salts 

Per  cent. 

3.50 
7.00 
1.50 
0.20 

87.80 

Per  cent. 

4.00 
4.50 
3.50 
0.75 

Water 

87.25 

100.00 

100.00 

These  quantitative  differences  in  the  constituents  are  important.  It  will 
be  seen  that  cow's  milk  has  an  excess  of  protein  and  salts,  but  is  de- 
ficient in  sugar.  Far  more  important,  however,  for  the  infant  are  the 
qualitative  differences.  The  sugar  in  the  two  milks,  it  is  true,  is  nearly 
if  not  quite  the  same.  The  fat  of  cow's  milk,  however,  contains  a  smaller 
proportion  of  oleic  acid  and  a  much  larger  proportion  of  volatile  fatty 
acids.  The  salts  are  excessive  in  amount,  particularly  calcium  phos- 
phate, but  are  deficient  in  iron  and  potassium.  There  are  important 
differences  in  the  protein.  The  total  protein  of  cow's  milk  is  nearly  two 
and  a  half  times  as  great  as  that  in  woman's  milk.  In  cow's  milk  the  sol- 
uble protein  (lactalbumin;  etc.)  is  only  about  one-third  or  one-fourth  as 
abundant  as  the  insoluble  protein  (casein) ;  while  in  woman's  milk  the 
soluble  protein  forms  more  than  half  the  total.  But  the  difference  in  the 
digestibility  of  the  protein  of  the  two  milks  is  much  less  than  was  once 
believed.  Other  important  conditions  relate  to  the  reaction  of  milk,  its 
freshness,  bacterial  contamination,  etc.  The  modification  of  milk  must 
aim,  therefore,  at  something  more  than  overcoming  the  quantitative  dif- 
ferences in  the  constituents. 

In  the  adaptation  of  cow's  milk  for  infant-feeding  the  emphasis 
has  been  at  different  times  laid  upon  different  elements.  The  view  was 
long  held  that  the  chief  trouble  was  with  the  protein.  As  a  result  of  this 
the  use  of  predigested  milk  came  largely  into  vogue,  and  milk  formulas 


182  NUTRITION. 

with  high  fat  and  low  protein  were  widely  employed.  Then  came  the 
opinion  prominently  advanced  by  Czerny  and  Keller  that  it  was  the 
fat  which  produced  the  most  trouble.  More  recently  it  has  been  pointed 
out  by  Finkelstein  and  his  pupils  that  disturbances  of  the  gravest  char- 
acter may  be  due  to  the  sugar  and  even  to  the  salts.  Our  knowledge  on 
this  subject  leaves  many  points  still  unsettled.  Meanwhile,  the  im- 
portant thing  for  the  student  and  the  practitioner  to  appreciate,  is  the 
fact  that  any  of  the  elements  of  cow's  milk  may  cause  serious  disturb- 
ance. For  the  healthy  child  we  are  safe  in  emphasising  that  trouble  is 
most  likely  to  be  due  to  the  fat,  while  one  with  disordered  digestion  may 
be  disturbed  by  any  one  of  the  elements.  However,  one  must  be  care- 
ful about  inferring,  from  the  disturbances  in  sick  infants,  how  healthy 
ones  are  to  be  fed. 

Fat. — ^The  amount  of  fat  of  cow's  milk  which  a  healthy  infant  can 
digest  varies  considerably ;  the  usual  limits  are  between  1  and  4  per  cent. 
There  are  not  many  infants  who  can  digest  as  much  fat  of  cow's  milk  as 
the  proportion  often  present  in  a  good  sample  of  breast-milk.  With 
most  infants  it  is  necessary  to  begin  with  as  low  a  proportion  as  1  per 
cent.  The  increase  should  be  made  very  gradually.  I  have  not  found 
it  advantageous  to  increase  the  fat  above  4  per  cent;  for  most  infants 
under  usual  conditions  the  upper  limit  should  not  be  over  3.5  per  cent. 
I  constantly  see  serious  derangements  of  digestion  produced  by  the  use 
of  higher  percentages.^ 

The  danger  of  disturbing  the  infant's  digestion  by  fat  has  only 
recently  been  sufficiently  appreciated.  This  mistake  is  frequently  made 
when  rich  Jersey  milk  is  employed,  and  also  when  the  fat  percentage 
is  steadily  raised  for  the  purpose  of  overcoming  chronic  constipation. 
For  nearly  all  infants  with  disordered  digestion  the  fats  must  be  much 
reduced.  No  modification  of  the  fat  of  cow's  milk  is  possible  except 
in  the  amount.  There  seems  to  be  no  difference  in  the  digestibility 
of  gravity  and  centrifugal  cream.  Freshness  is  a  very  important  con- 
sideration in  all  extra  fat  added  to  milk. 

Sugar. — In  woman's  milk  the  percentage  of  sugar  varies  but  little; 
it  is  usually  between  six  and  seven  per  cent.  In  feeding  cow's  milk  it 
is  seldom  necessary  to  have  the  sugar  less  than  five  or  more  than  seven 
per  cent.  To  obtain  the  proper  proportion  of  sugar  is  the  simplest  part 
of  the  modification.  It  is  only  necessary  to  calculate  the  amount  to 
be  added  to  bring  this  up  to  the  per  cent  desired.  While,  for  reasons 
given  elsewhere,  lactose  is  the  form  of  sugar  generally  preferred,  when 
this  can  not  be  obtained,  cane  sugar  may  be  substituted,  but  in  a 
somewhat  smaller  amount.  Besides,  there  is  some  difference  in  the  diges- 
tibility of  these  two  sugars.     In  certain  forms  of  intestinal  indigestion 

*  Archives  of  Paediatrics,  January,  1905. 


ARTIFICIAL  FEEDING. 


183 


cane  sugar  is  soinetiines  better  tolerated  than  is  milk  sugar.  Maltose 
also  may  be  used ;  it  possesses  certain  advantages  as  well  as  disadvantages, 
which  should  be  carefully  considered  before  it  is  employed.  It  should 
be  distinctly  understood  that  the  purpose  of  adding  sugar  is  not  to 
sweeten  the  food,  but  to  furnish  the  proper  proportion  of  soluble  carbo- 
hydrates for  nutrition. 

PEOTEiisr. — To  the  modification  of  the  protein  of  cow's  milk  most  of 
the  attention  was  formerly  given.  The  evidence  seems  conclusive,  how- 
ever, that  healthy  infants  digest  this  protein  without  difficulty.  The 
main  point  necessary  therefore  is  to  decide  upon  the  quantity  which  shall 
be  given. 

During  the  early  weeks  not  more  than  one  per  cent  of  protein  is 
required.  The  amount  should  be  gradually  increased  so  that  an  aver- 
age child  will  receive  at  four  or  five  months  two  per  cent  of  protein 
and  three  per  cent  at  eight  or  nine  months.  It  is  a  common  mistake 
to  continue  long  with  too  low  protein.  Anaemia,  malnutrition,  and,  I 
believe,  sometimes  scurvy  are  seen  as  a  consequence  of  this  practice. 
The  gradual  increase  is  therefore  just  as  important  as  the  low  beginning. 

Inorganic  Salts. — These  may  generally  be  calculated  in  cow's  milk 
as  one-fifth  the  total  protein.  When  the  total  protein  has  been  suitably 
reduced  by  dilution  the  amount  of  total  salts  will  approximate  that  pres- 
ent in  woman's  milk.  But  it  should  not  be  forgotten  that  such  dilution, 
while  it  brings  down  those  salts  which  are  in  excess,  chiefly  calcium 
phosphate,  to  a  proper  proportion,  also  reduces  to  the  same  degree  the 
iron  and  potassium  which  originally  were  not  in  excess.  The  influence 
of  the  inorganic  salts  upon  nutrition  is  something  deserving  further 
study.  In  certain  pathological  conditions  the  salts  are  undoubtedly 
capable  of  producing  serious  disturbances. 

The  amount  of  reduction  obtained  by  the  different  dilutions  is  shown 
in  the  following  table : 


Cow's  milk. 

Diluted 
once. 

Diluted 
twice. 

Diluted 
3  times. 

Diluted 
4  times. 

Protein 

3.50 
0.75 

1.75 
0.37 

1.16 
0.25 

0.87 
0.18 

0  70 

Inorganic  salts 

0.15 

Eeaction. — It  has  been  customary  to  overcome  the  exces&ive  acidity 
of  cow's  milk  by  adding  either  lime-water  or  bicarbonate  of  soda.  Of 
the  former,  there  is  generally  employed  about  one  ounce  to  each  twenty 
ounces  of  the  food;  of  the  latter,  about  one  grain  to  each  ounce  of  the 
food.  The  manner  in  which  the  addition  of  these  substances  affects  the 
digestion  of  milk  is  not  fully  understood.  The  practical  value  of  adding 
lime-water  is  well  established  by  clinical  experience.  Some  recent  ex- 
periments of  T.  W.  Clarke  indicate  that  its  chief  effect  may  be  due  to 


184  NUTRITION. 

its  stimulation  of  the  secretion  of  hydrochloric  acid.  Lime-water  also 
causes  a  retardation  of  coagulum  formation  in  the  stomach. 

Bacteria. — These  are  always  present  in  cow's  milk.  They  have 
been  already  considered  in  the  pages  devoted  to  the  Sterilisation  of 
Milk. 

The  Observation  of  Cases  of  Infant-Feeding. — For  the  first  few 
weeks  it  is  essential  that  the  physician  see  the  infant  every  few  days, 
inspect  the  stools,  hear  the  nurse's  report,  and  see  how  his  directions  are 
being  carried  out.  When  the  child  is  well  started  and  has  begun  to 
gain  regularly  in  weight,  a  weekly  visit  will  be  sufficient.  Still  later 
a  regular  weekly  report  in  writing,  to  be  continued  up  to  the  seventh  or 
eighth  month,  may  be  all  that  is  required;  after  that  time  monthly 
reports  are  usually  sufficient.  My  plan  is  to  have  the  weekly  report 
include  only  answers  to  certain  questions,  viz. : 

1.  Weight: gain  or  loss  since  last  report. 

2.  Stools:  frequency  and  general  character. 

3.  Vomiting  or  regurgitation — when?  and  how  much? 

4.  Flatulence  or  colic? 

5.  Appetite:  Is  the  child  satisfied?     Does  he  leave  any  of  his  food? 

6.  Is  he  comfortable  and  good-natured  and  sleeping  well? 

7.  The  formula  of  the  food  now  given;  quantity  and  frequency  of 

feedings. 

8.  Date. 

9.  Date  of  last  report. 

An  excellent  plan  is  to  furnish  the  patient  with  printed  forms  con- 
taining these  questions  to  be  filled  out  and  returned.  This  is  a  simple 
matter,  and  there  are  very  few  intelligent  mothers  who  will  be  unwilling 
to  co-operate  with  the  physician  to  this  extent.  With  information  re- 
garding the  points  indicated,  it  is  possible  for  the  physician  to  know 
pretty  accurately  how  the  case  is  doing,  what  changes,  if  any,  are  desir- 
able in  the  food,  and  whether  he  ought  to  see  the  patient.  It  is  only 
by  some  systematic  method  of  observation  that  one  can  secure  the  best 
results  with  any  form  of  infant-feeding. 

Milk  Laboratories. — The  first  milk  laboratory  was  established  in 
Boston  by  the  Walker-Gordon  Company  in  1893 ;  one  in  New  York  in 
1893,  and  since  that  time  others  in  many  American  cities.  They  under- 
take to  furnish  "  modified  milk  "  of  any  desired  proportions,  upon  the 
prescription  of  physicians..  The  elements  chiefly  used  by  the  Walker- 
Gordon  laboratories  are:  (1)  Cream  containing  33  per  cent  of  fat; 
(3)  separated  milk,  from  which  the  fat  has  been  removed  by  the 
centrifugal  machine;  (3)  a  standard  solution  of  milk  sugar,  30  per 
cent  strength.  These  contain  fat,  sugar,  and  protein  in  the  following 
proportions : 


ARTIFICIAL   FEEDING. 


185 


Fat .  .  . 
Sugar . 
Protein 


Cream. 


Per  cent. 

32.00 
3.40 
2.50 


Separated  milk. 


Per  cent. 

0.05 
5.00 
3.55 


Sugar  solution. 


Per  cent. 

20'00 


By  combining  these  it  is  possible  to  vary  the  percentages  of  fat,  sugar, 
and  protein  in  the  milk  to  almost  any  degree  desired,  and  to  do  this  with 
very  great  accuracy.  By  using  whey,  a  separate  modification  of  the 
protein  is  accomplished;  so  that  within  certain  limits  a  larger  propor- 
tion of  whey  protein,  chiefly  lactalbumin,  can  be  given.  The  highest 
proportion  of  whey  protein  with  the  lowest  proportion  of  casein  can  be 
given  when  the  total  protein  does  not  exceed  1.15  per  cent;  of  this, 
0.90  per  cent  may  be  whey  protein  and  0.25  per  cent  casein.  The 
alkalinity  is  usually  obtained  by  adding  lime-water  in  any  desired 
amount.  The  laboratory  adds,  Avhen  requested,  gruels  of  wheat,  oats,  or 
barley  of  any  desired  strength;  and,  finally,  it  delivers  the  milk  raw, 
or  heats  it  for  sterilisation  to  any  temperature  ordered  by  the  physician. 
The  food-supply  for  the  entire  day  is  delivered  each  morning  in 
the  bottles  from  which  it  is  to  be  fed.  The  empty  bottles  returned  are 
washed  and  sterilised  at  the  laboratory.  In  ordering  the  food  the  phy- 
sician simply  writes  for  the  percentages  of  fat,  sugar,  and  protein  which 
he  desires,  together  with  the  number  of  feedings  for  twenty-four  hours 
and  the  quantity  for  each  feeding: 

Fat 2  per  cent. 

Sugar 6      " 

Protein 1       " 

Alkalinity,  lime-water 5       " 

Number  of  feedings 8 

Amoimt  for  each  feeding 4  ounces. 

Heat  to  155°  F.,  30  minutes. 

The  aim  of  the  laboratory  is  to  supply  the  physician  with  any  milk 
modification  which  he  may  desire  to  use  and  to  do  this  with  accuracy. 

One  is  not  restricted  to  any  method  or  plan  of  feeding,  but  can 
carry  out  his  own  method  with  much  greater  accuracy  than  is  possible 
when  the  milk  is  prepared  in  the  average  home.  He  is  independent  of 
the  ignorance,  carelessness,  or  caprice  of  the  nurse  who  otherwise  would 
probably  prepare  the  food.  But  by  whatever  method  the  child  is  fed  the 
physician  who  assumes  the  responsibility  to  direct  must  be  familiar  with 
the  subject  and  he  must  keep  in  touch  with  the  case  if  he  expects  good 
results. 

As  a  general  guide  to  the  modification  of  milk  for  an  average  healthy 
infant  the  following  table  is  introduced,  showing  the  manner  in  which 
the  changes  required  by  the  development  of  the  child  may  be  made : 


186 


NUTRITION. 


Table  showing  percentages  of  fat,  sugar  and  protein  which  may  be  ordered 

from  the  Milk  Laboratory  and  are  suitable  for  healthy 

infants  for  the  first  year. 


Fat. 

Sugar. 

Protein. 

Whey  protein.      Casein. 

Weak  Formulas.         I. 

0.75 

4.00 

0.75 

or    0.70    and    0.05 

II. 

1.00 

5.00 

0.75 

"     0.70      "      0.05 

III. 

1.00 

5.00 

1.00 

"     0.85      "      0.15 

IV. 

1.25 

5.00 

1.00 

"     0.85      "      0.15 

V. 

1.50 

5.00 

1.25 

"    O.SO      "      0.45 

Medium  Formulas.  VI. 

1.75 

6.00 

1.50 

VII. 

2.00 

6.00 

1.50 

VIII. 

2.25 

6.00 

1.75 

IX. 

2.50 

6.00 

1.75 

X. 

2.75 

6.00 

1.75 

XI. 

3.00 

6.00 

2.00 

Strong  Formulas.  XII. 

3.25 

6.00 

2.00 

XIII. 

3.50 

6.00 

2.25 

XIV. 

3.50 

6.00 

2.50 

(Whole  Milk.) 

XV. 

3.50 

6.00 

3.00 

XVI. 

4.00 

4.50 

3.50 

The  first  group,  classed  as  weak  formulas,  are  designed  for  normal 
infants  during  the  first  few  weeks,  or  for  those  with  feeble  digestion, 
of  whatever  age. 

The  second  group  is  designed  for  the  needs  of  normal  infants  from 
about  one  month  to  four  or  five  months,  although  there  are  many  who 
can  not  take  a  stronger  food  for  a  much  longer  time. 

The  third  group  is  expected  to  cover,  for  children  with  good  diges- 
tion, the  period  from  about  the  fifth  month  to  the  twelfth  or  thirteenth 
month,  gradually  leading  up  to  whole  milk. 

It  is  important  to  begin  with  a  weak  formula  for  a  young  infant, 
and  for  one  with  feeble  digestion,  whatever  its  age.  One  may  then 
gradually  increase  the  strength  of  the  milk  according  to  the  indications 
afforded  by  the  child's  appetite  and  powers  of  digestion.  With  some  the 
increase  can  be  made  more  rapidly  than  with  others,  but  with  all  children 
it  is  important  that  the  steps  of  increase  should  be  gradual  and  not 
greater  than  are  indicated  in  the  formulas  of  the  table ;  it  may  even  be 
desirable  at  times  to  make  tliem  more  slowly  than  is  there  suggested. 
In  the  table  the  total  protein  to  be  used  is  indicated  and  also  the  quan- 
tities of  whey  protein  and  casein,  when  one  desires  to  order  these  sep- 
arately. There  is  some  advantage  in  so  dividing  the  protein  for  very 
young  or  premature  infants. 

Home  Modification  of  Milk. — For  the  great  majority  of  infants  the 
milk  is  necessarily  prepared  at  home.    No  plan  of  home  modification  yet 


ARTIFICIAL  FEEDING.  187 

proposed  secures  more  than  approximate  accuracy  in  the  percentages  of 
fat,  sugar,  protein,  etc.;  yet,  if  the  directions  given  l)elow  are  carefully 
carried  out,  a  degree  of  accuracy  suflBcient  for  all  practical  purposes  can 
be  secured.  The  physician  thus  can  not  only  know  the  percentages  he 
is  giving,  but  he  can  himself  readily  vary  them  within  the  range  usually 
required,  according  to  the  indications  presented.  The  thing  desired  is 
a  method  simple  enough  to  be  readily  grasped  by  the  average  mother 
or  nurse  who  is  to  carry  out  the  physician's  directions. 

The  requisites  for  success  in  the  home  modification  of  milk  are: 

Good  raw  materials — the  freshest  and  cleanest  milk  obtainable. 

Knowledge  on  the  part  of  the  physician  of  at  least  the  fat  content 
of  the  milk  and  cream  used  in  the  home  as  it  is  only  the  fat  which  is 
subject  to  much  variation. 

Directions  which  are  clear,  explicit,  and  in  writing,  that  they  may 
not  be  misunderstood. 

The  co-operation  of  an  intelligent  mother  or  nurse,  that  they  may 
be  properly  carried  out. 

How  TO  Obtain  Formulas  Required  for  General  Use. — A  con- 
siderable variety  of  formulas  is  required.  For  normal  children  with 
good  digestion  the  fat  should  usually  be  higher  than  the  protein,  the 
upper  limit  being  twice  as  much  fat  as  protein.  For  those  with  dis- 
turbances of  digestion,  the  fat  should  usually  be  lower  than  the  protein. 
A  series  of  formulas,  with  the  range  required,  can  readily  be  obtained 
by  the  method  given  below.  Nearly  all  who  practise  home  modification 
of  milk  purchase  milk  in  quart  bottles.^  This  has  therefore  been  made 
the  basis  of  calculation.  If  the  milk  used  has  4  per  cent  of  fat  and 
the  directions  given  are  closely  followed  the  results  obtained  will  be 
very  nearly  accurate. 

The  first  step  is  to  secure  milks  containing  definite  amounts  of  fat 
varying  from  7  per  cent  down  to  1  per  cent.  This  has  been  described 
in  detail  for  -1-  and  5-per-cent  milk  in  the  chapter  on  Cow's  Milk. 

It  is  convenient  to  calculate  all  food  formulas  on  a  basis  of  a 
20-ounce  mixture. 

Every  ounce  of  7%  milk  in  20-oz.  mixture  has  one-twentieth  of  7,  or  0.35%  fat. 

"6%     "      "     "  "       "  "  "6,"   0.30%    " 

u  u    507^       u        u       u  u  u  u  u    5^   u     0.25%      " 

«  ti         a    jo^      a    ■   u       u  <,         a  a  u    j^  «     0.05%      " 

The  percentage  of  protein  and  sugar  in  the  various  milks  we  are  con- 
sidering  differs   so   little   that   the   variation   may   be   ignored.      Since 

*  If  instead  of  purchasing  milk  in  bottles  milk  fresh  from  the  cow  is  used,  as  soon 
as  received  it  should  be  strained  through  three  thicknesses  of  cheesecloth  or  a  layer 
of  absorbent  cotton  into  quart  jars  or  milk  bottles,  and  allowed  to  stand  in  ice- water 
or  cold  spring  water  for  at  least  four  hours.     The  top  milk  may  then  be  removed. 


1S8 


NUTRITION. 


10 

1 

4J 

(N 

>o 

lO 

g 

0 

»o 

>o 

0 

8 

10 

m 

0 

8 

W3 

10 

H 

<N 

■* 

«D 

I— ( 

C<5 

iC 

00 

(N 

■* 

t^ 

l-H 

CO 

0 

0 

0 

0 

"-• 

'-' 

I-H 

r-t 

<N 

(N 

(N 

(N 

(N 

CO 

CO 

a 

M 

N- 

■* 

'- 

^ 

■« 

— 

■« 

*- 

— 

■»• 

>• 

'- 

>- 

>• 

9 

ai 

»- 

^ 

10 
I— 

«c 

0 

0 

10 

IC 

0 

0 

^ 

»o 

^ 

0 

>o 

0 

0 

^ 
^ 

?^ 

•^ 

CO 

10 

r- 

00 

0 

<N 

•^ 

■^ 

r^ 

(N 

■>* 

<£> 

d 

d 

d 

d 

d 

1— t 

l-H 

ifH 

^H 

1-H 

I-H 

<N 

C^ 

ci 

(N 

.a 

:i. 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

0 

" 

"• 

- 

- 

^ 

" 

" 

** 

** 

" 

'* 

*• 

** 

's- 

ac 

s 

^ 

^ 

^ 

^ 

^ 

„ 

„ 

^ 

_ 

^ 

^ 

^ 

^ 

, 

^ 

•& 

1 

fe 

•c 

0 

10 

0 

10 

0 

10 

0 

IC 

0 

to 

Q 

10 

0 

»o 

f4. 

n 

r^ 

0 

1-H 

c^ 

(N 

cc 

ec 

■* 

■* 

10 

10 

U? 

<£> 

t^ 

t^ 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

*> 

!& 

0 

0 

0 

0 

0 

^ 

0 

0 

0 

0 

0 

0 

0 

0 

0 

TT) 

f^ 

(N 

M 

•* 

iC 

0 

t^ 

00 

a>  0 

(N 

CO 

■<** 

10 

-o 

e* 

0 

0 

0 

0 

0 

0 

0 

0 

0 

rH 

I-H 

1-H 

1-H 

l-H 

I-H 

? 

J 

10 

0 

10 

0 

10 

^ 

10 

0 

»o 

0 

10 

0 

«o 

0 

10 

H 

(^ 

CO 

-<*< 

<© 

I^ 

03 

0 

(N 

CO 

iCl 

CO 

00 

05 

(N 

n 

0 

0 

0 

0 

0 

0 

l-H 

l-H 

l-H 

I-H 

l-H 

I-H 

I-H 

(N 

C<l 

§ 

0 

0 

0 

0 

8 

0 

0 

0 

^ 

8 

0 

0 

0 

0 

8 

:S 

Q 

^ 

IN 

■* 

<£> 

00 

(N 

Tt< 

-X! 

uo 

<N 

-* 

CO 

00 

S 

d 

d 

d 

d 

T-l 

I-H 

l-H 

l-H 

l-H 

(N 

(N 

<N 

(N 

ci 

CO 

lO 

0 

»o 

8 

10 

0 

10 

8 

10 

0 

IC 

8 

10 

0 

< 

O 

t^ 

(N 

U3 

t^ 

(N 

IC 

i^ 

(M 

10 

t^ 

(N 

>o 

•« 

0 

0 

0 

i-i 

r-t 

l-H 

l-H 

<M 

(N 

(N 

(N 

CO 

CO 

CO 

^» 

g 

0 

0 

g 

0 

0 

Q 

0 

0 

0 

8 

0 

0 

8 

fi 

» 

f^ 

CO 

;o 

(N 

»c 

UC 

»-l 

•* 

t^ 

fC 

0 

rO 

« 

0 

0 

0 

^ 

l-H 

_l 

(N 

(N 

(N 

CO 

cc 

CO 

CO 

C) 

s 

^:a 

»o 

0 

IC 

0 

10 

0 

10 

Q 

>o 

0 

0 

s 

< 

<rc 

l^ 

0 

T}< 

t^ 

»H 

■* 

00 

0 

U5 

00 

^S 

0 

0 

»-l 

I— 1 

l-H 

(M 

(N 

iM 

CO 

CO 

CO 

fe! 

2 

^ 

:: 

: 

2 

= 

= 

:: 

- 

:: 

= 

= 

- 

= 

^ 

s 

s. 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

.« 

0 

N 

a 

« 

s 

0 

v 

a 

e 

^ 

2 

^ 

2 

^ 

^ 

^ 

^ 

2 

^ 

^ 

^ 

^ 

3 

3 

0 

0 

.-H 

(N 

CO 

>* 

»o 

tf> 

t^ 

00 

OS 

0 

1-1 
rH 

1-1 

CO 

1-H 

•>* 

1-H 

I-H 

1— 1 

1— 1 

l-H 

> 
»— 1 

> 

> 

»— t 
> 

)-H 
l-H 

> 

X 

X 

1— t 

X 

l-H 
HH 

X 

K 

> 

< 

3 

cr 


C^  CO   "2   00 

ttt ,  -  - 


a. 
a" 


"5  (N  (N 


P^ 


a 

3 


-a 
a 

a 


•  -    (3  -     - 
CO. 


«C  :: 
o 


a 


^3 

C 

•s 
-^  a 

03  t; 


aJ  CO 
A  O 


o   « 

a  s 


o 


V 


3  -tj 

V    03 

o     „ 

c  > 

;-^ 


l-H    > 


V  03     a 

§=   =    =  --=    |3 

1  '     '     '  '     '     '       ^^ 

l>  CO  IC  Tfi  CO  c^ 

c 

■3  -    -    -  -    - 

+3     -        -         -  -         - 

O  -     -     -  -     w 

H 


^^ 


ARTIFICIAL  FEEDING.  189 

4-per-cent  milk  contains  4 .  50  per  cent  of  sugar,  eacli  ounce  of  any  of 
these  milks  in  a  20-ounce  mixture  will  have  one-twentieth  of  4.50  or 
0.325  per  cent  of  sugar.  Each  ounce  in  a  20-ounce  mixture  will  have 
one-twentieth  of  3 .  50,  or  0 .  175  per  cent  of  protein.  The  figures  given  in 
the  accompanying  table  will  now  be  clear.  The  table  shows  the  percent- 
age composition  of  the  different  formulas  containing  twenty  ounces, 
which  can  be  derived  from  the  different  milks  and  the  manner  in  which 
they  are  obtained.  It  should  be  emphasised  that  in  general,  formulas 
from  7-,  6-,  5-,  and  4-per-cent  milk  are  to  be  used  for  healthy  infants 
with  good  digestion ;  formulas  from  3-,  2-,  and  1-per-cent  milk  are  to  be 
used  for  infants  suffering  from  disorders  of  digestion. 

These  formulas  cover  practically  all  our  needs.  This  table  may  seem 
at  first  glance  somewhat  complicated;  but  it  is  not  so  if  we  observe  that 
column  A,  for  instance,  gives  the  fat  percentage  of  the  food  when  one, 
two,  three  or  more  ounces  of  a  7-per-cent  milk  are  used  in  a  20-ounce 
mixture;  column  B  gives  the  same  when  a  6-per-cent  milk  is  used,  etc. 

From  left  to  right  the  table  would,  therefore,  read  as  follows:  Tak- 
ing Formula  VIII,  eight  ounces  in  twenty  has  2.80  per  cent  of  fat  if 
7-per-cent  milk  is  used ;  2 .  40  per  cent  of  fat,  if  6-per-cent  milk  is  used, 
etc.,  with,  in  every  case,  1.40  per  cent  of  protein  and  1.80  per  cent  of 
sugar.  It  will  be  noted  that  the  protein  and  sugar  percentages  remain 
the  same  whichever  percentage  of  fat,  from  7  per  cent  to  1  per  cent,  the 
milk  contains  from  which  the  formula  is  made  up.  It  is  thus  evident 
how  one  may  vary  the  fat  without  varying  the  protein  and  sugar. 

Thus  far  only  the  protein  and  fat  have  been  considered.  To  secure 
the  desired  percentage  of  sugar  is  a  simple  matter.  One  notes  first  the 
percentage  of  sugar  contained  in  the  milk  after  dilution;  subtract- 
ing this  from  the  percentage  desired  will  give  the  percentage  to  be 
added.^ 

Thus,  if  we  use  ten  ounces  in  twenty  of  milk  containing  any  of  the 
percentages  of  fat  from  7  to  1,  the  sugar  present  in  the  mixture  is  2.25. 
To  raise  this  to  6  per  cent,  one  must  add  3.75  per  cent,  or  a  little  over 
two  even  tablespoonfuls,  to  each  twenty  ounces  of  the  mixture.  The 
sugar  should  be  dissolved  in  the  diluent  before  adding  to  the  milk. 

The  usual  proportion  of  lime-water  added  is  5  per  cent,  or  one  ounce 
in  a  20-ounce  mixture;  this  may  be  increased  to  any  desired  quantity. 

The  quantity  of  the  diluent  must  in  each  instance  be  sufficient  to 
bring  the  total  up  to  twenty  ounces.  As  a  diluent  for  the  early  months 
plain  boiled  water  is  generally  to  be  preferred.  After  five  or  six  months 
barley  or  oatmeal  water  may  be  substituted. 

To  make  more  than  a  20-ounce  mixture  will  be  found  simple  if  one 

'  One  ounce  of  milk  sugar  by  weight  in  a  20-ounce  mixture  adds  5  per  cent. 
"        "      "      "        "      "  volume  "  "       "  "  "  about  3  per  cent. 

"    even  tablespoonful  ""      "  "  "       "     1.75  per  cent. 


190 


NUTRITION. 


calculates  for  25,  30,  35  ounces,  etc.  Thus,  for  25  ounces  there  is  added 
one-fourth  more  of  each  ingredient;  for  30  ounces,  one-half  more,  etc. 

The  Application  of  the  Foregoing  Formulas  in  Practice. — 
General  Rules  for  Varying  Milk  Percentages. — We  have  indicated 
in  the  paragraph  upon  laboratory  feeding  a  series  of  formulas  suitable 
for  the  first  year,  and  have  sho^\•n  how  similar  formulas  can  be  obtained 
when  the  milk  is  prepared  at  home.  A  schedule  like  that  given  in  the 
table  is  useful  to  indicate  in  a  general  way  what  percentages  an  average 
infant  may  be  expected  to  take.  But  no  schedule  can  be  closely  fol- 
lowed with  any  given  child.  One  can  not  conclude  that  because  a  child 
is  six  weeks  old  he  is  able  to  digest  milk  containing  certain  percentages, 
and  certain  others  because  he  is  six  months  old.  To  attempt  to  follow 
a  schedule  too  closely  is  to  violate  the  fundamental  principle  of  per- 
centage feeding,  which  is  to  adapt  the  milk  to  the  child's  requirements 
and  powers  of  digestion  at  any  time.  In  brief,  one  should  begin  with 
weak  formulas  and  gradually  increase  their  strength  according  to  the 
child's  needs  and  his  ability  to  digest  cow's  milk. 

Although  it  is  impossible  to  follow  a  schedule  in  regard  to  the  com- 
position of  the  food  for  the  first  year,  one  may  generally  with  advan- 
tage follow  a  schedule  with  regard  to  quantity  and  frequency  of  feeding. 

Schedule  for  Healthy  Infants  during  the  First  Year. 


Age. 

Interval 

between 

meals, 

by  day. 

Night 

feedings 

10  P.M.  to 

7  A.M. 

No.  of 
feed- 
ings, 24 
hours. 

Quantity  for 
one  feeding. 

Quantity  for 
24  hours. 

2d  to  7th  day 

2d  to  4th  week 

5  weeks  to  2  months 

2  to  5  months 

5  to  9  months 

9  to  12  months 

Hours. 

2 

2h 

3 

3 

3 

4 

2 

1 
1 
1 

0 
0 

10 

8 
7 
7 
6 
5 

Ounces.     Grammes. 

1  -1^     30-  45 
l|-3^     45-110 

3  -5       90-155 

4  -6     125-185 

5  -7|  150-235 
7  -9     220-280 

Ounces.          Grammes. 

10-15      300-    450 
12-28      360-    875 
21-35     630-1,085 
28-42      875-1,300 
30-45      900-1,400 
35-45  1,085-1,400 

How  and  Where  to  Begin. — With  young  infants  having  presumably 
normal  digestion  it  is  desirable  to  begin  with  weak  formulas,  such  as 
No.  V  of  C  or  D,  with  sugar  raised  to  5  or  6  per  cent. 

The  same  strength  should  be  used  for  a  few  days  to  test  the  child's 
digestion.  For  a  healthy  infant  of  eight  pounds  weight,  two  weeks  old, 
one  should  begin  with  2|  ounces  at  a  feeding  and  feed  eight  times  a 
day,  interval  between  feedings  two  and  a  half  hours.  The  quantity  for 
one  feeding  can  soon  be  increased  to  3,  then  to  3|  ounces. 

For  a  smaller  or  less  vigorous  child,  one  should  begin  with  No.  IV 
of  C  or  D  and  give  1^  or  2  ounces  at  the  same  intervals,  increasing  the 
quantity,  however,  more  slowly. 

For  a  healthy  child  with  normal  digestion,  weaned  at  four  or  five 


ARTIFICIAL  FEEDING.  191 

months,  one  should  begin  with  No.  VI  of  B  or  C  and  give  a  larger 
quantity,  i.  e.,  4|  to  6  ounces  at  three-hour  intervals,  and  increase  the 
strength  more  rapidly  than  with  a  younger  infant. 

For  one  weaned  at  nine  or  ten  months  one  should  begin  with  No. 
VII  of  B  or  C,  6  or  7  ounces  at  a  feeding  and  increase  both  strength 
and  quantity  rather  rapidly. 

A  stationary  weight  for  a  week  or  two,  or  even  a  loss  of  a  few  ounces, 
is  of  no  importance,  provided  the  change  in  diet  can  be  effected  without 
deranging  digestion ;  for  as  soon  as  a  child  becomes  accustomed  to  cow's 
milk  the  percentages  can  be  raised,  and  progress  is  assured.  Nothing 
is  easier  than  to  derange  the  digestion  in  the  beginning  by  the  use  of 
too  strong  food ;  such  disturbances,  though  they  may  not  be  severe,  often 
continue  for  many  weeks  (Fig.  30).  The  closest  attention  is  required 
in  the  beginning.  If  a  good  start  is  made,  subsequent  progress  is  easy ; 
but  with  a  bad  start  there  is  likely  to  be  trouble  most  of  the  time.  As 
soon  as  an  infant's  capacity  to  digest  cow's  milk  is  ascertained,  the  food 
can  be  increased  accordingly. 

Indications  for  Increasing  the  Food. — While  it  is  important  to  begin 
with  low  percentages,  it  is  a  serious  mistake  to  continue  long  with  them. 
The  power  of  digestion  is  strengthened  by  gradually  increasing  the  work 
the  organs  are  given  to  do.  Abrupt  increases  are  almost  certain  to 
disturb  digestion.  A  proper  rate  of  increase  of  the  fat  and  protein  is 
indicated  in  the  table  of  formulas  reading  downward  in  the  different 
columns. 

How  rapidly  the  increase  is  made  will  vary  much  with  the  individual 
infant.  With  a  vigorous  child,  above  average  weight,  with  good  diges- 
tion, the  strength  may  be  increased  rather  rapidly,  and  also  the  quantity 
given  at  one  feeding.  With  a  small  or  delicate  child,  or  one  with  feeble 
digestion,  one  must  advance  much  more  slowly  both  with  respect  to  the 
strength  and  quantity  of  food.  No  greater  mistake  can  be  made  than 
to  attempt  to  measure  the  increase  in  food  by  the  age  of  the  child.  We 
can  not  raise  the  percentages  every  week  or  every  month  regardless  of 
other  conditions.  The  progress  in  weight  is  important,  yet  one  should 
not  be  guided  by  it  alone  in  increasing  the  food.  With  the  weak  food 
necessary  at  first  no  material  gain  in  weight  is  to  be  expected.  How- 
ever, if  there  is  no  vomiting  or  colic,  if  the  child  is  entirely  comfortable 
and  sleeps  most  of  the  time,  and  if  the  stools  have  a  normal  colour 
and  odour,  conditions  may  be  considered  satisfactory.  The  food  may 
be  cautiously  strengthened  with  the  demands  of  the  child's  appetite, 
and  soon  the  increase  in  weight  will  begin,  and  when  once  begun  it  is 
likely  to  continue.  On  the  contrary,  if  the  weight  is  made  the  chief 
concern,  there  is  a  constant  temptation,  when  the  child  is  not  gaining  as 
rapidly  as  the  mother  thinks  he  should,  to  increase  the  food,  regardless  of 
conditions  and  beyond  his  requirements,  usually  with  the  result  of  seri- 


192 


NUTRITION. 


ously  disturbing  the  digestion.  The  best  of  all  guides  to  increasing  food 
is  the  child's  demonstrated  powers  of  digestion.  If  the  child  is  not  satis- 
fied and  digesting  well  it  is  usually  safe  to  increase  the  food.  But  such 
increases  should  seldom  be  made  more  frequently  than  once  in  three  days. 
In  increasing  the  quantity,  it  is  not  wise  to  add  more  than  half  an 
ounce  to  each  feeding.  During  the  early  weeks  both  the  quantity  and 
the  strength  of  the  food  should  be  increased  every  few  days.    It  may  be 


WEEK 

OFAOE2     4     6     8    10   12   14  16   18  2022242628303234363840424446485052 

23 
22 
21 
20 

le 

18 

17 

„I6 

a 

|,6 

2'* 

13 
12 
1  1 
10 

g 

8 

7 
6 

u          .-■' 

U-H^--- 

/ 

J.            

^ 

• 

f 

■' 

' 

* 

^ 

/ 

/ 

/■ 

^ 

-y 

-^ 

/ 

f 

^ 

/" 

^ 

•■'■ 

y 

- 

'^ 

-^ 

^ 

^ 

y 

/ 

-' 

' 

y 

-^ 

J 

f 

/> 

_ 

-I' 

V 

/ 

' 

A 

i' 

1 

/ 

1 

/ 

1 

/* 

• 

... 

FiQ.  30. — Weight  Curve  of  Artificially  Fed  Infant,  showing  the  Effect  of  Be- 
ginning WITH  too  High  Percentages.  Robu.st  child;  digestion  deranged  when  a 
few  days  old  by  beginning  with  fat  2  per  cent,  sugar  6  per  cent,  protein  0.75  per  cent; 
food  in  two  or  three  days  was  increased  to  fat  3  per  cent,  sugar  6  per  cent,  protein 
1  per  cent.  A  good  deal  of  indigestion  resulted,  and  the  disturbance  was  such  that 
it  was  eight  weeks  before  the  digestion  became  normal  and  the  gain  in  weight  regular ; 
progress  for  the  rest  of  the  year  satisfactory. 


difficult  to  tell  which  of  these  it  is  best  to  do.  It  is  well  to  alternate; 
thus,  when  the  infant  requires  more  food,  first  to  increase  the  quantity; 
then,  after  a  few  days,  if  still  unsatisfied,  to  increase  the  strength ;  the 
next  time,  to  increase  the  quantity  again,  etc.  In  this  way  will  be 
avoided  the  error  into  which  mothers  and  nurses  often'  fall,  who  adopt  a 
single  formula  and  keep  on  simply  increasing  the  quantity  indefinitely 
whenever  the  child  is  unsatisfied.  I  have  frequently  seen  infants  of  two 
or  three  months  taking  as  much  as  7  or  8  ounces  every  two  hours,  and 
even  then  crying  from  hunger.  After  a  daily  total  of  32  to  36  ounces 
is  reached,  as  happens  with  most  infants  by  the  fourth  month,  the  in- 
crease in  the  food  should  be  chiefly  in  strength ;  for  the  same  child  at 
eight  months  will  rarely  require  more  than  40  to  45  ounces. 


ARTIFICIAL  FEEDING.  193 

A  caution  is  necessary  against  changing  the  formula  too  frequently. 
It  is  not  possible  to  modify  the  milk  in  such  a  way  as  to  relieve  every 
trivial  discomfort  or  disturbance  an  infant  may  have.  Nurses  are  usu- 
ally ready  to  ascribe  every  slight  symptom  to  the  food,  particularly  if 
they  have  strong  opinions  of  their  own  upon  the  subject  of  feeding,  and 
are  not  in  full  sympathy  with  the  method  employed.  Very  often  the 
cause  is  outside  of  the  food  and  even  of  the  organs  of  digestion.  Unless 
some  very  definite  symptoms  of  indigestion,  such  as  severe  colic,  vom- 
iting, etc.,  are  produced  by  the  formula  ordered,  it  is  usually  better  to 
continue  with  it  for  at  least  two  days,  as  it  is  hardly  possible  in  a  shorter 
time  to  determine  what  the  child's  digestive  organs  are  capable  of  doing. 
For  slight  disturbances  of  a  transient  nature  it  is  usually  enough  to 
dilute  the  food  for  a  day  or  more;  just  before  the  bottle  is  given,  one 
ounce  or  more  of  milk  may  be  poured  off  and  replaced  by  boiled  water. 

Methods  of  increasing  the  Fat  and  Protein. — To  increase  the  fat  and 
protein  at  the  same  time,  one  more  ounce  of  the  milk  already  employed 
is  added  in  the  20-ounce  mixture.  In  other  words,  one  uses  successively 
No.  IV,  V,  VI,  etc.,  of  series  A,  B,  or  C,  etc. 

To  raise  the  fat  without  raising  the  protein,  one  should  use  the  same 
numl)er  of  ounces,  but  employ  a  milk  with  a  higher  fat  content ;  e.  g., 
one  is  using  No.  VI,  series  D,  with  fat  1 .  20,  protein  1 .  05.  The  fat  is 
raised  to  1 .  50,  by  using  a  5-per-cent  milk  in  place  of  a  4-per-cent  milk ; 
to  1 .  80,  by  using  a  6-per-cent  milk ;  to  2 .  10,  by  using  a  7-per-cent  milk. 

To  raise  the  protein  without  increasing  the  fat,  a  larger  number  of 
ounces  in  twenty  are  used,  but  of  a  milk  with  a  lower  fat  content ;  e.  g., 
one  is  using  No.  IV,  series  A,  fat  1 .  40  per  cent,  protein  0 .  70  per  cent. 
The  protein  is  raised  to  0 .  85  by  using  5  ounces  of  series  B ;  to  1 .  05,  by 
using  6  ounces  of  series  C ;  to  1 .  20,  by  using  7  ounces  of  series  D,  etc. 
Although  the  fat  in  this  is  not  exactly  the  same  the  variation  is  so  slight 
that  it  may  be  ignored. 

Conditions  determining  the  choice  of  MilJc  Formulas. — It  has  al- 
ready been  stated  that  with  a  healthy  young  infant  one  should  begin  with 
protein  of  not  over  1  per  cent  and  .fat  of  1.00  or  1.25  per  cent.  With 
formulas  derived  as  these  are,  from  4-  and  5-per-cent  milk,  respectively, 
very  many  infants  can  be  successfully  carried  through  the  first  year  by 
merely  increasing  the  number  of  ounces  of  the  milk  in  the  formula  ac- 
cording to  the  gradations  given  in  the  table.  Most  healthy  infants, 
however,  with  the  percentage  of  protein  which  we  wish  to  give,  can  take 
a  higher  percentage  of  fat  than  is  given  in  formulas  from  4-  or  5-per- 
cent milk.  It  is  therefore  advantageous  and,  from  a  point  of  view  of 
nutrition,  it  is  economical,  to  give  them  a  higher  fat  percentage,  such  as  is 
obtained  by  using  formulas  derived  from  6-  or  7-per-cent  milk.  The 
fat  percentage  in  the  food  as  given  should  not,  however,  be  raised  above 
4  per  cent,  and  under  most  circumstances  it  is  wise  to  stop  somewhat 
14 


194  NUTRITION. 

below  this.  When  formulas  containing  the  higher  fats,  such  as  those 
mentioned,  cause  vomiting,  loss  of  appetite,  or  symptoms  of  intestinal 
indigestion,  they  should  be  immediately  discontinued  and  formulas  de- 
rived from  milks  of  lower  fat  percentage  substituted. 

Children  with  feeble  digestion  or  those  suffering  from  disturbances 
of  digestion  should  not  be  placed  upon  formulas  derived  from  milk  con- 
taining 7,  6,  or  5  per  cent  of  fat.  Often  with  advantage  they  may  be 
put  upon  formulas  derived  from  milk  containing  even  less  fat  than 
does  whole  milk.  Tlie  special  indications  for  such  children  will  be  con- 
sidered more  fully  later. 

To  Reduce  Milk  Formulas  to  Percentages. — In  order  to  appre- 
ciate the  composition  of  any  milk  formula  which  a  patient  may  be  taking 
it  is  necessary  to  reduce  this  to  its  approximate  percentages.  One  who 
forms  the  habit  of  making  such  calculations  soon  finds  it  easy,  and  se- 
cures a  basis  for  comparison  with  the  percentages  given  as  proper  for 
the  average  normal  child.  A  simple  method  of  calculation  is  as  fol- 
lows :  To  determine  the  percentage  of  any  constituent  in  the  food,  multi- 
ply its  percentage  in  the  original  milk,  cream,  or  top-milk  by  the  num- 
ber of  ounces  of  each  in  the  food,  and  divide  by  the  total  number  of 
ounces  of  food  prepared.^ 

'  A  patient  is  taking  a  formula  comiwsed  of  cream  4  ounces,  milk  16  ounces,  milk 
sugar  13^  ounces,  in  a  mixture  containing  36  ounces.  The  cream  is  ordinary  centrif- 
ugal cream,  estimated  to  have  20  per  cent  fat;  the  milk  is  good  average  milk,  estimated 
to  have  4  per  cent  fat. 

4  X  20  =  80,  which  represents  the  fat  in  the  cream 
16  X    4  =  M,       "  "  "     "    "     "  milk 

144,       "  "  "    "    "     "  total  food 

144  -i-  36  (mmaber  of  ounces  of  food)  =  4,  the  percentage  of  fat  in  the  food. 
The  protein  is  calculated  in  the  same  way.     In  the  illustration  we  estimate  the 
protein  of  20  per  cent  cream  at  3.05;  in  the  whole  milk,  at  3.50  per  cent. 
4  X  3.05  =  12.20,  which  represents  the  protein  in  the  cream 
16  X  3.50  =  56.00,      "  "  "  "      "     "  milk 

68.20,      "  "  "  "      "  . "  total  food 

68.20  -f-  36  =  1.90,  the  percentage  of  protein  in  the  total  food. 
In  a  similar  way,  sugar  is  calculated.     The  sugar  of  a  20  per  cent  cream  may  be 
estimated  at  3.90;  in  the  milk,  4.50  per  cent. 

4  X  3.90  =  15.60,  which  represents  the  sugar  in  the  cream 
16  X  4.50  =  72.00,      "  "  "        "     "     "    milk 

87.60,      "  "  "        "     "     "    total  food 

87.60  -j-  36  (number  of  ounces  of  food)  =  2.40,  the  percentage  of  sugar  in  the 
food  before  any  is  added. 

To  add  1 1^2  ounces  to  a  36-ounce  mixture  adds  approximately  4  per  cent  of  sugar; 
for  1.5  is  4  per  cent  of  36  [1.5  ^  36  =  .04]. 

The  total  sugar  in  the  mixture  therefore  is  2.40  +  4,  or  6.40  per  cent. 

The  formula  contains  therefore,  approximately,  4  per  cent  of  fat,  1.90  per  cent  of 
protein,  6.40  per  cent  of  sugar. 


ARTIFICIAL   FEEDING.  195 

Special  Modifications  Kequired  by  Particular  Symptoms. — 
Most  of  the  children  for  whom  the  physician's  advice  is  sought  in  mat- 
ters of  feeding  are  not  thriving,  or,  besides,  are  suffering  fr.om  some  evi- 
dent symptoms  of  indigestion,  and  for  these  reasons  changes  in  the  food 
are  required.  In  adapting  milk  for  such  cases  one  must  rid  his  mind 
entirely  of  the  notion  that  the  food  can  be  prescribed  according  to  the 
child's  age  or  even  its  weight,  although  both  must  be  taken  into  account. 
The  essential  thing  is  the  condition  of  the  digestive  organs,  and  unless 
this  is  carefully  considered,  failure  is  almost  inevitable.  To  decide  as 
to  the  proportions  with  which  it  is  best  to  begin  one  must  know,  besides 
the  age  and  weight,  the  nature  and  quantity  of  the  food  which  has  been 
taken,  the  appetite,  the  number  and  character  of  the  stools,  and  also 
whether  digestive  symptoms  are  present,  such  as  vomiting,  flatulence, 
diarrhoea,  colic,  or  constant  discomfort.  In  any  case  the  first  prescrip- 
tion is  somewhat  in  the  nature  of  an  experiment,  but  if  the  symptoms 
have  been  intelligently  judged  the  experiment  is  likely  to  prove  suc- 
cessful. 

Even  with  infants  who  are  properly  fed  there  are  few  whose  diges- 
tion remains  perfectly  normal  throughout  the  entire  first  year.  Changes 
in  the  food  are  therefore  necessary  from  time  to  time,  even  in  the  most 
healthy,  to  meet  special  symptoms  which  may  arise.  Many  of  these  are 
due  to  disturbances  of  a  minor  character,  but  are  none  the  less  important, 
as  they  may  lead  to  serious  consequences  when  not  immediately  recog- 
nised and  properly  treated. 

Vomiting. — The  common  causes  of  habitual  vomiting  referable  to 
the  food  are:  too  high  fat  or  too  high  sugar,  especially  if  the  sugar  is 
either  maltose  or  cane  sugar,  too  frequent  feedings  and  too  much  food  at 
one  time.  Frequent  vomiting  or  regurgitation,  often  one  or  two  hours 
after  feeding,  of  curdled  milk  or  of  a  sour,  watery  fluid,  is  usually  an 
indication  that  the  proportion  of  fat  is  too  high.  Sometimes  it  is  the 
sugar  that  is  in  excess,  and  sometimes  both  fat  and  sugar  are  at  fault. 
The  first  indication  is  to  reduce  the  fat.  Formulas  from  top-milk  or 
milk  and  cream  should  not  be  used,  but  rather  formulas  from  whole 
milk ;  and  if  the  vomiting  is  frequent,  formulas  from  skimmed  milk  are 
advisable  for  temporary  use,  afterward  those  from  whole  milk.  If  a 
reduction  of  the  fat  does  not  give  relief  the  sugar  should  also  be  reduced 
and  neither  maltose  nor  cane  sugar  should  be  used.  Other  changes 
which  are  sometimes  helpful  are  to  use  twice  the  usual  amount  of 
lime-water,  making  this  10  per  cent,  or  2  ounces  in  each  20-ounce 
mixture. 

An  infant  who  vomits  often  should  not  be  fed  at  shorter  intervals 
than  three  hours,  even  if  only  two  or  three  weeks  old.  If  considerable 
quantities  are  ejected  almost  immediately  after  feeding,  it  is  usually 
because  too  much  food  has  been  given.    Other  caufees  must  be  considered 


196  NUTRITION. 

also — the  food  may  be  too  rapidly  taken,  the  child  may  be  moved  about 
too  much,  the  abdominal  band  may  be  too  tight,  etc. 

Constipation. — The  principal  causes  of  constipation  referable  to  the 
food  are  too  low  total  solids  and  too  low  fat.  Habit  and  general  train- 
ing are  also  important  factors.  Sterilisation,  and  to  a  slight  degree 
pasteurisation,  cause  milk  to  be  somewhat  constipating.  During  the  first 
few  weeks,  if  the  percentages  are  low,  there  is  often  a  species  of  consti- 
pation present  which  is  simply  the  result  of  the  low  total  solids  in  the 
food  given.  The  bowels  usually  move  every  day,  sometimes  even  twice  a 
day;  but  the  stools  are  often  small  and  rather  dry.  Unless  there  is 
manifest  discomfort  on  the  part  of  the  child,  such  a  condition  may  be 
disregarded,  especially  if  the  odour  and  colour  of  the  discharges  are 
nearly  normal.  As  the  proportions  of  all  the  elements  of  the  food  are 
gradually  increased  along  the  general  lines  previously  indicated,  this 
form  of  constipation  passes  away.  Mothers  and  physicians  often  expect 
that  the  bottle-fed  infant  will  have  during  its  first  month  or  two  the  two 
or  three  large  stools  daily  to  which  they  have  been  accustomed  with 
healthy  breast-fed  infants.  But  finding  instead  only  one  movement  a 
day,  and  that  small  and  sometimes  dry,  they  resort  to  laxatives  or 
enemata,  and  by  their  use  really  cause  much  of  the  trouble  they  are  seek- 
ing to  remove. 

The  low  fat  is  often  the  explanation  of  the  constipation  seen  when 
infants  are  fed  upon  formulas  derived  from  whole  milk.  If  such 
is  the  case  relief  may  sometimes  be  afforded  by  changing  to  formulas 
made  from  milk  containing  6  or  7  per  cent  fat.  The  increase  in  the 
fat  to  overcome  constipation  can  only  be  carried  up  to  a  certain  point; 
this  is  generally  2.5  or  3  per  cent  for  a  young  infant  and  3 . 5  or  4  per 
cent  for  one  who  is  older.  If  the  fat  is  raised  beyond  this  other  dis- 
turbances of  digestion,  particularly  vomiting,  are  likely  to  result,  and 
sometimes  there  may  even  be  an  increase  in  the  constipation.  Some 
other  means  of  overcoming  the  constipation  should  be  resorted  to. 

The  substitution  of  the  milk  of  magnesia  for  lime-water  in  milk 
modifications  is  often  of  service.  It  may  be  continued  for  several 
months  without  harm.  One  teaspoonful  added  to  the  total  food  for  the 
day  is  usually  sufficient ;  this  amount  may  be  slightly  increased  or 
lessened  according  to  the  effect  produced. 

Milk  sugar  is  somewhat  laxative  and  the  raising  of  the  proportion 
of  this  ingredient  as  high  as  7  per  cent,  if  a  smaller  proportion  is  being 
used,  will  often  be  all  that  is  needed.  Maltose  is  much  more  laxative  in 
its  effect,  and  may  be  substituted  wholly  or  in  part  for  milk  sugar.  Its 
use  will  be  more  fully  discussed  later.  It  should  not  be  given  if  there 
is  vomiting. 

Colic  and  Flatulence. — The  habitual  colic  of  early  infancy  may  occur 
with  any  form  of  intestinal  indigestion;  its  causes  therefore  are  varied. 


ARTIFICIAL  FEEDING.  197 

Colic  and  flatulence  are  especially  common  in  infants  who  suffer  from 
constipation.  Excessive  flatulence  may  occur  also  when  cereal  gruels 
are  added  to  the  milk  of  young  infants,  particularly  if  the  amount  is 
considerable  and  if  the  cereal  is  insufficiently  cooked.  If  symptoms  are 
severe  a  reduction  in  all  the  elements  of  the  food  may  be  necessary. 

"  Curds  "  in  the  Stools. — The  undigested  masses  appearing  in  the 
stools  of  infants  taking  milk  are  usually  spoken  of  as  "  curds."  These 
may  be  small,  soft,  and  white,  and  may  make  up  a  large  part  of  the 
stool.  An  excess  of  mucus  is  usually  present.  Such  masses  are  com- 
posed almost  entirely  of  fat.  There  are  also  seen,  but  much  less  fre- 
quently, larger,  smooth,  hard  masses  of  a  yellowish-brown  colour,  but 
white  on  section.  They  are  generally  present  in  small  numbers  in  a  stool 
the  rest  of  which  may  be  quite  normal.  These  are  composed  chiefly  of 
protein,  usually  with  an  envelope  of  fat.  Curds  of  the  first  variety, 
if  numerous,  call  for  a  considerable  reduction  in  the  fat  percentage. 
The  smooth,  hard  curds,  if  numerous  and  persistent,  should  lead  one  to 
reduce  the  protein  at  least  temporarily. 

Loose,  Green,  or  Yellowish-green  Stools  of  a  Sour  Odour. — These  are 
sometimes  due  to  too  high  a  percentage  of  sugar,  especially  lactose,  often 
to  an  excess  of  fat.  The  number  of  stools  is  usually  from  two  to  five 
daily.  In  appearance  the  stools  resemble  thin  scrambled  eggs.  Stools 
such  as  those  described  are  often  seen  in  nursing  infants  as  well  as  in 
those  artificially  fed,  and  the  condition  is  not  incompatible  with  steady 
and  regular  gain  in  weight.  After  it  has  persisted  any  length  of  time 
mucus  is  regularly  present. 

Large,  Dry,  Clayey  Stools.- — These  are  often  smooth,  and  are  gener- 
ally due  to  an  excess  of  fat.  They  have  usually  a  peculiarly  foul  odour, 
owing  to  the  presence  of  fatty  acids. 

No  Gain  in  Weight  without  evident  Symptoms  of  Indigestion. — This 
is  sometimes  due  to  too  weak  food,  all  the  percentages  being  too  low, 
the  child  usually  manifesting  signs  of  hunger.  Occasionally  it  is  due  to 
the  fact  that  all  the  percentages,- particularly  that  of  the  fat,  are  too  high. 
In  the  latter  case  it  frequently  happens  that  the  appetite  is  much  re- 
duced, so  that  the  infant  takes  perhaps  less  than  half  his  usual  allow- 
ance. A  considerable  reduction  in  the  fat  and  an  increase  in  the  sugar, 
particularly  the  addition  of  maltose,  will  often  lead  to  immediate  im- 
provement. The  amount  used  should  at  first  be  small,  not  more  than 
two  or  three  drachms  to  the  day's  food,  and  gradually  increased  to  half 
an  ounce  or  an  ounce  a  day.  Too  frequent  feedings  and  the  practice 
of  constantly  coaxing  the  infant  to  take  more  food,  often  produce  the 
same  aversion  to  food.  It  is  much  better  to  offer  food  at  three  or  four 
hour  intervals  and  take  away  the  bottle  as  soon  as  the  child  shows  that 
he  does  not  want  more. 

Modifications  in  the  food  to  meet  the  indications  afforded  by  more 


198  NUTRITION. 

serious  conditions  than  those  here  described  are  considered  in  the  later 
pages  devoted  to  Difficult  Cases  of  Feeding. 

The  Apparatus  Required  for  the  Preparation  of  Milk  at 
Home. — This  includes  a  glass  graduate,  a  glass  or  agate  funnel,  a  cream 
dipper,  a  pitcher  for  mixing  food,  feeding-bottles,  a  tall  cup  for  warm- 
ing the  food,  a  small  ice-box,  and  a  steriliser.  Other  articles  needed  are 
lime-water,  milk  sugar,  rubber  nipples,  absorbent  cotton,  bottle-brushes, 
borax  or  boric  acid,  bicarbonate  of  soda,  and  an  alcohol  lamp,  or  better, 
if  gas  is  available,  a  Bunsen  burner.  The  best  style  of  bottle  is  that 
which  can  be  most  readily  cleaned.  The  graduated  cylindrical  bottles 
with  wide  mouths  are  to  be  preferred.  The  best  nipples  are  those  of 
plain  black  rubber,  which  slip  over  the  neck  of  the  bottle,  and  are  not  so 
thick  as  to  prevent  their  being  turned  inside  out  for  cleansing.  Those 
with  a  long  rubber  tube  going  to  the  bottom  of  the  bottle  should  not  be 
used.  In  many  places  their  use  is  prohibited  by  law.  The  hole  in  the 
nipple  should  be  large  enough  for  the  milk  to  drop  rapidly  when  the 
bottle  is  inverted,  but  not  so  large  that  it  will  run  in  a  stream.  Xew 
nipples  should  be  boiled ;  but  the  daily  boiling  of  nipples  is  unnecessary. 
It  soon  makes  them  so  soft  as  to  be  useless.  They  should  be  rinsed 
in  cold  water  immediately  after  using  and  washed  daily  in  soap  and 
water.  When  not  in  use,  nipples  should  be  kept  covered  in  a  solution 
of  borax  or  boric  acid.  Bottles  should  first  be  rinsed  with  cold  Avater, 
then  washed  with  hot  soap-suds  and  a  bottle-brush.  When  not  in  use 
they  should  stand  full  of  water.  Before  the  milk  is  put  into  them  they 
should  again  be  placed  in  boiling  water  for  a  few  minutes. 

Directions  foe  Preparing  the  Food. — All  the  food  needed  for 
twenty-four  hours  should  be  prepared  at  one  time.  The  first  thing  to  be 
decided  is  the  formula  to  be  used ;  next,  the  quantity  of  food  for  twenty- 
four  hours  with  the  number  of  feedings  into  which  it  is  to  be  divided. 

Let  us  suppose,  for  example,  that  the  child  to  be  fed  is  a  normal 
three-months-old  infant  weighing  twelve  pounds.  Referring  to  the 
table  of  formulas  previously  given,  we  first  decide  upon  the  percentage 
of  protein  to  be  used ;  1.20  or  1 .  40  per  cent  would  seem  appropriate. 
By  referring  to  the  figures  in  the  column  on  the  extreme  left  we  see 
that  1,40  per  cent  of  protein  is  obtained  by  using  8  ounces  in  20  of  any 
of  the  various  milks.  We  may  obtain  2.80  per  cent  of  fat  if  we  start 
with  7-per-cent  milk;  2,40  per  cent  of  fat  if  we  start  with  6-per-cent 
milk ;  2  per  cent  of  fat  if  we  start  with  5-per-cent  milk,  etc.  It  is  prob- 
able that  such  a  child  as  that  mentioned  could  take  2.80  per  cent  of  fat 
without  difficulty.  Instead,  however,  of  using  this  at  the  outset,  a  safer 
plan  would  be  to  start  with  2  per  cent,  and  later,  if  this  was  well  borne, 
raise  the  proportion  gradually  to  2.40  and  2.80  per  cent.  A  mixture 
having  2  per  cent  of  fat  and  1 .  40  per  cent  of  protein  is,  as  seen  from 
the  table,  obtained  by  diluting  5-per-cent  milk. 


ARTIFICIAL   FEEDING. 


199 


The  proper  amount  of  sugar  would  be  G  per  cent.  The  milk  having 
1.40  per  cent  of  protein  has  but  1.8U  per  cent  of  sugar.  It  is  therefore 
necessary  to  add  4.30  per  cent,  to  bring  the  proportion  up  to  the  desired 
amount.  Since  one  even  tablespoonful  in  20  ounces  adds  1.75  per  cent 
of  sugar,  about  two  and  a  half  tablespoonfuls  in  30  will  be  needed. 

The  formulas  would  therefore  be : 


For  20  ounces. 

For  30  ounces. 

For  40  ounces. 

5-per-cent  milk 

Milk  sugar 

Lime  water     

8oz. 

2|  even  tablesp'ls 
1  oz. 
11  oz. 

12  OZ. 

3i  even  tablesp'ls 
1§  oz. 
16^  oz. 

16  oz. 

5  even  tablesp'ls 
2  oz. 

Water 

22  oz. 

20  oz. 

30  oz. 

40  oz. 

Such  a  child  as  the  one  assumed  would  probably  take  seven  feedings 
of  5  ounces  each.^  It  would  be  well  to  prepare  40  ounces  of  food  and 
have  one  extra  bottle  on  hand  in  case  of  accident. 

The  milk  sugar  should  be  dissolved  in  boiled  water,  which  is  then 
mixed  with  the  milk  in  a  pitcher  and  the  lime-water  added.  The  food 
is  now  divided  into  the  seven  bottles,  which  are  stoppered  with  cotton. 
They  are  placed  at  once  in  an  ice  chest,  or  first  sterilised,  then  cooled, 
and  afterward  placed  upon  ice. 

Directions  for  Feeding. — The  food  should  be  warmed  to  about 
100°  F.  before  feeding,  best  by  placing  the  bottle  in  a  tall  pitcher  or 
cup  filled  with  hot  water,  not  by  pouring  the  food  from  the  bottle  into 
a  saucepan.  The  temperature  of  the  food  may  be  tested  by  the  nurse 
with  a  thermometer,  or  by  pouring  a  few  drops  upon  the  front  of  the 
wrist;  it  should  feel  warm,  but  not  hot.  The  nurse  should  never  take 
the  nipple  of  the  bottle  into  her  own- mouth.  A  bottle  should  not  be 
warmed  over  for  a  second  feeding.  A  child  should  not  be  more  than 
twenty  minutes  in  taking  its  food,  and  should  not  sleep  with  the  nip- 
ple of  the  bottle  in  his  mouth.  It  is  preferable  to  have  a  young  infant 
held  while  taking  his  bottle.  If  this  is  not  done,  the  bottle  should  at 
least  be  held  in  such  a  position  that  the  neck  of  the  bottle  is  kept  full, 
so  that  the  child  gets  milk,  and  not  air.  It  is  even  more  necessary  than 
in  breast-feeding  that  rules  as  to  frequency  and  regularity  of  meals  be 
observed. 

The  Use  of  other  Food  than  Milk  during  the  First  Year. — In  the  dis- 
cussion up  to  this  point  nothing  but  the  elements  of  milk  has  been  con- 
sidered.    Upon  these  alone  tlie  average  healthy  infant  is  best  nourished 


^  Calculating  the  calories  in  the  food  offered,  by  the  use  of  the  table  of  caloric 
values  already  given,  it  will  be  found  that  the  35  ounces  of  food  will  furnish  about 
510  calories,  which  will  represent  about  95  calories  per  kilo,  of  body  weight 


200  NUTRITION. 

for  the  first  four  or  five  months.  The  use  of  the  various  cereals  as  an 
addition  to  the  milk  for  young  infants  is  a  useful  measure  for  some 
infants,  but  not  desirable  for  all.  The  early  use  of  much  farinaceous 
food  often  results  in  serious  harm. 

For  the  average  healthy  infant  it  is  desirable  to  begin  with  farina- 
ceous food  in  some  form  by  the  fifth  or  sixth  month.  By  this  time  the 
power  of  digesting  starch  is  sufficiently  strong  for  the  infant  to  receive 
some  of  its  carbohydrates  in  this  form,  instead  of  all  of  it  in  the  form 
of  sugar,  as  has  been  previously  the  case.  As  starch  is  added,  the  sugar 
may  be  gradually  reduced.  The  form  of  starch  used  may  be  a  gruel 
made  of  wheat,  barley,  oatmeal,  or  arrowroot.  This  will  take  the  place 
of  part  or  all  of  the  boiled  water  in  the  preparation  of  the  food.  It  is 
thus  given  with  each  of  the  feedings.  By  the  eleventh  or  twelfth  month 
the  quantity  of  the  cereal  may  be  considerably  increased. 

The  only  other  things  to  be  advised  during  the  first  year  are  beef 
juice  and  the  juice  of  some  fresli  fruit.  Beef  juice  may  be  begun  in  the 
tenth  or  eleventh  month,  earlier  with  anaemic  children;  at  first  not  more 
than  two  teaspoonfuls  daily,  later  the  amount  may  be  increased.  The 
best  fruit  juice  is  that  of  the  orange,  which  should  be  fresh  and  sweet. 
It  may  with  advantage  be  given  to  most  infants  ten  months  old,  and  to 
many  when  seven  or  eight  months  old.  Beginning  with  half  an  ounce, 
the  quantity  may  be  gradually  increased  to  two  ounces,  given  preferably 
about  one  hour  before  the  second  milk-feeding. 

The  Tolerance  of  Healthy  Infants  for  the  Different  Food  Elements. — ■ 
In  the  foregoing  pages  we  have  indicated  the  percentages  which,  in  our 
experience,  have  been  shown  in  the  majority  of  instances  to  be  the  best 
for  feeding  healthy  infants.  However,  Nature  will  often  tolerate  very  wide 
variations  from  what  is  best.  The  desire  for  a  rapid  increase  in  weight 
often  leads  to  an  increase  of  the  fat  in  the  food  much  beyond  the  limits 
which  are  usually  considered  safe.  There  are  some  children  of  vigorous 
constitution  and  strong  digestion,  living  under  good  surroundings,  who 
tolerate  this  for  a  long  time;  some  may  even  go  through  infancy  to  a 
period  of  mixed  diet  without  any  visible  disturbance,  and  appear  to 
thrive  exceedingly  well.  There  are  others  who  bear  such  high  fat  pro- 
portions for  a  considerable  time  and  then  show  serious  disturbances. 
They  thrive  so  long  as  all  the  other  conditions  are  perfect;  but  the 
slightest  deviation  from  these  conditions,  as,  for  example,  some  mild 
intercurrent  illness,  tonsillitis,  bronchitis,  etc.,  possibly  so  slight  a  thing 
as  dentition,  may  bring  about  an  acute  condition  which  may  be  of  a 
most  alarming  character.  Most  frequently  it  is  the  advent  of  very  hot 
weather  which  is  the  occasion  of  the  breakdown.  There  are  others  who 
are  upset  almost  from  the  beginning  if  liigh  proportions  of  fat  are  used. 
Still  others  gradually  develop  subacute  or  chronic  disturbances  of  di- 
gestion and  nutrition  which  may  last  for  months.     What  is  true  of  the 


FEEDING   IN   DIFFICULT   CASES. 


201 


use  of  excessive  amounts  of  fat  is  true  to  a  less  degree  of  tlie  sugar  and 
very  rarely  of  protein  also.  One  should  be  very  cautious,  therefore,  in 
inferring  that,  because  a  few  exceptionally  strong  infants  thrive  on 
unusual  proportions  or  excessive  amounts  of  some  one  of  the  food  ele- 
ments, this  is  to  be  taken  as  a  guide  in  feeding  the  average  child. 

FEEDING   IN   DIFFICULT   CASES. 

There  are  included  under  this  head,  infants  who,  owing  to  feeble 
digestion  or  individual  peculiarities,  do  not  thrive,  even  from  the  out- 
set, upon  the  usual  milk  modifications,  although  they  may  be  used  in- 


Of  AGE  2  4  6  8  1  0  1  2  1 4  1  6  1 8  20  22  24  26  28  30  32  34  36  38  40  42  44  46  48  SO  62 

26 
24 
23 
22 
21 
20 
10 
18 
gl7 
1.6 
Sl6 
14 
13 
12 
1  1 

to 

9 
8 

7 

1 

-P-- 

/ 

n 

/ 

u 

/ 

i 

3 

/ 

1;; 

1 

f- 

a 

/ 

u 

y 

/ 

^ 

Ul 

3 

^ 

^ 

/ 

^ 

3 

/ 

■' 

Z 

'< 

,/ 

Z 

^ 

^ 

^ 

i 

= 

= 

■> 

H 

/ 

< 

/ 

^ 

-^ 

- 

-^^ 

B 

/ 

-■ 

> 

£ 

A 

-^ 

X 

P 

'' 

■^ 

/ 

y 

y 

/ 

-^ 

- 

/ 

/ 

/ 

/ 

/ 

, 

/ 

^ 

- 

^ 

/ 

/ 

J 

^ 

^ 

_j 

1 

FiG.  31. — Weight  Chart  showing  the  Effect  of  Intelligent  Care.  Maternal  nurs- 
ing in  the  beginning;  A,  began  part  feeding;  B,  attack  of  indigestion;  C,  weaned  en- 
tirely. The  departure  and  return  of  the  trained  nurse  are  indicated  upon  the  chart. 
In  the  interval  there  was  constant  indigestion  for  which  no  sufficient  explanation 
could  be  found  in  the  food.  Subsequently  this  was  discovered  to  be  due  to  the  care- 
lessness and  neglect  of  the  nurse.  Immediate  improvement  on  the  return  of  the 
trained  nurse  without  any  important  change  in  the  food.  It  will  be  noticed  that 
during  the  four  and  one-half  months  of  the  trained  nurse's  absence  the  net  gain  in 
weight  was  only  1  pound  3  ounces. 


telligently,  and  a  much  larger  group  who  have  prolonged  disturbances 
of  digestion,  the  result  of  previous  improper  methods  of  feeding.  In  the 
aggregate  the  number  of  children  included  in  these  two  groups  is  large, 
and  few  cases  in  the  practice  of  the  physician  cause  him  more  trouble  or 
anxiety.  Even  one  of  large  experience  often  finds  himself  baffled  by 
the    problems    which    individual    cases    present.     The    difficulties    are 


202  NUTRITION. 

greatest  in  early  infancy,  in  cities,  in  institutions,  in  hot  weather,  and 
they  are  further  increased  by  the  existence  of  constitutional  debility,  and 
where  the  trouble  is  of  long  standing.  That  chronic  indigestion  in  a 
young  infant  is  a  serious  thing  is  often  not  appreciated.  The  mother 
is  apt  to  think  the  problem  one  easy  of  solution;  she  only  wants  to  be 
told  what  to  feed  her  baby,  imagining  that  a  single  food  prescription 
should  set  the  child  right  at  once.  The  physician,  too,  sometimes  regards 
the  condition  lightly  because  these  infants  do  not  seem  really  ill;  he 
therefore  considers  the  subject  hardly  important  enough  for  his  careful, 
continuous  attention.  What  I  wish  to  emphasise  is  that  these  cases  are 
serious,  that  they  are  difficult,  that  in  most  of  them  nothing  can  be 
accomplished  without  close  and  continuous  personal  observation,  that 
tliey  do  not  tend  to  right  themselves,  and  that  infants'  lives  are  often 
sacrificed  as  a  result  of  bad  management. 

While  these  infants  present  great  variety  in  their  symptoms,  and 
must  be  carefully  individualised  in  their  management,  there  are  some 
general  principles  applicable  to  all.  One  should  begin  by  obtaining  a 
careful  history  of  what  has  been  previously  tried,  in  order  to  get  all 
possible  information  respecting  the  type  of  indigestion  which  the  child 
presents.  These  previous  efforts  in  feeding  should  be  studied  with  great 
minuteness;  the  different  changes  made  and  the  effect  of  each  one  upon 
the  principal  symptoms,  the  vomiting,  the  stools,  and  the  child's  weight 
should  be  considered.  With  a  good  history  obtained  from  an  intelligent 
mother  or  nurse  one  can  often  at  once  determine  where  mistakes  have 
been  made,  and  in  many  cases  the  same  mistake  has  been  repeated  with 
each  change  of  food. 

A  thorough  investigation  into  the  nursery  routine  sliould  be  made  to 
ascertain  not  only  what  has  been  tried,  but  how  it  has  been  tried.  It 
is  frequently  found  that  the  failure  is  due  not  to  any  fault  with  the 
food  prescribed,  but  to  other  conditions.  The  food  may  be  improperly 
prepared  or  given — e.  g.,  it  may  be  cold  or  given  too  rapidly ;  the  bottles 
or  nipples  may  be  dirty ;  the  proper  quantities  and  intervals  not  observed, 
etc.  Another  factor  of  importance  is  the  environment  as  affecting  the 
nervous  system  of  the  infant.  Among  the  well-to-do  this  may  be  the 
chief  trouble.  The  constant  or  frequent  excitement  by  visitors,  or  play- 
ing with  a  child  by  parents  or  nurses,  may  result  not  only  in  lack  of 
sleep,  but  in  disturbances  of  digestion,  often  in  habitual  vomiting,  though 
the  food  itself  is  proper.  Under  such  circumstances  the  removal  of  the 
child  from  its  surroundings  or  placing  it  in  charge  of  a  competent  nurse 
will  often  cause  an  immediate  and  marked  improvement  without  any 
change  in  the  food.  Another  cause  of  disturbance  is  the  habitual  use 
of  the  "  pacifier,"  something  frequently  resorted  to  in  these  cases,  but 
which  should  under  no  circumstances  be  tolerated.  Success  in  treatment 
will  depend  largely  upon  how  accurately  one  is  able  to  discover  the 


FEEDING   IN   DIFFICULT   CASES.  203 

essential  cause  or  causes  of  trouble  and  the  nature  of  the  disorder  of 
digestion  in  the  case  under  treatment.  Without  such  knowledge  all  is 
haphazard  experimentation. 

In  dealing  with  these  cases  drugs  are  of  little  assistance;  in  most 
cases  they  are  better  omitted  altogether. 

■  In  carrying  out  any  line  of  treatment  little  can  be  accomplished 
without  continuous  observation  at  fairly  frequent  intervals  on  the  part 
of  the  physician  and  tlie  co-operation  of  an  intelligent  mother  or  nurse. 
Particular  attention  sliould  be  paid  to  the  stools,  which  tlie  physician 
should  see  for  himself,  to  the  presence  of  colic  or  flatulence,  vomiting, 
the  appetite,  and  the  body  weight.  A  daily  record  is  of  great  assistance. 
The  weight,  though  important,  is  not  the  only  guide  as  to  progress.  It 
should  be  taken  regularly  in  order  that  a  steady  loss  may  not  go  on 
unnoted;  but  the  first  signs  of  improvement  are  usually  observed  in  other 
symptoms — the  child  is  more  comfortable,  sleeps  better,  and  suffers  less 
from  his  special  disturbances  of  digestion. 

Generally  speaking,  the  intervals  between  feedings  should  be  longer 
than  for  infants  with  good  digestion.  It  is  never  wise  to  make  them  less 
than  three  hours  for  young  infants,  or  less  than  four  hours  for  those  who 
have  passed  the  eighth  or  ninth  month. 

Regarding  the  effect  upon  the  digestion  of  concentration  of  the  food 
(i.  e.,  a  large  quantity  of  a  weak  food,  or  a  small  quantity  of  a  strong 
food),  different  results  are  seen  with  different  children.  The  usual 
tendency  when  an  infant  suffers  from  indigestion  is  to  dilute  the  food, 
and  in  some  cases  this  is  perfectly  proper;  but  to  continue  increasing 
the  dilution  because  the  patient  does  not  do  well  may  be  the  very  worst 
treatment.  This  may  do  harm  by  causing  too  much  dilution  of  the 
digestive  fluids.  Small  feedings,  not  weak  food,  are  what  benefit  some 
of  these  children  most,  the  balance  of  the  daily  amount  of  water  needed 
by  the  child  being  given  between  the  feedings. 

In  very  troublesome,  protracted  cases  minor  variations  in  the  com- 
position of  the  food  or  slight  changes  in  the  plan  of  feeding  rarely 
accomplish  much.  Radical  changes  are  usually  necessary.  If  small 
feedings  at  short  intervals  have  failed,  one  may  succeed  with  larger 
feedings  and  much  longer  intervals.  If  very  dilute  food  in  large  quan- 
tities has  failed,  improvement  may  follow  much  smaller  feedings  and 
a  much  stronger  food.  For  similar  reasons  the  most  brilliant  results 
are  often  obtained  from  as  complete  a  change  in  the  diet  as  possible. 
An  infant  who  has  been  long  on  farinaceous  foods  is  most  likely  to 
improve  when  these  are  stopped  entirely  and  suitable  percentages  of 
cow's  milk  given.  One  whose  digestion  has  become  seriously  deranged 
while  taking  milk,  and  whose  symptoms  have  continued  in  spite  of  many 
intelligent  variations  in  the  food,  is  sometimes  helped  by  nothing  so 
much  as  temporarily  withdrawing  all  milk. 


204  NUTRITION. 

Clinical  Types. — The  greater  number  of  these  cases  may  be  divitled 
into  three  groups:  (1)  Those  whose  chief  symptom  is  habitual  vomiting, 
or  regurgitation  of  food;  (2)  those  with  intestinal  symptoms,  most  fre- 
quently with  loose  stools;  (3)  those  without  any  marked  symptoms  of 
indigestion,  yet  whose  weight  is  much  below  the  average,  who  do  not 
gain  on  weak  food  and  are  upset  if  stronger  food  is  used.  They  have 
feeble  digestion  rather  than  indigestion. 

The  first  group,  the  cases  with  vomiting,  are  the  least  difficult  of 
the  three  to  control.  The  causes  which  produce  tliis  are  usually  more 
obvious  and  more  easily  removed.  Altogether  the  most  frequent  cause  of 
symptoms  of  this  kind  is  the  use  of  too  high  fats  of  cow's  milk.  The  pro- 
portions used  may  not  be  improper  for  normal  children,  but  they  are  exces- 
sive for  the  particular  patient.  A  less  frequent  cause  is  high  carl)oh3'^drates, 
especially  foods  containing  maltose,  sometimes  cane  sugar.  Some  of  these 
children  vomit  only  "occasionally  and  in  large  quantities ;  but  the  frequent 
regurgitation  of  undigested  food  in  small  quantities,  often  several  times 
after  each  feeding,  is  more  characteristic.  After  a  time  the  vomitus 
invariably  contains  more  or  less  mucus.  Vomiting  of  this  type  is  to  be 
sharply  distinguished  from  that  which  occurs  only  immediately  after 
feeding  from  overfilling  of  the  stomach.  The  symptoms  also  should 
not  be  confused  with  those  of  pyloric  stenosis.  Often  the  early  mis- 
takes in  feeding  are  not  gross  ones,  but  the  gastric  disturbance  becomes 
established  because  suitable  changes  in  the  food  are  not  at  once  in- 
stituted. 

In  the  second  group,  the  cases  with  intestinal  symptoms  are  the  most 
difficult  to  control.  Usuall}',  if  not  actual  diarrhoea,  there  are  at  least 
frequent  stools,  from  three  to  six  a  day  of  almost  every  conceivable 
colour  and  variety,  and  large  in  proportion  to  the  quantity  of  food  taken. 
Mucus  is  almost  always  present ;  in  the  more  severe  cases  and  in  those  of 
long  standing  the  quantity  may  be  excessive.  Exceptionally  the  children 
suffer  from  constipation.  Such  cases,  however,  are  generally  easier  to 
manage,  as  there  is  not  the  same  intolerance  of  food ;  but  these  patients 
may  suffer  from  abdominal  distention,  flatulence,  and  colic.  The  most 
important  element  in  the  food  which  produces  the  first  disturbance 
in  these  intestinal  cases  is  excessive  fat;  frequently,  also,  it  is  due  to 
excessive  carbohydrates,  particularly  cane  sugar  or  maltose,  and  some- 
times to  starchy  foods.  Very  soon,  in  severe  cases,  all  the  elements  of  the 
food,  but  especially  fat  and  sugar,  are  badly  borne.  After  the  condi- 
tion has  existed  for  some  time  it  may  be  impossible  to  determine  which 
of  the  food  elements  is  really  doing  the  most  harm. 

In  the  third  group,  the  cases  with  feeble  digestion,  mistakes  in  feed- 
ing are  less  prominent  as  causes.  Much  more  important  is  the  feeble 
constitution.  This  may  be  the  result  of  prematurity  or  of  congenital 
feebleness.     The  most  striking  feature  of  these  patients  is  tlie  extreme 


FEEDING   IN   DIFFICULT   CASES.  205 

sensitiveness  of  their  digestive  organs  to  even  the  smallest  deviation  from 
the  best  methods  of  feeding.  The  slightest  mistake  may  result  in  a 
serious  upset,  and  it  may  be  several  weeks  before  the  child  is  as  well  as 
before.  Often  under  the  best  surroundings,  and  when  fed  with  the 
greatest  care  and  intelligence,  such  infants  do  not  thrive. 

Management. — Passing  now  to  the  treatment  of  these  different  con- 
ditions we  find  that,  so  far  as  the  elements  of  cow's  milk  are  concerned,, 
the  greatest  difficulty  is  with  the  fat;  this  applies  particularly  to  the 
first  two  groups.  Xext  to  the  fat,  the  most  trouble  is  with  the  carbo- 
hydrates. Of  the  sugars,  maltose  is  more  likely  to  disagree  than  cane 
sugar  or  starchy  foods,  while  milk  sugar  is  by  most  children  the  most 
easily  borne.  That  protein  causes  trouble  also,  and  how  and  when  it 
does  so,  is  much  less  evident  and  lacks  conclusive  proof.  This  appears 
to  be  true  at  times  in  very  young  infants. 

With  these  points  in  mind  it  will  be  evident  that,  for  the  class  of 
patients  under  consideration,  top-milk  or  milk  and  cream  mixtures  are 
not  admissible.  For  nearly  all  of  them  the  fat  must  be  even  lower  than 
in  formulas  made  from  whole  milk.  According  to  the  severity  of  the 
symptoms,  there  should  be  employed  dilutions  of  3-per-cent,  2-per-cent, 
or  1-per-cent  milk,  and  in  extreme  cases  even  fat-free  milk.  It  is  also 
a  principle  of  wide  application  that  cases  with  predominant  gastric  or 
intestinal  symptoms  tolerate  maltose  badly,  and  in  most  cases  cane  sugar 
also.  Some  marked  cases  may  be  unable  to  tolerate  more  than  a  small 
amount  of  milk  sugar. 

At  the  very  outset  it  should  be  clearly  borne  in  mind  that  notwith- 
standing the  fact  that  these  patients  are  much  below  normal  weight,  and 
often  losing  steadily,  the  treatment  should  be  directed  first  of  all  to 
allaying  the  most  marked  symptoms  of  indigestion.  Until  these  are  re- 
lieved no  permanent  improvement  can  be  expected.  For  the  time  being 
the  weight  must  be  disregarded.  Xo  time  should  be  lost  in  attempting 
to  correct  the  digestive  symptoms  by  the  use  of  drugs  or  the  administra- 
tion of  digestive  ferments.  Our  resources  for  controlling  these  cases 
are  chiefly  variations  in  the  food. 

The  milk  modifications  which  are  suitable  in  different  cases  are :  ( 1 ) 
Formulas  from  partially  or  completely  skimmed  milk;  (2)  buttermilk 
and  other  fermented  milks;  (3)  protein  milk  (Eiweiss-milch  of  Fin- 
kelstein) ;  (-1)  condensed  milk.  (Their  preparation  has  already  been 
described  in  the  chapter  on  Cow's  Milk.)  (5)  "Wet-nursing;  (6)  sub- 
stitutes for  milk. 

The  variations  which  may  be  obtained  from  skimmed  milk  are  suf- 
ficient for  the  relief  of  a  large  number  of  the  cases  met  with,  particularly 
those  with  gastric  symptoms.  Such  an  one,  three  or  four  months  old, 
with  symptoms  of  moderate  severity  would  probably  take  1  to  1.50 
per  cent  of  protein,  but  not  more  than  0.6  to  0.8  per  cent  of  fat.     Such 


206  NUTRITION. 

formulas  can  be  derived,  as  may  be  seen  from  tbe  table,  from  2-per- 
cent  milk.  The  sugar  should  seldom  be  higher  than  5  per  cent.  With 
improvement  in  the  symptoms  the  proportion  of  all  the  ingredients  may 
be  gradually,  but  very  slowly,  raised ;  it  will  usually  be  months,  ho^\"«ver, 
before  such  a  patient  can  take  as  much  as  2  per  cent  of  fat.  A  similar 
plan  of  treatment  will  sometimes  succeed  when  the  symptoms  are  in- 
testinal, but  in  such  cases  one  must  be  cautious  in  the  use  of  sugar. 

Buttermilk  and  the  other  fermented  milks  are  indicated  particularly 
in  cases  with  intestinal  symptoms.  Their  advtantages  over  skimmed  milk 
are  that  they  not  only  have  a  lower  fat  content,  but  a  lower  sugar  as  well, 
and  contain  some  lactic  acid.  They  succeed  in  a  certain  number  of  cases 
that  do  not  respond  to  skimmed  milk.  It  is  seldom  necessary  to  dilute 
them  more  than  with  an  equal  amount  of  water. 

Protein  milk  is  indicated  in  cases  with  intestinal  symptoms  where  it 
is  desired  to  reduce  the  sugar  as  much  as  possible,  but  still  retain  a 
considerable  proportion  of  the  fat.  It  is  not  necessary  to  dilute  this 
with  more  than  an  equal  volume  of  water,  and  it  may  be  given  from 
this  dilution  up  to  full  strength.  In  many  cases  with  marked  intestinal 
symptoms  it  is  more  efficacious  than  any  of  the  other  milk  modifications. 

Condensed  milk  is  the  direct  opposite  of  protein  milk  in  tliat  both 
the  fat  and  the  protein  are  low  while  the  carbohydrate  is  high  and  chiefly 
cane  sugar.  It  is  often  difficult  by  symptoms  alone  to  determine  the  pre- 
cise indications  for  using  condensed  milk  in  cases  with  intestinal  symp- 
toms, but  the  fact  remains  that  in  certain  cases  it  has  imdoubtcd  value. 
It  may  be  diluted  with  plain  water,  but  often  its  effect  is  better  if  tlie 
diluent  is  barley  water. 

For  the  first  and  second  groups  of  cases  the  milk  of  a  good  wet-nurse 
is  seldom  the  best  food.  Its  high  fat  content  will  usually  aggravate  the 
vomiting  and  increase  the  diarrhoea.  Its  use  should  therefore  be  deferred 
until  the  digestive  symptoms  are  under  control.  At  a  later  stage  it  may 
be  invaluable  for  increasing  weight.  For  the  third  group,  the  children 
with  feeble  digestion,  wet-nursing  is  unquestionably  the  most  successful 
method  of  treatment. 

The  stopping  of  all  milk  is  at  times  a  useful  procedure.  However, 
this  should  be  done  only  for  a  limited  time,  a  few  days  to  a  week  at 
most.  The  proprietary  foods,  under  such  conditions,  seldom  prove  valu- 
able and  often  do  much  harm  whether  used  alone  or  added  to  milk. 
Those  children  who  have  trouble  with  fats  and  sugars  are  sometimes 
enabled  to  take  a  sufficient  amount  of  farinaceous  food  to  maintain  the 
body  weight  for  some  time.  For  such  purposes  a  barley,  wheat  or  oat 
gruel  may  be  used,  but  it  should  be  made  strong — two  tablespoonfuls  of 
flour  to  a  pint,  occasionally  even  stronger  than  this.  A  substitute  some- 
times useful  is  a  gruel  made  from  the  soy  bean.  This  is  high  in  vege- 
table nitrogen  and  low  in  starch  while  it  contains  considerable  fat.     It 


FEEDING   IN   DIFFICULT  CASES.  207 

may  be  continued  as  the  sole  diet  for  a  short  time  during  periods  of 
marked  disturbance.  To  any  of  the  above  substitutes  milk  should  be 
added  in  small  quantities  as  soon  as  possible ;  at  first  either  fat-free  milk 
or  skimmed  milk  should  be  employed. 

All  the  above  resources,  except  feeding  by  a  wet-nurse,  are  to  be 
looked  upon  as  methods  of  relieving  digestive  disturbances,  not  as  per- 
manent foods.  When  the  symptoms  have  disappeared  and  there  is  no 
longer  vomiting  and  the  stools  have  approached  the  normal,  other  food 
stuffs  may  be  employed  to  increase  weight.  The  most  valuable  one  of 
these  is  maltose.  Maltose  ^  has  the  advantage  over  all  sugars  in  point  of 
easy  assimilation.  It  has  also  the  disadvantage  in  that  it  breaks  down 
more  readily  than  do  other  sugars.  It  should  not  therefore  be  employed 
so  long  as  either  gastric  or  intestinal  symptoms  are  present.  The  direc- 
tions upon  the  package  should  not  be  followed,  but  the  amount  added 
should  at  first  be  small,  i.  e.,  one  teaspoonful  of  a  maltose  solution  or 
malt-soup  extract  to  the  daily  food.  This  may  be  increased  every  few 
days  imtil  the  total  amount  is  from  six  to  eight  teaspoonfuls  daily.  If  it 
causes  vomiting  or  too  frequent  stools  it  should  be  omitted. 

Another  valuable  food  stuff  is  olive  oil.  It  is  a  form  of  fat  which 
can  at  times  be  tolerated  when  the  fat  of  cow's  milk  habitually  disagrees. 
I  have  used  olive  oil  in  cases  of  this  kind  for  the  past  two  years  with,  in 
many  instances,  most  striking  benefit.  Some  children  who  are  unable 
to  take  as  much  as  one  per  cent  of  the  fat  of  cow's  milk  bear  olive  oil 
without  difficulty.  The  amount  used  at  first  should  be  small,  not  more 
than  one-half  teaspoonful  three  times  a  day.  It  may  be  gradually  in- 
creased until  one-half  teaspoonful  is  given  directly  after  each  feeding, 
six  or  seven  times  a  day.  The  maximum  amount  to  be  used  for  infants 
of  the  first  year  should  seldom  be  over  half  an  ounce  daily.  Only  ex- 
ceptionally when  used  in  this  way  does  it  cause  diarrhoea  and  still  less 
frequently  does  it  excite  vomiting.  It  is  therefore  of  value  as  a  form 
of  fat  which  may  be  given  to  infants  whose  greatest  difficulty  in  digestion 
is  their  inability  to  tolerate  milk  fat.  The  chief  means  by  which  weight 
can  be  increased  in  children  suffering  from  malnutrition  is  therefore 
through  the  addition  of  carbohydrates,  next  by  the  addition  of  fat,  but 
neither  of  these  is  to  be  employed  in  any  considerable  quantity  until 
the  marked  symptoms  of  indigestion  have  been  controlled.     As  a  means 

'  Many  malt  preparations  sold  in  the  market  also  contain  diastase,  which  is  not  de- 
sirable for  use  under  the  conditions  here  considered.  Loeflund's  and  Borcherdt's  "  malt- 
soup  extracts"  are  reliable  but  expensive.  Also  reliable  and  much  more  moderate 
in  price  are  the  "neutral  maltose"  of  the  Maltzyme  Co.,  Brooklyn,  and  the  "malt 
syrup"  of  the  Freihofer  Bakery  Co.,  Philadelphia.  Both  these  preparations  are 
somewhat  acid.  To  the  former,  five  grains  and  to  the  latter  ten  grains  of  potassium 
carbonate  should  be  added  to  each  ounce  of  the  malt  before  it  is  used  in  the  food. 
All  of  the  preparations  mentioned  contain  from  65  to  85  per  cent  of  carbohydrates, 
about  two-thirds  of  which  is  maltose  and  the  balance  chiefly  dextrin. 


208  NUTRITION. 

of  allaying  such  symptoms  nothing  compares  with  the  various  modifica- 
tions of  cow's  milk  above  described. 

The  use  of  formulas  made  from  whey  has  already  been  referred  to 
in  the  chapter  on  laboratory  feeding.  Whey  mixtures  are  indicated 
whenever  there  is  especial  difficulty  in  digesting  the  casein  of  cow's  milk. 
It  may  be  hard  to  tell  by  symptoms  when  this  is  the  case.  It  is  more 
often  true  of  very  young  infants  than  in  those  who  have  reached  the  age 
of  three  or  four  months.  Such  infants  are  frequently  constipated  and 
suffer  in  consequence  from  flatulence  and  colic.  Plain  whey  may  be 
used,  or  the  fat  may  be  raised  by  adding  a  small  proportion  of  7-per-cent 
milk  (one  ounce  in  twenty),  or  the  carbohydrates  may  be  increased  by 
the  addition  of  maltose.  Some  patients  are  helped  very  much  by  whey 
mixtures;  very  many  are  not  helped  at  all  for  the  reason  that  the 
trouble  with  such  patients  is  not  in  digesting  casein. 

What  has  just  been  said  of  whey  applies  also  to  the  use  of  peptonised 
milk.  It  is  employed  too  frequently,  and  is  apt  to  be  continued  too  long, 
and  but  very  few  of  the  troublesome  feeding  problems  are  solved  by  its 
use.  Citrate  of  soda  has  been  added  to  milk,  usually  in  the  proportion  of 
one  grain  to  the  ounce  of  food,  with  the  belief  that  a  delay  in  the  coagu- 
lation of  casein  in  the  stomach  which  this  brings  about,  is  a  desirable  re- 
sult. Neither  on  theoretical  nor  practical  grounds  can  I  see  any  reason 
for  its  use.  Although  I  have  tried  it  extensively  I  can  not  say  that  I 
have  ever  seen  any  marked  benefit  from  it. 

The  disturbances  of  nutrition  with  which  the  difficult  feeding  just 
described  is  associated,  have  been  regarded  by  Finkelstein  from  a  point 
of  view  somewhat  different  from  the  usual  one.  He  groups  infants  with 
nutritional  disturbances  not  so  much  according  to  the  character  of  their 
stools  or  their  previous  digestive  symptoms  as  by  the  way  in  which  they 
react  to  food.  He  thus  attempts  to  classify  them  on  the  basis  of  their 
functional  capacity. 

A  child  with  normal  digestion  and  perfect  nutrition  has  a  tempera- 
ture which  fluctuates  within  narrow  limits,  and  he  responds  to  a  proper 
increase  in  food  by  a  gain  in  weight.  On  the  other  hand,  the  response 
of  the  abnormal  child  to  food  is  something  quite  different  and  varies 
according  to  the  degree  of  his  disturbance. 

In  the  mildest  grade  of  nutritional  disorder,  that  of  disturbed  equi- 
librium (Bilanzstorung) ,  with  sufficient  food  there  is  no  regular  gain  in 
weight;  but  the  weight  fluctuates  for  a  considerable  period  until  more 
serious  symptoms  develop  or  until  an  adjustment  is  reached.  The  stools 
may  appear  nearly  normal  but  the  infant's  tolerance  of  food  is  consider- 
ably reduced.  The  temperature  fluctuations  also  are  wider  than  are 
seen  in  health. 

If  the  condition  is  not  relieved  symptoms  more  definitely  related  to 
the  digestive  tract  supervene,  usually  diarrhoea  (Dyspepsie) .    The  stools 


HEALTHY  INFANTS  DURING   THE  SECOND  YEAR.  209 

are  thin,  green,  and  contain  mucus.*  The  loss  in  weight  for  some  time 
is  not  marked,  but  other  symptoms  are  more  severe  and  from  time  to 
time  there  is  a  moderate  elevation  of  temperature.  In  this  stage  the 
child's  tolerance  of  food  is  still  further  reduced. 

In  the  third  degree  of  disturbance  (DeJcomposition)  which  follows 
after  a  longer  or  shorter  period  there  is  rapid  and  marked  loss  in  weight. 
The  temperature  is  usually  below  normal ;  the  pulse,  slow ;  the  respira- 
tion, often  irregular,  and  food  tolerance  falls  to  a  minimum.  The 
character  of  the  stools  depends  much  upon  the  diet.  When  the  food 
is  greatly  reduced  the  stools  may  appear  normal,  but  any  increase  in 
food  is  followed  by  bad  stools.  It  will  thus  be  seen  that  these  three 
groups  of  Finkelstein  represent  the  usual  types  seen,  viz.,  slight,  mod- 
erate, and  severe  nutritional  disturbances  due  to  improper  feeding. 

His  chief  contribution  is  in  the  emphasis  laid  upon  the  fact  that 
under  certain  conditions  the  food  elements,  even  though  not  in  large 
amount,  may.be  injurious.  They  may  themselves  produce  most  definite 
and  severe  symptoms  which  are  in  no  way  dependent  upon  bacterial 
infection. 

Finkelstein's  fourth  stage  (Intoxication)  indicates  a  complete  break- 
down of  all  the  processes  of  nutrition.  This  is  discussed  in  a  succeeding 
chapter. 

CHAPTER    IV. 
FEEDING  AFTER   THE  FIRST   YEAR. 

HEALTHY   INFANTS   DURING  THE   SECOND   YEAR. 

The  physician  should  not  relax  his  vigilance  in  the  feeding  of  a 
child  after  the  first  year  has  passed.  The  ideas  of  the  laity  in  regard  to 
what  a  child  can  digest  after  it  has  outgrown  an  exclusive  milk  diet,  are 
very  erroneous.  The  majority  of  infants  are  given  solid  food  too  early, 
in  too  large  quantities,  and  improperly  prepared.  Most  of  the  attacks 
of  indigestion  during  the  second  year  are  directly  traceable  to  gross 
dietetic  errors.  The  diet  of  a  healthy  child  during  the  second  year  should 
consist  mainly  of  milk,  and  some  farinaceous  food  with  bread,  a  small 
amount  of  animal  food — beef  or  mutton,  beef  juice,  eggs — and  fruit 
juice  or  cooked  fruit. 

Milk  should  be  the  basis  of  the  diet.  The  popular  idea  that  there 
are  many  children  who  can  not  take  milk  is  an  erroneous  one;  the  real 
trouble  usually  is  that  they  will  not  take  it  because  other  food  pleases 
the  palate  better,  and  they  are  allowed  to  have  their  own  way  in  this 
as  in  other  things.  It  is  of  the  utmost  importance  that  the  transition 
from  a  purely  fluid  diet  to  one  of  solid  food  should  be  made  very  slowly, 
and  that  the  habit  of  drinking  milk  should  not  be  discontinued. 
15 


210  NUTRITION. 

During  the  second  year  with  average  milk  and  average  infants  very 
little  modification  of  the  milk  is  required.  The  addition  of  milk  sugar 
is  unnecessary,  since  the  child  is  now  able  to  take  a  considerable  part  of 
his  carbohydrates  in  the  form  of  starch.  If  the  milk  is  very  rich,  such 
as  that  from  a  Jersey  herd,  it  should  be  diluted  with  at  least  one-fourth 
water.    In  hot  weather  a  still  greater  dilution  may  be  necessary. 

Weaning  from  the  Bottle. — This  should  always  be  begun  by  the  thir- 
teenth month ;  by  the  fifteenth  month  an  infant  should  take  all  his  milk 
from  a  cup,  except  possibly  the  10  p.m.  feeding,  when  the  bottle  may  be 
allowed  for  the  sake  of  convenience.  Early  weaning  from  the  bottle  is 
a  matter  of  no  small  importance.  When  the  bottle  is  allowed  to  older 
children  the  disposition  to  overfeeding  especially  during  the  summer  may 
be  very  great.  Again  there  are  many  children  with  the  "  bottle-habit " 
80  developed  that  throughout  childhood,  although  at  any  time  they 
will  take  milk  from  the  bottle,  they  can  never  be  induced  to  take  it 
any  other  way. 

From  Twelve  to  Fourteen  Months. — The  daily  schedule  at  this  period 
should  be  about  as  follows : 

6.30  A.M.     Milk,  six  to  eight  ounces;  diluted  with  barley  or  oat  gruel,  two  to  three 
ounces. 
9  A.M.     Orange  juice,  one  to  two  ounces. 
10  A.M.     Same  as  at  6.30  a.m. 
2  P.M.     Beef  juice,  one  to  two  ounces; 

or,  the  white  of  one  egg,  slightly  cooked;  later,  the  entire  egg; 
or,  mutton  or  chicken  broth,  four  to  six  ounces. 
Milk  and  gruel  in  prop>ortions  above  given,  four  to  six  ounces. 
6  P.M.     Same  as  at  6.30  a.m. 
10  P.M.     Same  as  at  6.30  a.m. 

In  preparing  the  food,  the  milk  and  the  gruel  are  simply  mixed 
together  while  the  latter  is  warm,  and  salt  and  a  very  small  quantity  of 
cane  sugar  added  to  make  it  palatable.  It  is  then  divided  into  as  many 
feedings  as  are  required  for  the  day,  each  one  being  placed  in  a  separate 
bottle.  As  to  handling  the  bottles  and  pasteurising  or  sterilising,  the 
same  rules  apply  as  during  the  first  year. 

From  Fourteen  to  Eighteen  Months. — The  diet  may  be  increased  by 
the  addition  of  more  solid  food.     The  average  child  will  take: 

6.30  A.M.     Milk,  warmed,  eight  to  ten  ounces. 
9  A.M.     Fruit  juice,  one  to  three  ounces. 

10  A.M.  Cereal:  one,  later  two  or  three,  tablespoonfuls  of  oatmeal,  hominy,  or 
wheaten  grits,  cooked  for  at  least  three  hours;  for  the  first  month  or 
two  this  should  be  strained;  upon  the  cereal  from  one  to  two  ounces 
of  thin  cream,  or  milk  and  cream,  with  plenty  of  salt,  but  without 
sugar. 
Crisp  dry  toast,  one  piece;  or,  unsweetened  zwieback; 

or,  one  Huntley  and  Palmer  breakfast  biscuit. 
Milk,  warmed,  six  to  eight  ounces. 


•DIFFICULT  CASES  DURING   THE   SECOND  YEAR.  211 

2  P.M.      Beef  juice,  one  to  two  ounces;  and  one  egg  (soft-boiled,  poached,  or  cod- 
dled); and  boiled  rice,  one  tablespoonful,  cooked  foiu*  hours; 
or,  broth  (mutton  or  chicken),  four  ounces;  one  or  two  breakfast  bis- 
cuits, or  zwieback;  and  (if  most  of  the  teeth  are  present)  rare  scraped 
meat,  at  first  one  teaspoonful,  gradually  increasing  to  one  table- 
spoonful;  milk,  fou"  to  six  ounces,  if  desired. 
6  P.M.     Cereal:  two  tablespoonfuls  of  farina,  cream  of  wheat,  or  arrowroot,  cooked 
for  at  least  one  hoiu",  with  milk,  plenty  of  salt,  but  without  sugar; 
or,  bread  and  milk  or  milk  toast. 
Milk,  waxmed,  eight  to  ten  ounces. 
10  P.M.     Milk,  warmed,  eight  to  ten  ounces,  which  may  be  given  from  a  bottle. 

From  Eighteen  Months  to  Two  Years. — The  amount  of  solid  food 
may  be  somewhat  increased.  The  number  of  the  meals  should  be  the 
same  as  for  the  preceding  period.  In  addition,  cooked  fruits,  such  as  the 
pulp  of  stewed  prunes  or  baked  apple,  strained,  may  be  given  at  the  mid- 
day meal.  It  is  generally  best  not  to  give  fruits  and  milk  at  the  same 
meal.  Nothing  but  water  should  be  given  between  meals.  Potato  is 
best  deferred  "until  the  child  is  nearly  two  years  old,  and  other  vegetables 
still  longer. 

DIFFICULT   CASES   DURING  THE   SECOND   YEAR. 

The  number  of  children  whose  nutrition  is  a  matter  of  difficulty  dur- 
ing the  second  year  is  much  smaller  than  during  the  first  year ;'  yet  the 
difficulties  may  be  just  as  great.  Some  of  these  are  infants  who  have 
been  very  delicate  from  birth,  and  carried  through  the  first  year  only 
by  the  greatest  effort.  Others  are  healthy  at  birth,  but  their  digestion 
has  been  badly  deranged  in  consequence  of  improper  feeding.  Still  others 
did  well  until  they  were  weaned.  The  conditions  may  be  the  result  of 
a  severe  attack  of  acute  disease  of  the  stomach  or  intestines  during  the 
first  year.  Other  important  causes  are  the  early  use  of  solid  food  and 
the  too  exclusive  use  of  farinaceous  foods  of  all  varieties. 

Whatever  the  special  cause  of  the  condition,  cases  of  chronic  indi- 
gestion in  the  second  year  are  to  be  managed  along  the  same  general  lines 
as  have  already  been  laid  down  for  those  under  one  year.  Usually  the 
first  thing  to  be  done  is  to  stop  all  solid  food  except  possibly  rare  scraped 
beef.  Starches  must  be  greatly  reduced  or  prohibited  altogether.  The 
milk  should  be  modified  as  for  healthy  infants  who  are  much  younger 
than  the  patient  under  treatment.  The  daily  quantity  should  generally 
be  somewhat  larger  than  for  a  young,  healthy  infant  taking  food  of  the 
same  strength.  The  regular  intervals  of  feeding  should  never  be  shorter 
than  three  hours,  and  usually  intervals  of  four  hours  are  to  be  preferred. 
A  safeguard  against  overfeeding  or  underfeeding  these  patients  is  the 
determination  of  the  caloric  value  of  the  food  given. 

Striking  improvement  often  follows  the  administration  of  rare  scraped 
meat,  especially  to  those  who  are  over  eighteen  months  old.     From  one 


212  NUTRITION. 

to  two  ounces  may  be  given  daily.  Generally  the  protein  in  the  food 
has  previously  been  deficient.  Many  of  these  children  digest  meat  when 
given  in  this  way  better  than  they  do  milk.  Beef  juice  and  the  whites 
of  eggs,  partially  cooked,  may  also  be  given. 

Fruits  should  be  used  with  great  caution.  As  it  is  with  the  starches 
that  great  difficulty  is  usually  experienced,  the  carbohydrates  should  be 
administered  chiefly  in  the  form  of  milk  sugar  or  some  of  the  prepara- 
tions of  maltose. 

When  the  child  is  once  well  started  and  gaining  steadily,  the  food 
may  be  gradually  increased,  until  the  diet  recommended  for  healthy  in- 
fants of  the  same  age  is  reached.  All  changes  must  be  made  very 
gradually,  and  it  should  never  be  forgotten  that  there  is  a  constant  dis- 
position on  the  part  of  all  mothers  and  nurses  to  overfeed  these  children. 

FEEDING   FROM   THE  THIRD   TO   THE   SIXTH  YEAR. 

Articles  Allowed. — From  the  following  list  the  diet  of  a  healthy  child 
may  be  arranged: 

Milk. — This  should  be  the  basis  of  the  diet;  most  children  require 
about  one  quart  daily.  This  seldom  needs  modification,  but  if  some- 
what difficult  of  digestion,  it  should  be  diluted.  The  milk  should  usu- 
ally be  given  warm. 

Cream. — This  is  of  value,  especially  when  there  is  a  tendency  to  con- 
stipation. From  two  to  four  ounces  of  thin  cream  may  be  given  daily. 
Above  this  point  it  should  be  used  with  caution.  It  should  not  be  used 
upon  fruits,  especially  sour  fruits.  It  may  be  used  upon  cereals,  upon 
potato,  in  broths,  and  mixed  with  milk. 

Eggs. — These  are  a  valuable  form  of  protein.  They  should  be  fresh, 
soft-boiled,  poached,  coddled,  or  scrambled,  but  not  fried.  Children  vary 
greatly  as  regards  their  ability  to  digest  eggs;  most  children  will  take 
two  eggs  a  day,  some  only  one,  and  a  few  can  not  take  them  at  all. 

Meats. — Some  form  of  meat  should  be  given  once  a  day.  The  best 
are  beefsteak,  mutton  chop,  and  roast  beef  or  lamb;  next  to  these  the 
white  meat  of  chicken  and  certain  of  the  more  delicate  kinds  of  fresh 
fish,  which  should  be  boiled  or  broiled.  Beef  and  mutton  should  be 
given  rare. 

Vegetables. — Potato  may  be  given  once  a  day,  preferably  baked,  with 
the  addition  of  cream  or  beef  juice  rather  than  butter.  Of  the  green 
vegetables  the  best  are  asparagus  tops,  spinach,  stewed  celery,  string 
beans,  carrots,  and  fresh  peas.  One  of  these  vegetables  should  be  given 
daily — always  well  cooked  and  mashed. 

Cereals. — None  of  the  ready-to-serve  cereals  should  be  given  to  chil- 
dren. They  are  the  cause  of  more  disturbances  of  digestion  than  almost 
any  other  common  article  of  diet.     Almost  any  cereal  which  requires 


FEEDING   FROM   THE  THIRD   TO  THE   SIXTH   YEAR.       213 

cooking  may  be  allowed — oatmeal,  wheaten  grits,  hominy,  rice,  cornmeal, 
farina,  and  arrowroot.  The  most  important  part  of  the  preparation  is 
thorough  cooking.  If  the  grains  are  used,  cereals  should  be  cooked  at 
least  three  hours,  after  having  been  previously  soaked  for  several  hours. 
They  should  always  be  well  salted,  and  given  with  milk  or  cream,  but 
with  little  or  no  sugar. 

Broths  and  Soups. — The  meat  broths  are  preferable  to  the  vegetable 
broths.  Nearly  all  varieties  may  be  given.  Plain  broths  are  not  very 
nutritious,  but  when  thickened  with  arrowroot  or  cornstarch,  and  when 
cream  or  milk  is  added,  they  are  very  palatable,  and  at  the  same  time  a 
valuable  addition  to  the  diet.  Most  vegetable  purees  are  useful,  and 
when  properly  made  very  digestible.  Beef  juice  may  be  used  as  directed 
for  the  second  year. 

Bread  and  Biscuits  (Crackers). — In  some  form  these  may  be  given 
with  nearly  every  meal,  better  without  butter  until  the  third  year.  All 
varieties  of  bread  may  be  allowed  when  stale — i.  e.,  two  or  three  days 
old;  also  dried  bread,  zwieback,  and  oatmeal  or  Graham  crackers. 

Desserts. — The  only  ones  that  should  be  allowed  up  to  the  sixth  year 
are  junket,  plain  custard,  rice  pudding  without  raisins,  and,  not  oftener 
than  once  a  week,  ice-cream.  Of  the  last  three,  the  quantity  given 
should  be  very  moderate. 

Fruits. — Some  fruit  should  be  given  to  most  healthy  children  every 
day.  Oranges,  baked  apples,  and  stewed  prunes  are  the  most  to  be  de- 
pended upon.  Raw  apples  should  not  be  given  in  most  cases.  Peaches, 
pears,  and  grapes  (with  seeds  removed)  may  be  given  when  thoroughly 
ripe  and  fresh,  but  only  in  moderate  quantity.  Much  indigestion  is  pro- 
duced by  too  much  fruit  or  improper  fruits.  Special  care  should  be  ex- 
ercised in  the  use  of  fruits  in  very  hot  weather,  and  in  cities  where  they 
may  not  always  be  fresh.  The  juice  of  fresh  berries  may  be  given  in  the 
second  year;  but  the  whole  fruit  should  be  very  sparingly  given  to  all 
young  children,  and  always  without  cream. 

Articles  Forbidden. — The  following  articles  should  not  be  allowed 
children  under  four  years  of  age,  and  with  few  exceptions  they  may  be 
withheld  with  advantage  up  to  the  seventh  year: 

Meats. — Ham,  sausage,  pork  in  all  forms,  salt  fish,  corned  beef, 
dried  beef,  goose,  duck,  game,  kidney,  liver,  meat  stews  and  meat 
dressings. 

Vegetables. — Fried  vegetables  of  all  varieties,  cabbage,  potatoes  (ex- 
cept when  boiled  or  baked),  raw  or  fried  onions,  raw  celery,  radishes, 
lettuce,  cucumbers,  tomatoes  (raw  or  cooked),  beets  (unless  very  small 
and  fresh),  egg-plant,  and  green  corn. 

Bread  and  Cake. — All  hot  bread  and  rolls;  buckwheat  and  all  other 
griddle  cakes;  all  sweet  cakes,  particularly  those  containing  dried  fruits 
and  those  heavily  frosted. 


214  NUTRITION. 

Desserts. — All  nuts,  candies,  pies,  tarts,  and  pastry  of  every  descrip- 
tion; also  all  salads,  jellies,  syrups,  and  preserves. 

Drinks. — Tea,  coffee,  wine,  beer,  cider,  and  soda  water. 

Fruits. — All  dried  fruits;  bananas;  all  fruits  out  of  season  and  stale 
fruits,  particularly  in  summer. 

From  the  third  to  the  sixth  year  four  meals  should  usually  be  given 
daily  and  at  regular  intervals — e.g.,  7  and  10.30  a.m.;  1.30  and  6  p.m. 
The  second  meal  should,  in  most  cases,  be  smaller  than  the  others. 

There  are  a  few  simple  rules  in  feeding  which  should  always  be  fol- 
lowed :  A  child  should  be  taught  to  eat  slowly  and  thoroughly  masticate 
his  food.  The  food  must  always  be  very  finely  divided,  for  mastication 
is  very  imperfect  even  up  to  the  sixth  or  seventh  year.  It  is  unwise 
continually  to  urge  children  to  eat  when  they  are  disinclined  to  do  so 
at  the  regular  hours  of  meals,  or  when  the  appetite  is  habitually  poor, 
and  under  no  circumstances  should  children  be  forced  to  eat.  Indigesti- 
ble articles  of  food  should  not  be  given  to  tempt  the  appetite  when  ordi- 
nary simple  food  is  refused.  Food  should  not  be  allowed  between  meals 
when  it  is  habitually  declined  at  meal-time.  If  a  child  refuses  to  eat, 
and  examination  reveals  no  fault  with  the  food  prepared,  it  should  sel- 
dom be  offered  again  until  the  next  feeding  time.  In  all  cases  of  tem- 
porary indisposition,  no  matter  of  what  nature,  and  during  periods  of 
excessive  heat  in  summer,  the  amount  of  solid  food  should  be  reduced 
and  more  water  given.    If  milk  is  the  food,  it  should  be  diluted. 

FEEDING   DURING   ACUTE   ILLNESS. 

Infants. — Feeding  is  an  important  part  of  the  treatment  of  every 
acute  disease  in  childhood,  but  especially  so  in  infancy.  Unless  the  ill- 
ness is  due  to  disease  of  the  digestive  tract,  all  cases  must  be  fed  in 
about  the  same  way.  It  is  much  easier  by  proper  feeding  to  prevent 
disturbances  of  digestion  than  to  allay  them.  In  infancy  this  com- 
plication often  turns  the  scale  against  the  patient.  In  every  severe 
acute  illness,  especially  if  it  is  of  a  febrile  character,  the  power  of 
digestion  is  much  diminished.  One  evidence  of  this  is  the  onset  with 
vomiting;  another  is  the  anorexia  which  accompanies  the  early  stage 
of  nearly  all  acute  diseases.  We  should  respect  this  disinclination 
and  make  it  our  guide  in  the  treatment.  But  water  is  needed ;  with- 
holding this  will  often  cause  the  temperature  to  rise  even  higher  than 
before. 

In  all  acute  febrile  diseases  the  general  rule  should  be,  less  food 
and  more  water  than  in  health.  For  bottle-fed  infants  this  is  easily 
accomplished  by  simply  increasing  the  dilution  of  the  food ;  for  nursing 
infants  by  making  the  nursing  time  shorter  and  giving  water  freely 
between  feedings  either  from  a  spoon  or  bottle.     During  febrile  condi- 


FEEDING  DURlNd   ACUTE   ILLNESS.  215 

tions,  fat,  especially,  is  badly  borne,  and  this  should  therefore  be  reduced 
more  than  the  other  elements  of  the  food.  The  diet  should  consist 
largely  of  carbohydrates. 

Kegularity  in  feeding  is  too  often  entirely  ignored.  While  it  is  true 
that  with  some  capricious  children  all  rules  must  be  disregarded,  it  is 
with  the  great  majority  a  decided  advantage  to  adhere  to  proper  food 
and  regular  intervals.  Food  should  seldom  be  given  at  less  than  three- 
hour  intervals,  although  there  is  no  limit  to  the  frequency  with  which 
water  may  be  given,  and  unless  the  stomach  is  irritable,  almost  no  limit 
as  to  quantity.  Stimulants,  when  required,  are  often  best  given  in  a 
very  dilute  form  with  the  water. 

Forced  Feeding — Gavage. — Not  a  few  cases,  however,  are  seen  in 
which,  after  a  child  has  been  several  days  sick,  in  consequence  of  deliri- 
um, stupor,  sepsis,  or  some  other  serious  condition,  it  may  refuse  all 
food  or  take  so  little  that  it  is  in  danger  of  death  from  inanition.  At 
this  juncture  forced  feeding  or  gavage  serves  an  excellent  purpose. 
Both  food  and  stimulants  can  thus  be  introduced  at  regular  intervals 
with  slight  disturbance,  and  lives  saved  which  would  otherwise  be  lost. 
If  gavage  is  employed,  the  stomach  should  first  be  washed.  The  inter- 
vals of  feeding  should  be  made  at  least  one  hour  -longer  than  .is  cus- 
tomary in  health,  and  usually  predigested  foods  given.  Forced  feeding 
is  not  applicable  to  chronic  conditions. 

Older  Children. — The  same  conditions  with  reference  to  digestion 
exist  as  in  the  case  of  infants.  Older  patients,  however,  are  not  so 
easily  disturbed,  and  the  disturbance  of  digestion  is  not  so  likely  to  be 
serious  as  in  the  ease  of  infants.  Even  here  the  physician  should  direct 
the  food  to  be  given  at  regular  intervals,  usually  not  oftener  than  every 
three  hours,  but  should  never — as  is  so  often  done — order  milk  to  be 
given  to  the  child  every  time  he  asks  for  a  drink.  In  most  cases,  for 
children  under  five  years  old,  milk  should  be  somewhat  diluted,  usually 
with  lime-water.  Children  who  do  not  take  milk  readily  may  be  given 
beef  tea,  broth,  gruel,  or  kumyss,  but  rarely  ice-cream  or  jellies  so  fre- 
quently prescribed,  as  these,  if  given  in  any  considerable  quantity  or 
very  often,  are  likely  to  disturb  the  stomach  and  take  away  what  little 
desire  for  food  the  child  may  have.  Raw  eggs  are  palatable  when  beaten 
up  with  sherry,  a  little  sugar,  and  cracked  ice.  Fruits,  especially  orange 
and  grape  juice,  may  be  allowed  in  almost  every  febrile  disease,  but 
never  given  within  two  hours  of  a  milk  feeding. 

The  water  given  may  be  plain  boiled  water,  but  better,  in  most  cases, 
are  some  of  the  carbonated  waters,  A^ichy,  Seltzer,  or  Apollinaris,  these 
being  less  likely  to  disturb  the  stomach. 

It  is  certainly  a  mistake  to  force  food  upon  older  children  in  any  dis- 
ease in  which  their  condition  is  not  dangerous.  But  when  there  is  sepsis, 
delirium,  or  coma  associated  with  other  dangerous  symptoms,  gavage 


216  NUTRITION. 

may  be  resorted  to  with  but  little  more  difficulty,  and  with  no  less  satis- 
factory results,  than  in  infants. 


CHAPTER    V. 
THE  DERANGEMENTS  OF  NUTRITION. 

The  derangements  of  nutrition  form  a  distinct  and  a  very  large  class 
in  the  ailments  of  infancy,  particularly  during  the  first  year.  The 
symptoms  are  sufficiently  definite  and  characteristic  for  them  to  be  re- 
garded as  separate  diseases,  and  to  be  discussed  as  such.  In  adults  such 
symptoms  are  seldom  seen  except  in  connection  with  organic  disease. 
These  cases  are  often  very  puzzling,  and  in  a  large  number  of  them  a 
diagnosis  of  some  constitutional  disease,  such  as  hereditary  syphilis,  or 
tuberculosis,  or  organic  disease  of  the  stomach  or  intestines,  is  errone- 
ously made.  At  other  times  the  symptoms  resemble  those  of  acute  tox- 
aemia. The  essential  condition  in  all  these  cases  is  the  inability  of  the 
infant  to  get  from  its  food  what  its  system  needs.  It  can  not  digest  or 
assimilate  enough  to  support  life.  It  is  unable  to  replace  from  its  food 
the  daily  waste  of  its  tissues.  The  constructive  metabolism  is  imperfect ; 
the  process  is,  therefore,  essentially  one  of  starvation,  which  may  be 
rapid  or  slow,  according  to  circumstances. 

The  fault  in  these  cases  is  partly  with  the  organs  of  digestion,  bat 
principally  wath  the  food.  The  problem  is,  to  adapt  the  food  to  the 
digestion  of  the  individual  child  under  consideration.  The  solution  is 
often  very  easy  at  first,  but  the  difficulties  multiply  rapidly  the  longer 
the  condition  has  lasted.  It  is  therefore  essential  that  the  true  expla- 
nation of  the  symptoms  should  be  recognised  at  the  earliest  possible 
moment.  Changes  occur  so  rapidly  in  very  young  infants  that  a  mis- 
take in  diagnosis  and  a  consequent  delay  of  a  few  days,  may  be  suffi- 
cient to  determine  a  fatal  result.  The  outcome  in  cases  of  imperfect 
nutrition  depends  almost  entirely  upon  their  management.  The  condi- 
tion is  not  one  which  tends  to  right  itself.  Spontaneous  improvement 
or  recovery  rarely  takes  place.  In  order  to  recognise  the  condition  and 
anticipate  the  result,  nothing  is  so  important  as  a  close  observation  of 
the  body-weight.  A  child  whose  nutrition  is  a  matter  of  difficulty 
should  be  weighed  regularly,  in  the  early  months  at  least  twice  a  week, 
and  once  a  week  throughout  the  first  year.  If  this  is  done,  the  first 
signs  of  failing  nutrition  are  unerringly  detected.  If  an  infant  does 
not  gain  in  weight  something  is  wrong;  a  steady  loss  in  weight  is  a 
warning  which  should  never  pass  unheeded;  for,  unless  the  conditions 
are  changed,  it  is  practically  certain  to  continue,  and  generally  with 
increasing  rapidity,  until  the  vitality  has  been  reduced  to  such  a  point 


ACUTE   INANlTlOxN.  217 

that  no  means  of  treatment  can  restore  it.  The  younger  the  child,  the 
more  rapid  the  loss,  and  the  longer  it  has  continued,  the  greater  is  the 
danger. 

For  convenience  of  description  these  derangements  of  nutrition  have 
been  divided  into  three  groups,  differing,  however,  rather  in  degree  than 
in  kind: 

1.  Cases  of  acute  inanition,  which  are  quite  rapid,  generally  lasting 
from  a  few  days  to  a  few  weeks.  They  are  rare  except  in  young  infants, 
being  most  frequently  seen  in  the  first  three  months. 

2.  Cases  of  malnutrition,  in  which  the  symptoms  are  much  less  se- 
vere than  in  the  other  groups,  although  they  may  be  of  long  duration. 
While  it  is  most  common  in  the  first  two  years,  malnutrition  may  be 
seen  at  any  age. 

3.  Cases  of  marasmus.  This  is  similar  to  inanition,  but  a  much 
slower  process,  lasting  usually  for  several  months.  It  may  be  seen  in 
infants  of  any  age. 

ACUTE   INANITION. 

Inanition,  or  starvation,  is  a  condition  depending  upon  lack  of  assim- 
ilation. It  is  common  in  early  infancy,  when  it  often  simulates  serious 
organic  disease.  In  older  children  it  is  not  frequent,  and  not  usually 
obscure.  In  all  the  acute  diseases  of  the  digestive  tract  many  of  the 
symptoms  are  due  to  inanition.  The  cases  considered  in  the  present 
chapter,  however,  are  those  in  which  there  is  no  such  association,  or 
where  the  digestive  symptoms,  strictly  speaking,  are  not  prominent. 

Etiology. — The  essential  cause  of  inanition  is  that  the  child  does  not 
get  sufficient  food,  or  that  the  food  taken  is  not  assimilated.  It  usually 
develops  under  one  of  the  following  conditions :  ( 1 )  When  a  child  re- 
fuses all  food,  whether  from  the  breast  or  the  bottle,  or  can  be  made  to 
take  only  an  insignificant  amount.  The  cause  of  this  it  is  often  im- 
possible to  discover.  I  have  seen  it  in  a  variety  of  circumstances,  once 
in  an  infant  five  months  old,  previously  healthy,  who  was  suffering  from 
whooping-cough.  This  infant  utterly  refused  the  breast,  and  from  the 
spoon  would  take  less  than  two  ounces  a  day.  After  four  days  and 
the  production  of  most  alarming  symptoms,  feeding  by  gavage  was 
begun,  and  its  life,  I  think,  saved  by  it.  Symptoms  of  inanition  are 
sometimes  seen  at  weaning,  where  a  child  persistently  refuses  to  take 
food  from  a  bottle  or  spoon.  (2)  When  the  food  given  is  entirely  inade- 
quate, as  when  an  infant  is  nursing  upon  a  dry  breast,  or  one  in  which 
the  milk  supply  is  so  scanty  that  the  child  gets  practically  nothing.  I 
have  occasionally  seen  it  later,  when  the  breast-milk,  for  some  unex- 
plained reason,  had  suddenly  failed.  (3)  Where  the  character  of  the 
food  is  improper.  On  account  of  extreme  poverty,  the  infant  may  be 
getting  only  tea,  as  I  have  known  to  be  the  case  many  times.    Some  cases 


218  NUTRITION. 

occur  in  young  infants  who  are  fed  entirely  on  starchy  foods.  (4) 
Where  the  infant  at  birtli  has  such  feeble  powers  of  digestion,  because 
premature  or  delicate,  that  it  is  unable  to  take  or  to  digest  sufficient  food 
to  maintain  life.  (5)  When  a  sudden  change  of  food  is  made  to  one  so 
difficult  of  digestion  that  the  child  is  unable  to  assimilate  it.  This  may 
happen  after  sudden  weaning.  In  such  cases  the  symptoms  of  inanition 
are  mingled  with  those  of  acute  indigestion,  but  the  former  usually  pre- 
dominate. 

Symptoms. — The  mode  of  development  depends  upon  the  antecedent 
condition.  In  young  infants  inanition  often  follows  malnutrition  where 
perhaps  there  has  been  nothing  noticeable  except  a  gradual  loss  in 
weight;  or  if  the  weight  has  not  been  watched,  it  may  be  observed  only 
that  the  infant  has  not  been  doing  well.  Severe  symptoms  may  come  on 
quite  suddenly,  and  if  the  nature  and  the  gravity  of  the  condition  are  not 
appreciated  the  case  may  terminate  fatally  in  two  or  three  days.  The 
loss  in  weight  is  now  rapid,  amounting  often  to  three  or  four  ounces  a 
day.  The  temperature  in  the  newly  born  may  be  high,  but  it  is  more 
often  subnormal.  The  pulse  is  always  weak  and  rapid.  The  urine  is 
scanty  and  very  low  in  chlorides  and  often  contains  acetone.  The  ex- 
tremities are  cold,  and  the  peripheral  circulation  poor.  There  is  usually 
complete  muscular  relaxation,  almost  collapse.  The  skin  may  be  dry 
or  covered  with  a  clammy  perspiration.  There  is  extreme  pallor,  and 
often  there  is  cyanosis.  This  is  always  a  grave  symptom,  and  when  it  is 
marked  the  case  usually  ends  fatally.  Cyanosis  may  be  present  in  chil- 
dren who  have  previously  cried  well  and  in  whom  there  is  no  suspicion 
of  atelectasis.  The  respirations  are  rapid  and  may  be  irregular.  There 
may  be  constant  worrying  and  fretfulness,  or  a  condition  of  semi-stupor, 
in  which  the  child  makes  no  sign  of  wanting  food.  The  fontanel  is 
sunken  and  the  pupils  are  contracted.  The  stools  contain  undigested 
food.  The  bowels  usually  move  frequently,  although  there  may  be  con- 
stipation, due  to  the  small  amount  of  food  taken.  When  all  food  is 
refused  for  two  or  three  days  the  stools  may  resemble  meconium.  While 
no  desire  for  food  is  manifested,  infants  will  sometimes  swallow  food 
when  it  is  offered,  retaining  everything  given  for  several  feedings,  when 
the  whole  quantity  is  vomited. 

The  course  of  the  disease  depends  much  upon  the  age  of  the  infants. 
Those  under  one  month  succumb  most  quickly.  In  them  the  symptoms 
sometimes  last  but  two  or  three  days,  seldom  more  than  a  week  or  ten 
days,  the  children  simply  drooping  steadily  until  death  occurs.  With 
proper  treatment  complete  recovery  may  take  place  in  a  week.  In 
older  infants  the  progress,  whether  upward  or  downward,  is  usually  less 
rapid. 

Prognosis. — The  outcome  of  these  cases  is  always  uncertain.  In  few 
conditions  is  it  more  so.    It  is  hard  for  one  who  is  not  familiar  with  the 


ACUTE  INANITION.  219 

condition  to  appreciate  the  great  and  even  the  immediate  danger  in 
which  a  young  infant  may  be  from  inanition,  notwithstanding  the  absence 
of  both  vomiting  and  diarrhoea.  It  is  difficult  to  estimate  the  gravity 
of  an  individual  case  except  after  twenty-four  hours'  observation.  The 
best  of  all  guides  is  perhaps  the  weight.  Where  the  loss  is  several  ounces 
each  day  the  chances  of  recover}'^  are  small.  The  presence  also  of  fre- 
quent vomiting  or  of  diarrhoea  makes  the  outlook  very  bad.  A  high 
temperature,  very  marked  relaxation,  copious  perspiration,  cold  extrem- 
ities, and  cyanosis  are  all  bad  symptoms. 

Diagnosis. — Inanition  is  distinguished  from  malnutrition  by  its 
greater  severity,  and  from  marasmus  by  its  more  acute  character.  The 
usual  mistake  is  that  of  confounding  inanition  with  some  local  or  consti- 
tutional disease.  It  may  be  mistaken  for  acute  indigestion,  meningitis, 
gastro-enteritis,  pneumonia,  or  septicaemia.  The  temperature  when  ele- 
vated is  especially  likely  to  mislead. 

Treatment.: — The  existence  of  inanition  in  young  infants  presupposes 
only  the  feeblest  powers  of  digestion  and  assimilation.  If  possible,  a 
good  wet-nurse  should  be  secured,  for  in  most  of  the  cases  the  time  for 
action  is  so  short  that  there  is  no  opportunity  to  experiment  with  arti- 
ficial feeding. 

The  breast-milk  should  usually  be  diluted,  at  first  with  an  equal  vol- 
ume of  water  or  lime-water,  and  the  quantity  should  be  only  a  few 
drachms.  It  may  be  given  with  a  spoon,  a  medicine-dropper,  or  a  Breck 
feeder.  If  there  is  vomiting  or  diarrhoea,  the  milk  should  be  pumped 
from  the  breasts,  and  the  cream  removed,  since  the  high  fat  of  good 
breast-milk  is  not  well  borne.  Gradually  the  quantity  and  strength  of 
the  milk  are  increased  until  the  child  is  allowed  to  take  the  breast 
in  the  usual  manner. 

When  no  wet-nurse  can  be  obtained,  the  artificial  food  should  be  low 
in  fat  and  protein  and  relatively  high  in  carbohydrates.  Formulas  such 
as  are  desired  may  be  obtained  from  whole  milk.  The  fat  and  protein 
should  be  from  0.50  to  1  per  cent  and  milk  sugar,  4  or  5  per  cent, 
and  in  addition  maltose  may  be  added  to  bring  the  total  carbohydrate 
up  to  7  per  cent.  A  5-per-cent  solution  of  milk  sugar  may  be  given  with 
egg  albumin;  or  condensed  milk  may  be  tried.  The  quantity  given 
should  be  small  and  the  frequency  not  oftener  than  every  two  hours. 
When  food  is  not  readily  taken,  it  may  be  given  by  gavage.  Rectal  feed- 
ings may  be  of  scfme  assistance  for  a  short  period. 

Often  the  symptoms  are  due  quite  as  much  to  a  lack  of  water  as  to  a 
lack  of  food.  Injections  of  a  normal  salt  solution  may  be  given  per 
rectum  or  even  under  the  skin  with  very  great  advantage.  Rectal 
injections  should  be  given  at  104°  to  110°  F.  and  carried  high  into 
the  colon  by  a  catheter;  they  should  be  repeated  every  four  or  five 
hours. 


220  NUTRITION. 

In  extreme  eases  the  slow  and  continuous  rectal  saline  injection 
known  as  the  Murphy  method  may  be  employed. 

The  other  treatment  required  by  these  cases  is  the  reduction  of  high 
temperatures  by  sponging  or  tepid  baths,  and  the  raising  of  subnormal 
temperatures  by  electric  pads,  hot-water  bags,  and  wrapping  in  cotton. 
Stimulants  are  indicated,  but  are  not  very  well  borne;  alcoholic  prepa- 
rations by  the  mouth  often  excite  vomiting,  but  by  the  rectum  they  may 
be  better  tolerated.    Drugs  are  of  no  use  whatever. 

Inanition  in  older  infants  is  seldom  serious  unless  it  follows  some 
acute  illness.  Peptonised  milk  by  gavage  is  often  useful.  There  are 
some  patients,  usually  over  a  year  old,  who  refuse  fluid  food  of  every 
description,  and  vomit  it  when  it  is  coaxed  or  forced,  yet  who  will  take 
and  digest  in  a  most  surprising  manner  some  form  of  solid  food,  such 
as  beef-steak,  oatmeal,  bread,  crackers,  or  even  potatoes.  For  tlie  time 
one  must  give  whatever  the  child  will  take,  and  gradually  change  to  a 
suitable  diet  as  soon  as  circumstances  will  permit.  The  needed  water 
may  be  given  per  rectum. 

All  children  who  have  suffered  from  acute  inanition  need  the  closest 
attention  for  a  long  time,  particularly  as  to  their  feeding,  regarding 
which  suggestions  will  be  found  in  the  pages  devoted  to  Infant  Feeding. 

MALNUTRITION. 

Cases  of  malnutrition  are  exceedingly  common,  and  occupy  a  large 
part  of  the  time  and  attention  of  one  engaged  in  practice  among  chil- 
dren. Although  these  children  can  not  be  said  to  be  actually  ill,  they 
are  very  far  from  well,  and  their  condition  is  often  the  cause  of  the  great- 
est solicitude  on  the  part  of  parents,  not  only  from  the  existing  state  of 
health,  but  from  the  apprehension  of  the  development  of  some  serious 
organic  or  constitutional  disease,  especially  tuberculosis. 

Etiology. — Malnutrition  may  depend  upon  inherited  conditions. 
Certain  children  are  delicate  from  birth,  possessing  only  feeble  vital- 
ity, though  without  giving  evidence  of  any  actual  disease.  Tliey  are 
often  the  offspring  of  parents  of  delicate  constitution  and  poor  phys- 
ical development,  or  of  those  with  tuberculosis,  gout,  syphilis,  or  alco- 
holism. Very  many  city  children  are  included  in  this  group.  Among 
the  poor  the  condition  is  the  result  of  bad  hygiene,  insufficient  or 
improper  food,  overcrowding,  etc.  Among  the  well-to-do  it  is  seen 
in  those  who  inherit  a  too  highly  developed  nervous  organisation  with 
a  corresponding  amount  of  physical  deterioration.  Another  group 
includes  those  children  who  were  premature  or  very  small  at  birth, 
weighing  perhaps  only  three  or  four  pounds.  Many  cases  are  trace- 
able to  improper  feeding  or  equally  poor  nursing  during  the  first  few 
months.     These  children  get  a  poor  start  in  life,  and  on  that  account 


MALNUTRITION.  221 

are  handicapped  throughout  infancy.  A  frequent  cause  of  malnutrition 
in  infants  is  the  pernicious  custom  of  keeping  them  in  close  apartments 
where  the  thermometer  ranges  from  72°  to  78°  F.,  and  where  the 
greatest  anxiety  is  constantly  felt  lest  they  take  cold.  Such  infants  may 
lose  in  weight,  become  anaemic,  and  exhibit  all  the  signs  of  malnutrition 
where  nothing  else  is  wrong  except  the  conditions  mentioned.  Malnu- 
trition often  depends  upon  some  previous  acute  disease,  especially  of  the 
stomach  and  intestines. 

In  children  who  are  over  two  years  old  the  condition  of  malnutrition 
may  be  due  to  any  of  the  factors  above  mentioned — inherited  feebleness 
of  constitution,  bad  feeding  and  its  resulting  indigestion,  too  little  fresh 
air,  and  close  confinement  indoors.  It  is,  however,  at  this  period  much 
more  frequently  than  in  infancy,  dependent  upon  some  previous  acute 
disease.  As  a  result,  an  impression  is  left  upon  the  child's  constitution 
which  lasts  for  months,  often  for  years,  and  which  manifests  itself  not 
by  any  special-  local  symptoms,  but  by  a  general  condition  of  debility 
or  malnutrition.  Sometimes  such  diseases,  instead  of  being  directly  the 
cause  of  the  symptoms,  are  the  occasion  which  brings  out  some  latent 
inherited  taint  or  constitutional  weakness  in  children  who  up  to  this 
time,  perhaps,  have  appeared  exceptionally  healthy.  In  other  cases  mal- 
nutrition depends  upon  faulty  methods  in  education,  especially  upon 
overpressure  in  schools. 

Symptoms. — In  Infants. — The  weight  is  much  below  the  average,  and 
is  either  stationary  or  the  gain  is  very  slow,  often  only  five  or  six  ounces 
a  month  at  a  period  when  it  should  be  from  one  to  two  pounds.  A 
child  under  my  care  weighed  at  fourteen  months  but  eight  and  a  half 
pounds.  This  infant  at  birth  weighed  three  and  a  half  pounds,  but  in 
a  few  weeks  the  weight  dropped  to  two  pounds. 

Not  only  the  weight  but  the  general  physical  development  is  much 
below  the  normal.  At  one  year  the  body  length  may  be  three  or  four 
inches  less  than  the  average.  Dentition  is  usually  but  not  always  de- 
layed. Muscular  development,  too,  is  backward;  many  of  these  chil- 
dren do  not  sit  alone  until  a  year  old,  and  barely  walk  at  two  and  a  half 
years.  The  muscles  are  soft  and  flabby,  and  the  ligaments  so  weak  that 
paralysis  is  often  suspected.  The  body  is  so  small  that  the  head  seems 
unnaturally  large,  and  a  diagnosis  of  incipient  hydrocephalus  is  fre- 
quently made.  Mentally  these  infants  are  often  quite  up  to  the  average. 
Some  symptoms  of  rickets  may  be  present,  but  often  there  are  none. 

The  examination  of  the  blood  reveals  the  usual  changes  of  secondary 
anaemia  which  varies  much  in  degree,  being  rarely  extreme.  The  circu- 
lation is  usually  poor,  the  hands  and  feet  are  frequently  cold.  In  many 
children  the  skin  is  unnaturally  dry;  in  others  there  is  a  disposition  to 
excessive  perspiration,  particularly  about  the  head.  Nervous  symptoms 
are  usually  present.     These  children  are  restless,  fretful,  and  irritable; 


222  NUTRITION. 

they  sleep  badly  during  the  day,  and  often  worse  at  night.  Enlargement 
of  the  lymph  glands  is  common,  especially  those  of  the  neck.  'The  cervi- 
cal adenitis  may  have  started  from  a  slight  catarrhal  cold,  but  the  glands 
continue  to  swell  after  this  has  subsided  and  may  remain  enlarged  for 
months. 

One  of  the  most  characteristic  things  about  these  infants  is  their 
feeble  power  of  digestion  and  assimilation.  Unremitting  care  and  con- 
stant watchfulness  are  required  to  keep  them  up  to  even  a  moderate 
standard  of  health.  The  most  trivial  changes  in  food  may  upset  them. 
Attacks  of  acute  indigestion  are  usually  brought  on  by  overfeeding — the 
mistake  which  is  almost  invariably  made  by  mothers  who  are  discouraged 
with  the  slow  progress  made,  and  are  anxious  to  make  their  children 
grow  fat  and  strong.  The  balance  is  so  delicately  adjusted  that  the 
slightest  deviation  from  proper  rules  of  feeding,  either  as  to  the  quality 
of  the  food  or  the  quantity  given,  is  immediately  followed  by  an  attack 
of  acute  indigestion,  often  by  severe  diarrhcea.  As  a  result,  the  child 
may  lose  as  much  in  two  or  three  days  as  it  has  gained  in  a  month  or 
more.  These  acute  attacks,  if  in  summer,  not  infrequently  prove  fatal. 
Not  only  do  these  patients  have  but  little  resistance  to  acute  disturbances 
of  the  stomach  and  intestines,  but  any  acute  disease  is  serious — measles, 
whooping-cough,  and  pneumonia  being  especially  fatal. 

Among  the  poor  or  in  institutions,  cases  of  malnutrition  like  those 
described,  if  in  children  under  nine  months  old,  are  almost  certain  to  go 
on  from  bad  to  worse  until  they  have  reached  the  condition  described 
as  marasmus.  Between  this  and  malnutrition  no  sharp  distinction  can 
be  drawn;  they  are  rather  different  degrees  of  the  same  general  process. 
In  private  practice,  where  it  is  possible  to  have  the  best  care  and  sur- 
roundings, with  the  co-operation  of  an  intelligent  mother  or  nurse,  a 
very  large  number  of  these  infants  can  be  reared.  After  the  second  year 
has  passed  the  problem  becomes  a  much  simpler  one,  and  if  infectious 
diseases  and  other  forms  of  acute  illness  can  be  avoided,  the  probabili- 
ties are  in  favour  of  the  child's  becoming  stronger  each  year  and  growing 
to  maturity. 

In  Older  Children. — In  general  appearance  these  children  are  thin, 
pale,  and  undersized,  particularly  if  the  condition  is  constitutional  or 
hereditary.  Sometimes  they  are  taller  than  the  average  for  their  age, 
and  their  symptoms  are  often  attributed  to  too  rapid  growth.  One  of 
the  most  striking  things  about  children  suffering  from  malnutrition  is 
their  vulnerability.  They  "  take "  everything.  Catarrhal  processes  in 
the  nose,  pharynx,  and  bronchi  are  readily  excited,  and,  once  begun, 
tend  to  run  a  protracted  course.  There  is  but  little  resistance  to  any 
acute  infectious  disease  which  the  child  may  contract.  One  illness  often 
follows  another,  so  that  these  children  are  frequently  sick  for  almost  an 
entire  season.     Their  muscular  development  is  poor,  they  tire  readily. 


MALNUTRITION.  223 

are  able  to  take  but  little  exercise,  and  their  circulation  is  sluggish. 
Mentally  they  are  usually  bright,  often  precocious.  Many  belong  to  the 
group  of  nervous  children.  They  are  cross,  fretful,  and  any  unusual 
excitement  produces  an  effect  which  lasts  for  some  time;  for  example, 
after  a  children's  party  or  a  Christmas  tree  they  may  lie  awake  half 
the  succeeding  night,  and  may  be  really  ill  for  two  or  three  days.  Their 
sleep  is  usually  disturbed  and  restless;  they  waken  frequently,  and  occa- 
sionally suffer  from  night-terrors.  At  a  later  age  they  are  favourable 
subjects  for  chorea,  neuralgia,  and  all  functional  nervous  disorders. 

Digestive  symptoms,  if  not  constant,  are  very  easily  excited.  In  fact, 
they  do  not  suffer  so  much  from  chronic  indigestion  as  from  a  delicate  or 
feeble  digestion,  which  is  easily  upset  by  the  slightest  deviation  from 
the  regular  routine.  Children  of  five  or  six  years  have  to  be  fed  as  care- 
fully as  infants  of  eighteen  months  or  two  years.  The  appetite  is  usu- 
ally poor,  and  mothers  are  distressed  because  their  children  eat  so  little, 
yet,  when  food  is  urged  upon  them,  attacks  of  indigestion  follow  with 
singular  uniformity.  The  tongue  is  slightly  coated  the  greater  part  of 
the  time.  The  bowels  are  apt  to  be  constipated,  apparently  more  from 
lack  of  muscular  tone  than  from  anything  else.  From  time  to  time, 
from  slight  causes,  such  as  exposure  to  cold,  or  even  from  fatigue,  there 
may  be  large  quantities  of  mucus  in  the  stools  for  two  or  three  days  at 
a  time,  although  this  is  not  a  prominent  feature  of  most  of  these  cases. 
When  they  are  not  fed  with  the  greatest  care  these  children  suffer  con- 
stantly from  indigestion.  A  moderate  amount  of  anaemia  is  always 
present,  and  this  may  be  the  most  striking  feature. 

The  duration  of  the  condition  depends  very  much  upon  the  cause. 
If  the  cause  is  constitutional  or  inherited,  it  is  likely  to  last  throughout 
childhood,  but  it  often  greatly  improves  about  the  time  of  puberty.  Where 
it  follows  some  acute  illness  it  commonly  lasts  for  a  few  months  only; 
but  the  effect  of  an  acute  attack  of  broncho-pneumonia  or  of  ileo-colitis 
may  continue  for  years.  If  the  malnutrition  is  the  result  only  of  the 
child's  surroundings,  like  the  confinement  incident  to  city  life,  very 
rapid  improvement  may  follow  a  removal  to  the  country.  In  some  chil- 
dren marked  improvement  is  seen  about  the  seventh  year;  in  others,  a 
great  change  comes  at  puberty. 

Diagnosis. — The  physician  should  not  be  too  ready  to  make  a  diag- 
nosis of  simple  malnutrition.  Before  accepting  such  a  diagnosis,  he 
should  examine  the  child  with  the  greatest  care,  to  exclude  the  com- 
mon organic  and  constitutional  diseases.  Much  regarding  inherited  con- 
stitutional tendencies  can  be  learned  from  the  family  history  and  from 
the  condition  of  other  children  in  the  family.  In  the  first  place,  tuber- 
culosis must  be  excluded  by  a  study  of  the  temperature  and  physical  signs 
rather  than  by  the  tuberculin  test.  This  often  gives  a  positive  reaction 
when  no  other  evidence  of  this  disease  exists  and  when  none  develops 


224  NUTRITION. 

subsequently.  It  is  in  such  cases  extremely  doubtful  whether  the  latent 
tuberculous  focus  plays  any  part  in  the  production  of  the  symptoms. 
Other  things  to  be  considered  are  syphilis,  rickets,  chronic  malarial 
poisoning,  diseases  of  the  blood,  intestinal  parasites  and  of  course  organic 
diseases  of  the  lungs,  heart,  stomach,  intestines,  liver,  and  kidneys.  Even 
malignant  disease,  though  rare,  should  not  be  overlooked.  It  may  take 
careful  observation  for  several  days,  and  sometimes  for  weeks,  with 
repeated  physical  examinations,  before  all  these  conditions  can  be  posi- 
tively excluded. 

The  next  step  in  the  diagnosis  is  to  discover  upon  which  one  of  the 
many  possible  causes  malnutrition  depends.  In  private  practice  the 
great  proportion  of  cases  are  due  to  improper  feeding  or  nursing;  next 
in  importance  are  improper  surroundings;  and  last  come  inherited  con- 
stitutional conditions.  In  other  Avords,  most  of  these  children  are  born 
healthy,  but  become  ill  or  delicate  in  consequence  of  improper  manage- 
ment. 

In  older  children,  after  excluding  constitutional  and  local  diseases, 
the  whole  life  of  the  child  must  be  investigated  to  discover  the  funda- 
mental condition  which  is  at  fault.  A  carefully  obtained  history  from 
infancy  is  of  the  greatest  assistance.  It  is  often  difficult,  and  some- 
times impossible,  to  get  at  the  primary  factor,  for  in  cases  of  long  stand- 
ing there  may  be  symptoms  connected  with  almost  every  function  of  the 
body.  One  should  scrutinise  closely  the  quality  and  quantity  of  food 
given,  the  amount  of  sleep,  the  hours  of  study  and  recreation,  the 
amount  of  exercise  in  the  open  air,  and  the  physical  conditions  surround- 
ing the  child.  Usually  the  most  important  factor  in  the  case  can  be 
discovered. 

Prognosis. — This  depends  much  upon  the  cause  of  the  condition;  if 
it  is  one  that  can  be  removed,  the  prognosis  is  good  not  only  for  im- 
provement but  for  complete  recovery.  The  longer  the  condition  has 
lasted  and  the  greater  the  general  disturbance  the  slower  will  be  the 
improvement.  The  great  danger  is  the  supervention  of  some  acute  dis- 
ease while  the  child's  resistance  is  so  greatly  reduced.  Acute  indigestion, 
gastro-enteritis,  and  broncho-pneumonia  are  especially  to  be  dreaded. 

Since  everything  depends  upon  the  fidelity  with  which  directions  as 
to  diet  and  general  management  are  carried  out,  the  cases  which  present 
the  greatest  difficulties  are  those  in  which  these  conditions  are  hardest 
to  control.  When  a  child  is  not  only  suffering  from  malnutrition,  but 
has  been  indulged  and  spoiled  in  every  way  by  anxious  but  unwise  par- 
ents, no  success  is  to  be  expected  unless  the  child  can  be  placed  in  the 
hands  of  an  experienced  and  trustworthy  nurse.  Cases  due  to  improper 
feeding  or  to  bad  surroundings  usually  improve  when  these  are  cor- 
rected, and  the  worse  these  conditions  have  previously  been  the  greater 
the  improvement  to  be  expected.     Those  depending  upon  an  inherited, 


MALNUTRITION.  225 

delicate  constitution  are  not  so  hopeful,  and  require  the  closest  attention 
throughout  childhood. 

Treatment. — This  is  a  problem  of  nutrition  to  be  solved  by  diet  and 
general  management,  drugs  occup3'ing  a  very  small  place. 

In  Infants. — In  very  young  infants  treatment  is  chiefly  a  question  of 
•feeding.  This  should  be  carried  on  according  to  the  rules  given  in  the 
chapter  upon  Feeding  in  Difficult  Cases.  These  children  often  do  fairly 
well  during  the  first  year,  but  after  this  time  frequently  do  very  badly, 
on  account  of  the  failure  to  appreciate  the  fact  that,  although  over 
twelve  months  old,  in  point  of  development  they  resemble  healthy  in- 
fants of  four  or  "five  months,  and  are  to  be  managed  as  such.  If  they 
are  nursing,  weaning  should  often  be  deferred  until  the  sixteenth  or 
eighteenth  month,  or  at  least  partial  nursing  should  be  continued  until 
that  time.  When  cow's  milk  is  begun  it  should  always  be  very  largely 
diluted,  usually  modified  as  for  a  healthy  infant  a  few  months  old. 
Very  rarely  a  child  is  met  with  who  has  an  idiosyncrasy  as  regards 
cow's  milk  and  can  not  take  even  the  smallest  amount  without  marked 
disturbance.  I  have  seen  a  single  feeding  in  which  one  ounce  of  milk 
was  given,  and  that  diluted  three  times,  produce  a  violent  attack  of 
acute  indigestion  which  proved  well-nigh  fatal.  Feeding  during  the 
entire  second  year  should  be  carried  on  very  much  as  in  ordinary  healthy 
children  from  the  sixth  to  the  twelfth  month.  A  deviation  from  this 
rule  almost  invariably  results  disastrously.  One  must  be  guided  as  to 
the  amount  and  character  of  the  food,  not  so  much  by  the  child's  age  as 
by  his  digestive  capacity,  and  in  most  cases  this  is  much  feebler  than 
the  mother  or  even  the  physician  supposes.  In  many  of  these  cases, 
cow's  milk — for  them  the  most  valuable  of  all  foods — has  been  excluded 
from  the  diet,  when  the  only  trouble  is  that  it  has  not  been  given  in 
sufficient  dilution.  For  some  children  it  may  be  partially  peptonised 
during  periods  when  digestion  is  especially  feeble. 

Next  in  importance  to  diet  is  fresh  air.  Often  these  patients  will 
not  improve  with  any  variation  in  diet  until  fresh  air  is  secured.  Then 
increased  digestive  power  is  seen  in  the  course  of  a  few  weeks,  some- 
times in  a  few  days.  The  natural  tendency  of  a  mother  who  has  a 
delicate  infant,  or  one  suffering  from  malnutrition,  is  to  house  it  closely 
and  never  allow  it  a  breath  of  fresh  air.  It  is  of  the  greatest  assistance 
if  these  children  can  be  sent  to  a  warm  climate  for  the  winter.  If  this 
is  not  possible,  fresh  air  may  be  obtained  by  changing  apartments,  or 
by  an  airing  in  the  room  with  the  windows  open.  In  the  beginning 
this  should  be  done  for  a  few  minutes  only,  the  time  being  gradually  in- 
creased to  two  or  three  hours  each  day.  The  child  should  be  clothed 
as  for  the  street,  and,  if  necessary,  hot  bottles  should  be  placed  at  the 
feet. 

Cold  sponging  is  another  valuable  tonic.  After  the  morning  bath  is 
16 


226  NUTRITION. 

given,  at  95°  F.,  the  entire  body  should  be  sponged  for  a  moment  only, 
with  water  at  a  temperature  of  60°,  or  even  55°  F.  This  produces  a 
certain  amount  of  shock  and  causes  loud  crying,  which  is  of  itself 
beneficial.  How  frequently  this  should  be  done  will  depend  upon  the 
reaction  following  it.  If  the  child  remains  blue  and  cold  for  some  time 
afterward,  the  cold  sponging  should  not  be  repeated.  If  there  is  a  good 
reaction,  it  may  be  used  daily. 

Friction  and  massage  are  useful  in  many  cases.  The  child  should  be 
laid  upon  the  lap  of  the  nurse,  if  possible  before  an  open  fire,  and  should 
always  be  covered  with  a  blanket.  The  entire  body  should  then  be  rubbed 
for  ten  or  twenty  minutes  with  the  bare  hand,  or,  better,  with  cocoa 
butter.  Simple  rubbing  may  be  used,  or  the  movements  of  massage  em- 
ployed. If  the  latter,  they  should  be  very  gentle  at  first,  and  only  for 
a  short  time.  Professional  operators  are  inclined  to  be  too  energetic 
for  little  children.  There  is  no  advantage  in  rubbing  with  cod-liver  oil 
instead  of  cocoa  butter,  while  the  odour  makes  it  decidedly  objectionable. 

The  only  tonics  I  have  found  of  much  value  are  iron,  nux  vomica, 
and  cod-liver  oil.  Nux  vomica  may  be  given  alone  or  with  wine.  Cod- 
liver  oil  is  too  much  used  in  these  eases,  and  in  too  large  doses.  Many  of 
these  infants  can  not  take  it  at  all.  It  should  rarely  be  given  when  the 
tongue  is  coated  and  the  appetite  very  poor.  The  dose  should  always  be 
small,  e.  g.,  ten  drops  of  the  pure  oil  three  times  a  day,  or  twice  as  much 
of  an  emulsion.  Olive  oil  in  many  eases  is  better  borne  and  quite  as 
efficacious;  it  may  be  given  in  half  or  teaspoonful  doses  three  times  a 
day. 

The  secret  of  success  in  treating  cases  of  malnutrition  is,  to  hold  the 
patient  to  a  regular  routine  in  feeding,  sleeping,  and  in  everything  relat- 
ing to  his  life.  Experiments  are  nearly  always  unfortunate.  The  physician 
should  lay  down  in  writing,  for  the  guidance  of  the  mother,  specific  rules 
with  regard  to  the  amount  of  food,  the  time  at  which  it  is  to  be  given, 
the  hours  for  bathing,  sleep,  and  airing.  He  should  see  the  patient  at 
regular  intervals  and  often  enough  to  be  sure  that  his  orders  are  being 
enforced.  Good  results  are  obtained  only  by  constant  watchfulness,  and 
although  improvement  may  not  be  seen  at  once,  it  is  in  most  cases  sure 
to  come  if  the  mother  will  co-operate.  In  my  own  experience  no  class 
of  patients  have  given  me  so  much  satisfaction  as  cases  of  malnutrition 
in  infancy.' 

In  Older  Children. — The  same  general  principles  are  to  be  applied 
to  them  as  to  infants.  The  diet  is  of  the  first  importance.  Only  the 
simplest,  plainest,  and  most  easily  digested  articles  of  food  should  be 
given.  The  problem  is  to  secure  the  maximum  nutritive  value  in  the 
food  with  the  minimum  tax  on  the  digestive  organs.  Milk,  beef,  eggs, 
the  lighter  and  more  easily  digested  cereals,  bread,  and  fruit  should 
form  the  diet.    All  sweets,  pastry,  highly  seasoned  food,  candy,  nuts,  tea. 


MARASMUS.  227 

and  coffee  should  be  absolutely  prohibited,  and,  in  fact,  all  the  articles 
mentioned  as  "  forbidden  "  in  the  chapter  on  the  Feeding  of  Older  Chil- 
dren. When  the  appetite  is  poor  and  simple  food  not  well  taken,  the 
child  should  not  be  allowed  to  take  indigestible  articles  for  the  sake  of 
eating  something.  Nothing  should  be  given  l)etwcen  meals,  and  regular 
hours  of  feeding  must  be  followed.  Usually  I  have  found  three  meals 
a  day,  for  children  over  three  years  old,  better  than  the  practice  of  giv- 
ing more  frequent  feedings.  But  this  is  not  always'  the  case.  Under 
no  circumstances  should  children  be  coaxed,  urged,  or  hired  to  eat; 
much  less  should  they  be  forced  to  do  so.  There  is  a  popular  misap- 
prehension in  regard  to  the  variety  in  diet  wliich  children  need.  Most 
cases  do  better  when  a  very  simple  and  fairly  uniform  diet  is  continued. 

The  nervous  factor  is  a  very  large  and  a  very  important  one.  Many 
of  these  children  are  essentially  cases  of  neurasthenia  at  as  early  an 
age  as  four  or  five  years.  Excitement  and  activity  are  what  they  crave 
and  what  must  be  most  carefully  avoided. 

The  general  habits  of  children  should  be  directed;  there  should  be 
regular  and  early  hours  for  retiring,  freedom  from  undue  excitement, 
and  interest  should  be  awakened  in  out-of-door  amusements.  A  pony  or 
dog  will  be  found  useful.  Children  should  be  kept  as  much  as  possible 
in  the  open  air,  but  the  amount  of  active  exercise  should  be  strictly 
limited.  Usually  they  do  much  better  if  they  can  be  in  the  country 
during  the  entire  year.  Only  a  limited  amount  of  reading  and  study 
should  be  allowed;  and  if  children  are  at  school,  care  should  be  taken 
that  overpressure  is  not  the  cause  of  the  symptoms,  particularly  in  an 
ambitious  child.  The  cold  sponging  given  in  the  morning,  as  described 
in  the  introductory  chapter  on  General  Therapeutics,  is  extremely  bene- 
ficial to  children  who  take  cold  readily.  Massage  is  useful  for  the  benefit 
which  it  affords  to  the  chronic  constipation  which  is  so  frequently  a 
symptom  of  malnutrition. 

Of  the  tonics,  iron,  arsenic,  and  cod-liver  oil  are  required  in  most 
cases,  and  the  amount  and  combination  may  be  varied  from  time  to  time, 
with  the  season  of  the  year  and  the  condition  of  the  child's  digestion. 
In  general,  these  children  require  early  hours,  a  simple  diet,  a  quiet, 
regular  life,  and  very  little  medicine. 

MARASMUS. 
{Infantile  Atrophy;  Simple  Wasting.) 

"Wasting  is  a  symptom  of  many  conditions  in  infancy.  It  occurs  in 
tuberculosis,  in  infantile  syphilis,  and  also  as  a  result  of  acute  or  chronic 
disease  of  the  stomach  and  intestines.  Cases  of  wasting  dependent  upon 
such  causes  are  not  included  in  this  chapteri 

Marasmus  is  the  extreme  form  of  malnutrition  seen  in  infancy,  oc- 


228  NUTRITION. 

curring,  so  far  as  is  known,  without  constitutional  or  local  organic 
disease.     It  is  a  vice  of  nutrition  only. 

Etiology. — Marasmus  is  not  very  often  seen  in  the  country  or  in 
private  practice;  but  it  is  frequent  in  dispensary  practice  in  all  large 
cities,  and  is  especially  common  in  institutions  for  young  infants.  In 
my  own  experience  in  four  institutions,  more  than  one  half  the  deaths 
under  one  year  were  directly  or  indirectly  from  this  cause.  Marasmus  is 
a  very  large  factor  in  the  immense  infant  mortality  of  large  cities  in 
summer.  Although  the  cause  of  death  is  usually  reported  under  some 
other  name,  the  determining  factor  in  the  fatal  result  is  the  previous 
marantic  condition  of  the  patient.  The  primary  cause  may  be  a  con- 
genital weakness  of  constitution  which  may  depend  upon  heredity.  It 
is  often  seen  in  premature  children  and  in  the  illegitimate  offspring 
of  girls  of  sixteen  or  eighteen.  In  the  vast  majority  of  cases,  however, 
it  depends  upon  two  factors-^the  food  and  the  surroundings.  Among 
the  poor  who  live  in  tenements,  infants  who  arc  artificially  fed  almost 
invariably  do  badly.  This  is  due  to  ignorance  in  regard  to  the  proper 
methods  of  infant  feeding  and  inability  to  procure  what  the  child  re- 
quires, especially  pure  cow's  milk.  A  country  infant  may  be  neglected 
in  many  respects,  and  is  often  badly  fed ;  but  he  has  plenty  of  pure  air, 
and  usually  thrives.  In  the  city,  as  long  as  an  infant  has  a  plentiful 
supply  of  good  breast-milk  he  continues  to  do  well  in  most  instances,  in 
spite  of  the  fact  that  his  surroundings  are  bad.  When  there  are  not  only 
bad  feeding  and  unhealthful  surroundings,  but  also  an  inherited  con- 
stitutional vice,  we  have  all  the  factors  required  to  produce  marasmus 
in  its  most  marked  form.  The  odds  are  so  against  the  infant  that  the 
feeble  spark  of  vitality  flickers  for  a  few  months  .only  and  gradually 
goes  out 

Another  prominent  factor  in  the  production  of  marasmus  is  the 
overcrowding  of  infants  in  institutions.  Even  though  artificially  fed 
after  the  most  approved  methods,  I  have  seen  scores  of  infants  who  were 
plump  and  healthy  on  admission  lose  little  by  little,  until  at  the  end  of 
three  or  four  months  they  had  become  wasted  to  skeletons — hopeless 
cases  of  marasmus,  dying  of  some  mild  acute  illness,  such  as  an  attack 
of  indigestion  or  bronchitis,  the  essential  cause,  however,  being  maras- 
mus. The  common  mistake  is  that  of  placing  too  many  children  in  one 
ward,  with  no  chance  of  obtaining  a  proper  amount  of  fresh  air.  No 
house-plant  is  more  delicate  or  sensitive  to  its  surroundings  than  is  an 
infant  during  the  first  few  months  of  life. 

Lesions. — The  post-mortem  findings  in  cases  of  marasmus  are  ex- 
ceedingly unsatisfactory,  and  throw  little  if  any  light  upon  the  disease. 
Every  now  and  then  general  tuberculosis  is  discovered  in  patients  dying 
apparently  of  marasmus,  the  existence  of  which  was  not  previously 
suspected.     An  occasional  lesion  is  fatty  liver.     This  may  lead  to  such 


MARASMUS.  229 

enlargement  of  the  organ  that  its  weight  is  increased  by  one  half.  Both 
to  the  naked  eye  and  imder  the  niicrost'ope  the  usual  changes  of  fatty 
infiltration  are  present,  often  to  an  extreme  degree.  In  the  past  too 
much  has  doubtless  been  made  of  this  condition  of  the  liver  in  maras- 
mus. From  figures  given  elsewhere  (see  article  on  Fatty  Liver),  it 
will  be  observed  that  the  lesion  is  not  more  frequent  in  this  condition 
than  in  infants  dying  from  other  diseases.  The  most  marked  examples 
are  seen  in  cases  of  marasmus  which  liave  lasted  for  seven  or  eight 
months.  Its  exact  relation  to  the  condition  of  wasting  has  not  yet  been 
determined. 

With  these  exceptions  the  autopsies  show  nothing  striking,  and  I 
have  had  the  opportunity  to  make  at  least  two  hundred  of  them.  The 
lesions  usually  found  are  the  following:  Tlie  brain  is  commonly  anaemic, 
with  dark  fluid  blood  in  the  sinuses,  marantic  thrombi  being  rare.  A 
strip  of  hypostatic  pneumonia,  from  one  to  two  inches  wide,  may  be 
seen  along  the  posterior  border  of  both  lungs,  involving  the  lung  to  the 
depth  of  half  an  inch,  or  less.  In  the  younger  infants  there  are  fre- 
quently areas  of  atelectasis  in  the  lower  lobes.  The  pleura  is  almost 
invariably  normal.  The  heart  is  pale,  with  perhaps  a  slight  increase  in 
the  pericardial  fluid.  The  spleen  and  kidneys  are  pale,  but  otherwise 
normal.  The  stomach  may  be  dilated ;  the  mucous  membrane  is  usually 
pale,  often  coated  with  tenacious  mucus.  The  intestines  contain  undi- 
gested food,  sometimes  mucus.  The  solitary  follicles  of  the  colon  and 
small  intestine,  and  sometimes  Peyer's  patches,  are  slightly  enlarged, 
the  mucous  membrane  in  other  respects  being  normal.  The  mesenteric 
glands  are  often  slightly  enlarged.  In  addition  to  the  above,  there  may 
be  evidence  of  some  recent  infection,  which  has  been  the  cause  of  death; 
there  may  be  acute  bronchitis,  broncho-pneumonia,  or  intestinal  catarrh. 

The  above  lesions  represent  what  has  been  found  in  the  great  major- 
ity of  the  cases,  and  very  disappointing  they  are  to  one  who  sees  them 
for  the  first  time.  Xor  does  the  microscopical  examination  of  the  organs 
throw  any  light  upon  these  cases.  I  have  personally  examined  with  care 
the  stomach  and  intestines  of  more  than  a  dozen  cases,  several  of  them 
in  which  autopsies  were  made  only  two  or  three  hours  after  death,  with- 
out finding  anything  of  pathological  importance.  The  theory  advanced, 
that  atrophy  of  the  intestinal  tubules  is  the  explanation  of  marasmus, 
has  found  little  support. 

The  condition  of  marasmus  seems  rather  to  be  a  failure  of  assimila- 
tion, owing  to  imperfect  digestion,  improper  food,  unhygienic  surround- 
ings, or  feeble  constitution.  As  a  result,  there  is  a  progressive  loss  in 
weight,  feeble  circulation,  imperfect  lung  expansion,  imperfect  oxida- 
tion of  the  blood,  lowered  body  temperature,  and,  finally,  a  deterioration 
of  the  blood  itself.  Each  of  these  effects  becomes  in  turn  a  cause  ag- 
gravating all  the  others,  continuing  until  a  condition  is  reached  which 


230 


NUTRITION. 


is  incompatible  with  life,  for  resistance  becomes  so  feeble  that  the  slight- 
est functional  disturbance  proves  fatal. 

Symptoms. — The  general  history  of  these  cases  is  strikingly  uniform. 
The  following  is  the  story  most  frequently  told  at  the  hospital :  '*  At 
birth  the  baby  was  plump  and  well  nourished,  and  continued  to  thrive 
for  a  month  or  six  weeks  while  the  mother  was  nursing  it;  at  the  end 
of  that  period,  circumstances  made  weaning  necessary.     From  that  time 


Fig.  32. 


-Marasmus;  a  Patient  in  the  Babies'  Hospital,  Ten  Months  Old,  Weight 
Six  Pounds.     Weight  at  birth  reported  to  have  been  nine  pounds. 


the  child  ceased  to  thrive.  It  began  to  lose  weight  and  strength,  at  first 
slowly,  then  rapidly,  in  spite  of  the  fact  that  every  known  form  of  infant- 
food  was  tried.'*  As  a  last  resort  the  child,  wasted  to  a  skeleton,  is 
brought  to  the  hospital. 

The  most  constant  symptom  is  a  steady  loss  in  weight  until  a  con- 
dition of  extreme  wasting  is  reached,  at  which  point  they  may  remain 
for  many  weeks.    The  general  appearance  of  these  patients  is  character- 


MARASMUS.  231 

istic.  They  have  an  old  look ;  the  skin  is  wrinkled,  has  lost  its  tone,  and 
hangs  in  folds  upon  the  extremities  (Fig.  32).  The  legs  are  like  drum- 
sticks; the  abdomen  is  prominent;  the  temples  are  hollow;  the  fontanel 
is  sunken ;  the  eyes  large ;  the  features  sharp ;  and  the  hands  resemble 
bird-claws.  Often  the  children  are  reduced  literally  to  skin  and  bones. 
Anaemia  is  a  very  marked  and  almost  a  constant  symptom,  the  amount 
of  haemoglobin  being  frequently  reduced  to  thirty  per  cent,  and  in  one 
of  my  cases  to  eighteen  per  cent.  Anaemic  heart-murmurs  are  frequently 
heard.  The  body  temperature  is  usually  subnormal,  vmless  artificial  heat 
is  used.  A  rectal  temperature  of  95°  or  9G°  F.  is  very  common,  and  one 
of  93°  or  94°  F.  is  occasionally  seen.  In  addition  to  the  pallor  of  the 
face,  there  may  be  a  leaden  hue  due  to  congenital  or  acquired  atelec- 
tasis. A  frequent  symptom  is  general  oedema.  The  first  thing,  which 
calls  attention  to  this  is  often  an  unexpected  gain  in  weight.  The 
oedema  may  increase  until  the  cellular  tissue  of  the  whole  body  is  affected. 
I  have  never,  however,  seen  effusions  into  the  large  cavities,  ffidema  is 
usually  associated  with  marked  anaemia,  and  is  generally  a  bad  symptom. 
The  stools  are  sometimes  normal,  but  usually  contain  undigested  food, 
and  are  large  in  proportion  to  the  amount  of  food  taken.  No  matter 
how  carefully  fed,  these  patients  are  easily  upset.  Now  and  then  mucus 
is  seen  in  the  stools,  but  this  is  neither  a  constant  nor  a  marked  feature. 
Vomiting  is  excited,  from  the  slightest  cause,  and  often  food  is  re- 
gurgitated almost  as  soon  as  swallowed.  The  appetite,  in  a  severe  case, 
is  almost  entirely  lost;  children  refuse  to  take  food  from  the  bottle  or 
spoon,  and  unless  fed  by  gavage  they  die  of  inanition.  In  the  earlier 
cases  there  may  be  an  unnatural  hunger,  so  that  the  children  cry  much 
of  the  time,  and  are  relieved  only  when  the  bottle  is  given. 

The  complications  are  thrush,  erythema  of  the  buttocks,  and  bedsores, 
sometimes  over  the  sacrum  and  heels,  but  most  frequently  upon  the 
occiput.  Occasionally  there  is  seen  a  reflex  spasm  of  the  muscles  of  the 
neck,  producing  a  marked  opisthotonus,  which  may  last  for  several  days 
or  weeks. 

The  course  of  the  disease  in  most  cases  is  steadily  downward.  It 
may  be  cut  short  at  any  time  by  acute  disease.  Frequently  these  infants 
die  suddenly  Avhen  apparently  they  are  as  well  as  they  have  been  for 
several  weeks.  In  many  instances  the  autopsy  reveals  no  explanation  of 
the  sudden  death;  but  in  other  cases  it  may  be  due  to  the  regurgitation 
of  food,  and  its  aspiration  into  the  larynx,  the  patient  being  too  weak  to 
cough.  Earel}^,  death  occurs  from  convulsions.  In  summer,  these  chil- 
dren wilt  with  the  first  days  of  very  hot  weather,  and  die  often  in  a  few 
hours  from  a  slight  functional  derangement  of  the  stomach  and  bowels. 

Diagnosis. — No  sharp  line  can  be  drawn  between  marasmus  and  mal- 
nutrition. In  the  wasting  which  follows  chronic  disease  of  the  stomach 
and  intestines  there  is  usually  a  history  of  an  antecedent  acute  attack. 


232  NUTRITION. 

Not  infrequently  tuberculosis  is  found  at  autopsy,  even  in  infants  of  a 
few  months,  in  whom  there  have  been  no  symptoms  except  those  of  ma- 
rasmus; but  during  life  tuberculosis  may  now  be  recognised  in  most 
cases  by  the  von  Pirquet  skin  test. 

Prognosis. — This  depends  on  the  age  of  the  infant  and  the  extent 
and  duration  of  the  disease.  If  the  child  is  over  eight  months  old,  the 
chances  of  recovery  are  much  better  than  in  one  under  four  months,  for 
the  fact  that  it  has  lived  so  long  is  generally  evidence  of  pretty  strong 
vitality.  Very  young  infants  are  always  difficult  subjects  to  deal  with. 
They  go  down  more  rapidly,  and  build  up  more  slowly  than  those  who 
are  older.  In  most  other  circumstances  the  prognosis  is  much  worse 
in  cases  of  long  duration.  In  a  given  case  much  depends  upon  whether 
everything  possible  can  be  done  for  the  child :  whether  a  wet-nurse  can 
be  secured  or  artificial  feeding  done  in  the  best  manner,  and  whether  the 
patient  can  have  the  benefit  of  the  best  surroundings,  in  the  country  in 
summer  and  in  winter  a  warm  climate  where  it  can  be  kept  out  of  doors 
the  greater  part  of  the  time.  In  institutions  cases  under  four  months  old 
are  usually  hopeless.  Of  those  over  eight  months  quite  a  proportion  can 
be  saved  by  proper  treatment,  even  though  the  body-weight  is  reduced  to 
eight  or  nine  pounds.  When  recovery  occurs  it  may  be  complete,  and 
the  child  at  two  or  three  years  may  be  as  vigorous  as  any  child  of  its 
age.  All  these  statements  refer  only  to  cases  of  simple  marasmus.  The 
presence  of  organic  disease  puts  the  case  into  another  category. 

Treatment. — The  most  important  is  that  which  relates  to  prophy- 
laxis. Maternal  nursing  should  be  encouraged  by  every  possible  means 
especially  among  the  poor.  For  those  who  must  be  artificially  fed  the 
important  things  are  a  pure  milk  supply  together  with  proper  instruc- 
tion as  to  how  it  is  to  be  used  in  infant  feeding.  At  the  same  time  op- 
portunities for  fresh  air  should  be  secured.  This  is  a  large  part  of  the 
difficulty  in  institutions.  At  least  one  thousand  cubic  feet  per  patient 
should  be  secured  with  proper  ventilation  and,  what  is  almost  as  essential, 
adequate  nursing. 

As  far  as  possible,  wet-nurses  should  be  obtained  if  the  infants  are 
under  four  months  old.  For  these  very  young  patients  success  by  arti- 
ficial feeding  is  generally  impossible.  With  those  of  six  months  or  over, 
good  artificial  feeding  is  very  frequently  successful.  In  modifying  cow's 
milk  for  these  cases  the  formulas  most  likely  to  agree  are  those  with  low 
fat,  low  protein — partially  peptonised  in  many  cases — and  relatively 
high  sugar.  Further  suggestions  will  be  found  in  the  chapter  on  Feed- 
ing in  Difficult  Cases.  In  institutions  we  seldom  succeed  without  wet- 
nurses. 

For  very  young  infants,  with  a  temperature  which  is  habitually  sub- 
normal, some  means  of  maintaining  the  body  heat  must  be  employed. 
The  simplest  and  usually  an  effective  means  is  to  oil  the  body  and  en- 


SCORBUTUS  233 

velop  it  completely  in  a  cotton  jacket  and  then  surround  it  with  hot- 
water  bags  or  bottles.  The  general  management  should  be  much  the 
same  as  described  in  the  chapter  on  Malnutrition.  They  require  no 
drugs,  but  a  great  deal  of  careful  nursing. 


CHAPTER    VI. 

DISEASES  DUE   TO   FAULTY  NUTRITION. 

The  diseases  due  to  faulty  nutrition  are  numerous.  There  are  two, 
however,  which  have  been  so  clearly  shown  to  originate  in  this  way  that 
they  may  be  put  in  a  class  by  themselves.  These  are  scorbutus  and 
rickets.  The  prevailing  opinion  of  the  medical  profession  is  that  both 
of  these  are  essentially  "  food-diseases."  The  purpose  of  considering 
them  in  connection  with  the  disturbances  of  nutrition  is  to  emphasise 
this  relationship. 

SCORBUTUS    {Scurvy). 

Scorbutus  is  a  constitutional  disease  due  to  some  prolonged  error  in 
diet.  It  is  characterised  by  spongy,  bleeding  gums,  swellings  and  ecchy- 
moses  about  the  joints,  especially  the  knee  and  ankle,  ha3morrhages  from 
the  nose,  and  occasionally  from  other  mucous  membranes,  extreme  hy- 
peresthesia, and  often  pseudo-paralysis  of  the  lower  extremities.  Added 
to  these  local  symptoms  there  is  in  advanced  cases  a  general  cachexia 
with  marked  ansemia.  While  scorbutus  and  rickets  are  very  frequently 
associated,  they  can  not  be  considered  as  different  forms  of  the  same 
disease.  Cases  of  scorbutus  were,  however,  described  in  older  writings 
under  the  title  of  Acute  Rickets. 

Scurvy  was  well  recognised  and  graphically  described  by  Glisson  as 
long  ago  as  the  middle  of  the  seventeenth  century.  For  our  modern 
knowledge  of  the  pathology  of  this  disease  we  are  indebted  to  the  obser- 
vations of  Barlow  and  Cheadle.  On  the  continent  of  Europe  scurvy  is 
most  frequently  known  as  Barlow's  disease. 

For  the  statistical  matter  here  presented  I  am  indebted  to  the  report 
of  the  American  Paediatric  Society's  Collective  Investigation  of  Infantile 
Scurvy  in  1898,  embracing  379  cases,  reported  by  138  observers.  Of 
these,  31  cases  were  from  my  own  practice. 

Etiology. — Age  is  an  important  factor;  more  than  four-fifths  of  the 
cases  occur  between  the  sixth  and  the  fifteenth  months,  and  half  of 
them  between  the  seventh  and  the  tenth  months.  Scurvy  has  been  seen 
in  infants  under  a  month  old.  The  great  majority  of  the  cases  reported 
have  been  observed  in  private  practice,  often  in  the  best  surroundings. 
Previous  disease  is  not  a  factor  of  much  importance.     Most  of  the  chil- 


234  NUTRITION. 

dren  attacked  have  been  in  good  health  up  to  the  development  of  scurvy. 
In  about  one-fourth  of  the  number  some  previous  derangement  of  the 
digestive  tract  has  existed. 

The  only  etiological  factor  yet  known  to  bear  any  constant  relation 
to  the  production  of  scurvy  is  diet.  The  important  facts  regarding  the 
previous  diet  brought  out  by  the  Society's  investigation  are  as  follows : 

'  Breast-milk in    12  cases;  alone  in  10. 


Previous  food  ^ 


Raw  cow's  milk 

Pasteurised  milk 

Condensed  milk 

Sterilised  milk 

^  Proprietary  infant-foods 


5  "  "  "    4. 

20  "  "  "  16. 

60  "  "  "  32. 

107  "  "  "  68. 

214  " 


This  table  shows  that  while  scurvy  may  occasionally  develop  with 
almost  any  variety  of  food,  three  stand  out  prominently — viz.,  pro- 
prietary infant-foods,  condensed  milk,  and  sterilised  milk.  In  all  of 
these  it  would  appear  that  something  needed  for  normal  healthy  nutri- 
tion is  wanting.  Scurvy  is  not  likely  to  follow  unless  an  improper  diet 
is  continued  for  a  long  period,  usually  several  months.  In  some  in- 
stances where  it  developed  in  nursing  infants,  the  nurse's  milk  has  been 
examined  and  found  totally  inadequate  to  the  needs  of  nutrition,  many 
of  the  children  having  exhibited  serious  disturbances  of  nutrition  before 
any  signs  of  scurvy  appeared. 

In  several  of  the  cases  reported  as  occurring  with  a  diet  of  raw  or 
pasteurised  milk  it  seems  certain  that  the  milk  formula  used  was  at  fault, 
the  most  common  error  in  those  I  have  seen  being  low  protein.  Several 
cases  have  come  under  my  personal  observation  where  children  had  been 
kept  for  four  or  five  months  upon  percentages-  which  should  have  been 
continued  only  a  few  weeks.  However,  I  have  seen  at  least  three  cases 
of  scurvy  which  developed  while  taking  pasteurised  milk  where  the  per- 
centages employed  could  hardly  have  been  the  explanation,  and  the 
heating  (167°  F.  for  thirty  minutes)  seemed  to  be  the  cause.  However, 
I  believe  scurvy  to  be  an  exceedingly  rare  result  of  the  pasteurisation  of 
milk,  80  rare,  indeed,  as  not  to  be  weighed  against  its  immense  advan- 
tages. With  the  lower  temperature  now  generally  employed  (155°  F.) 
it  need  not  be  feared.  The  number  of  cases  occurring  while  upon  a 
diet  of  sterilised  milk  (usually  heated  to  212°'  F.  for  one  hour)  is  so 
large  that  we  are  driven  to  the  conclusion  that  the  heating  alone  was  the 
cause,  especially  since  prompt  recovery  has  frequently  followed  when 
no  other  change  was  made  than  to  discontinue  the  heating.  These  facts 
show  that  sterilised  milk  should  not  be  continued  as  the  sole  diet  for 
long  periods — i.  e.,  for  several  months — and  that  its  possible  danger 
should  be  kept  in  mind. 

No  one  fact  in  the  etiology  of  scurvy  is  better  established  than  its 
development  after  the  prolonged  use  of  condensed  milk  or  the  propri- 


SCORBUTUS.  235 

etary  infant-foods.  Scurvy  occurs  not  only  when  the  foods  are  used 
with  condensed  or  with  sterilised  milk,  but  also,  though  less  frequently, 
with  fresh  milk.  The  inference  is  that  these  preparations  cause  scurvy 
not  only  by  what  they  lack,  but  possibly  by  something  wliieb  they  contain. 
Some  have  ascribed  the  results  to  the  ferments  present.  This  view  has 
some  support  in  the  occurrence  of  scurvy  after  the  prolonged  use  of  pep- 
tonised  milk,  an  infrequent  but  a  well-established  fact.  In  this  respect, 
as  with  reference  to  sterilised  milk,  my  personal  experience,  including 
now  nearly  one  hundred  cases  of  scurvy,  coincides  with  the  findings  of 
the  Society's  report. 

While  it  may  be  regarded  as  established  that  the  cause  of  scurvy  is 
dietetic,  no  single  dietetic  error  can  be  held  responsible  for  the  disease. 
None  of  the  theories  yet  advanced  in  explanation  of  how  diet  causes 
scurvy  is  wholly  satisfactory. 

Lesions. — The  most  marked  effects  of  scurvy  are  seen  in  the  bones, 
blood-vessels,  and  the  blood.  The  number  of  recorded  autopsies  is  not 
large,  only  six  being  included  in  the  Society's  report.  I  have  myself 
had  the  opportunity  of  making  examinations  in  three  cases.  The  find- 
ings are  remarkably  uniform,  but  represent,  of  course,  the  extreme  re- 
sults of  the  disease.  The  most  striking  lesion  is  subperiosteal  haemor- 
rhage, which  is  practically  constant  and  may  occur  almost  anywhere 
in  the  body,  but  affects  chiefly  the  bones  of  tlie  lower  extremities;  it  is 
often  very  extensive,  and  may  reach  from  the  knee  to  the  great  trochanter, 
or  from  the  ankle  nearly  to  tlie  knee.  Extravasations  may  also  be 
found  between  the  muscles,  and  blood  may  infiltrate  the  cellular  tissue 
in  the  neighbourhood  of  the  joints.  Besides  these  lesions  resulting 
from  haemorrhagic  periostitis  the  bone  itself  may  be  affected.  Separa- 
tion of  the  epiphysis  from  the  shaft  of  some  of  the  long  bones,  gen- 
erally at  the  lower  end  of  the  femur  or  lower  end  of  the  tibia,  is  found 
in  most  of  the  fatal  cases.  Notwithstanding  the  serious  lesions  near 
the  large  joints,  the  joints  themselves  are  usually  normal. 

The  minute  bone  changes  are  somewhat  similar  to  those  of  rickets. 
But  there  are  also  differences  of  importance.  The  disposition  to  haemor- 
rhage, which  is  altogether  the  most  characteristic  feature  of  scurvy,  is 
entirely  wanting  in  rickets.  The  visceral  lesions  are  inconstant.  Those 
most  frequently  found  are  small  haemorrhages  beneath  the  pleura, 
pericardium,  and  peritonaeum,  sometimes  into  the  various  organs, 
also  broncho-pneumonia,  and  nephritis.  There  may  be  small  ex- 
travasations found  upon  the  surface  of  any  of  the  mucous  membranes. 
The  alterations  in  the  blood-vessels  are  undoubtedly  an  important 
factor  in  bringing  about  the  disposition  to  haemorrhage,  but  as  yet 
they  have  been  very  imperfectly  studied.  The  changes  in  the  blood, 
in  the  gums,  and  the  lesions  of  the  skin  will  be  considered  with  the 
symptoms. 


236  .    •  NUTRITION. 

Symptoms. — In  many  cases  a  period  of  indisposition,  fretfulness, 
pallor,  and  failing  nutrition  precedes  the  local  symptoms,  but  usually 
tenderness  of  the  legs  is  the  first  symptom  noticed.  In  the  beginning 
this  is  occasional  and  so  slight  as  to  cause  the  infant  to  cry  only  upon 
being  handled.  Later  it  becomes  almost  constant  and  is  very  acute.  At 
first  this  soreness  is  not  very  definitely  localised,  but  is  generally  more 
marked  about  the  knees  and  ankles.  Some  swelling  may  be  noticed, 
often  just  above  the  ankle-joints.  Coincident  with  these  may  be  seen 
the  changes  in  the  mouth.  The  gums  are  of  a  deep  purplish  colour, 
swollen,  particularly  about  the  upper  central  incisors,  and  may  quite 
cover  the  teeth.  They  bleed  from  the  slightest  irritation,  and  sometimes 
spontaneously.  The  child  now  becomes  fretful  and  cross,  sleeps  badly, 
loses  colour,  weight,  and  appetite.  He  may  become  quite  cachectic  in 
appearance.  All  these  symptoms  come  on  very  gradually,  often  with 
periods  of  a  few  days  in  which  apparent  improvement  is  seen.  Some- 
times they  may  continue  for  several  weeks  without  making  any  percep- 
tible impression  upon  the  child's  previously  good  condition. 


Fig.  33. — Scuuvy  Showing  Characteristic  Swellings  and  Posture.  Patient  8i  months 
old,  fed  exclusively  upon  malted  milk  after  the  age  of  3  months.  Epiphyseal  separa- 
tion at  the  upper  extremity  of  both  humeri,  lower  extremity  of  both  femora  and  lower 
extremity  of  left  tibia.     Prompt  and  complete  recovery. 

If  the  disease  is  recognised,  and  proper  treatment  instituted,  rapid 
improvement  follows,  with  complete  and  permanent  recovery.  If  not 
recognised,  and  the  faulty  diet  is  continued,  the  disease  advances  to  the 
more  severe  form.  The  tenderness  of  the  legs  becomes  exquisite,  so  that 
any  movement  or  even  the  slightest  touch  causes  the  child  to  scream 
with  pain  or  apprehension.  The  posture  is  very  characteristic.  There 
is  semiflexion  of  thighs  and  legs  and  outward  rotation  at  the  hip.  (See 
Fig.  33.)  In  this  position  the  child  often  lies  motionless  and  voluntary 
movements  of  the  extremities  can  not  be  excited.  Paralysis  is  often  sus- 
pected. The  disability  is  chiefly  owing  to  the  extreme  pain  which  mo- 
tion provokes,  but  may  depend  upon  epiphyseal  separation.  Small 
ecehymoses  are  frequently  seen  about  any  of  the  large  joints,  resembling 


SCORBUTUS.  237 

the  ordinary  "  black-and-blue  "  spots,  and  these  often  confirm  the  opin- 
ion previously  formed  triat  the  chikl  has  met  with  some  accident.  The 
swelling  near  the  joints,  particularly  the  knee,  may  be  so  great  that  the 
limb  is  nearly  twice  the  size  of  its  fellow.  The  mouth  symptoms  are 
usually  striking.  In  addition  to  spongy,  swollen,  bleeding  gums,  dark 
purplish  bags  may  be  seen  over  teeth  not  yet  through.  There  may  be 
bleeding  from  the  roof  of  the  mouth  or  from  the  pharynx.  The  pain  is 
sometimes  so  severe  as  seriously  to  interfere  with  taking  food ;  there  is 
moderate  though  rarely  extreme  salivation.  Blood  may  be  vomited  or 
passed  with  the  fasces  or  the  urine.  In  the  severe  cases  the  stools  are 
rarely  normal,  more  or  less  catarrhal  colitis  usually  being  present.  The 
general  condition  is  one  of  grave  anaemia,  accompanied  by  a  marked 
cachexia  and  progressive  wasting.  The  child  cries  almost  constantly, 
sleeps  little,  and  is  truly  a  pitiable  object.  Slight  fever  is  often  present. 
Unless  recognised  and  the  cause  removed,  the  condition  grows  steadily 
worse,  the  symptoms  continuing  until  death  occurs  either  by  a  slow 
asthenia,  or  suddenly  from  heart  failure,  or  from  some  intercurrent 
disease,  sucli  as  broncho-pneumonia  or  acute  gastro-enteritis.  The  dura- 
tion of  the  illness  in  the  fatal  cases  is  from  two  to  four  months. 

The  onset  is  gradual  in  the  great  majority  of  the  cases,  the  earliest 
symptoms  noticed  in  the  order  of  frequency  being  pain  and  tenderness 
of  the  legs,  soreness  and  sponginess  of  the  gums,  disability,  anaemia, 
cutaneous  haemorrhages,  and  very  rarely  haematuria. 

Pain  and  tenderness  are  very  prominent,  being  noted  in  95  per  cent 
of  the  Society's  cases ;  in  the  majority  they  were  present  only  on  motion 
or  handling.  The  location  of  the  pain  and  tenderness  in  184  cases  was 
as  follows:  Lower  extremities  alone,  133;  upper  extremities  alone,  2; 
lower  and  upper,  42;  lower  and  trunk,  7.  In  all  but  two  cases,  there- 
fore, the  lower  extremities  were  affected,  the  lower  part  of  the  thigh 
and  the  leg  just  above  the  ankle  being  the  usual  seat. 

Disability,  or  pseudo-paralysis,  is  a  very  common  symptom,  and  in 
all  severe  cases  a  constant  one.  It  exists  in  varying  degrees  from  a 
slight  disinclination  to  use  the  limb  to  complete  helplessness.  In  many 
cases  it  is  more  marked  than  the  pain,  and  has  led  to  a  diagnosis  of 
poliomyelitis. 

Swellings  are  associated  with  pain  and  tenderness  in  most  of  the 
severe  cases.  They  are  most  marked  near  the  joints,  but  may  extend 
for  some  distance  along  the  shafts  of  the  bones.  In  nearly  all  cases  the 
location  is  the  lower  part  of  the  thigh  or  the  lower  part  of  the  leg,  and 
usually  of  both  sides.  Swellings  are  occasionally  seen  near  the  wrists, 
elbows,  shoulders,  and  hip-joints;  in  rare  cases,  over  the  ribs,  scapula, 
or  ilium.  Eedness  is  not  generally  present,  but  the  parts  may  have  a 
dark  purplish  colour.  It  is  to  the  haemorrhages  that  both  the  swellings 
and  the  discoloration  are  chiefly  due. 


238  NUTRITION. 

Protrusion  of  the  eyeball  is  present  in  about  ten  per  cent  of  the 
cases;  an  extreme  exophthalmus  is  sometimes  seen,  and  is  due  to  orbital 
haemorrhage. 

The  gums  are  affected  in  nearly  all  cases,  the  exceptions  being  those 
recognised  and  treated  early.  HaBmorrhage  occurs  in  about  one-half  the 
cases,  and  frequently  there  is  ulceration  not  unlike  that  of  a  mercurial 
stomatitis.  It  is  rather  curious  that,  though  the  lower  teeth  are  cut  first, 
the  upper  gum  is  almost  always  most  affected,  and  in  the  milder  cases 
usually  alone  involved.  Of  45  cases  in  which  no  teeth  had  been  cut,  the 
gums  were  affected  in  24  and  iiornial  in  "31.  This  is  sufficient  to  dis- 
prove the  old  opinion  that  the  gums  are  affected  only  when  teeth  have 
appeared.  The  severe  inflammation  and  ulceration  sometimes  seen 
seem  to  be  the  result  of  secondary  infection. 

Haemorrhages  beneath  the  skin  are  present  in  about  half  the  cases. 
They  are  rarely  extensive,  usually  multiple,  and  their  location  is  no 
doubt  often  determined  by  a  sliglit  traumatism.  Haemorrhages  from 
the  mucous  membranes  are  not  quite  so  frequent.  There  may  be  bleed- 
ing from  the  gums,  nose,  bowels,  kidneys,  and  rarely  from  the  stom- 
ach. Haemorrhages  in  most  cases  are  frequently  repeated,  but  seldom 
profuse. 

Epiphyseal  separation  is  seen  only  in  very  severe  cases.  It  is  most 
frequently  either  of  the  lower  epiphysis  of  the  femur  or  the  tibia,  or  the 
upper  epiphysis  of  the  humerus,  and  is  often  bilateral.  The  actual  sepa- 
ration may  be  caused  by  some  slight  injury,  the  condition  of  the  bone 
predisposing  to  this  occurrence.  In  three  cases  of  my  own  with  sepa- 
ration which  recovered,  rapid  union  occurred  under  anti-scorbutic 
treatment. 

Anaemia  is  slight  in  the  early  stage,  but  increases  as  the  disease 
progresses.  Blood  examinations  may  show  great  reduction  of  the  haemo- 
globin, sometimes  to  thirty-five  or  forty  per  cent;  also  in  nearly  all 
cases  a  proportionate  reduction  of  the  red  cells.  The  changes  are  those 
of  an  ordinary  secondary  anaemia. 

The  urine  contains  albumin  in  one-fourth  of  the  cases ;  in  nearly  half 
of  those  containing  albumin  casts  also  are  found.  In  rare  cases  haema- 
turia  has  been  an  early  symptom.  Blood  cells  usually  in  moderate 
numbers  are  found  in  practically  all  but  the  mildest  cases,  and  are  of 
some  diagnostic  importance. 

Evidences  of  general  malnutrition  are  present  in  all  advanced  cases, 
varying,  of  course,  greatly  in  degree.  In  a  few  infants  under  my  own 
observation  the  weight,  colour,  and  general  appearance  of  health  have 
continued  in  spite  of  very  decided  local  symptoms.  In  most  of  them 
the  impaired  nutrition  is  shown  by  loss  of  appetite,  occasional  attacks  of 
vomiting,  and  still  more  frequently  by  derangements  of  the  bowels, 
which  vary  from  slight  indigestion  to  a  serious  catarrhal  condition  of 


SCORBUTUS.  239 

both  small  and  large  intestine.  It  is  with  tlie  latter  that  the  discharge 
of  blood  is  usually  seen. 

Associatioii  with  Rickets. — In  the  Society's  investigation  great  pains 
were  taken  to  obtain  definite  and  accurate  data  regarding  this.  Of 
the  cases,  340  in  number,  in  which  this  point  was  noted,  symptoms  of 
rickets  were  present  in  1-52,  or  45  per  cent;  these  symptoms  were  re- 
corded as  slight  in  72;  marked  in  64;  and  not  specified  in  16.  In  the 
remainder  of  the  cases,  55  per  cent,  it  is  definitely  stated  that  symptoms 
of  rickets  were  absent.  It  is  also  stated  that  in  50  of  t\^e  patients  which 
were  rachitic,  the  rickets  antedated  the  development  of  the  scurvy. 
From  these  facts  it  would  seem  to  ])e  pretty  well  established  that 
though  rickets  and  scurvy  have  points  of  resemljlance,  such  as  the  age 
when  they  are  seen,  bony  changes,  dependence  on  defective  nutrition, 
etc.,  they  can  not  be  regarded  as  different  forms  of  the  same  disease. 
The  two  most  striking  characteristics  of  scurvy — viz.,  tendency  to  haem- 
orrhages and  prompt  curability  by  fresh  food  and  fruit  juices — have  no 
counterpart  in  rickets.  However,  their  co-existence  in  the  same  patient 
is  of  common  occurrence. 

Diagnosis. — The  disease  w^ith  which  infantile  scurv}'  is  most  fre- 
quently confounded  is  rheumatism.  In  fully  four-fifths  of  the  cases 
which  have  come  to  my  own  notice  this  has  been  the  previous  diagnosis. 
The  extreme  rarity  of  rheumatisjn  under  one  year  should  always  make 
one  cautious;  pain  and  tenderness  of  the  legs  only,  should,  in  an  infant, 
invariably  suggest  scurvy  rather  than  rheumatism.  The  extreme  disa- 
bility has  often  led  to  a  diagnosis  of  poliomyelitis,  l)ut  here  again  the 
acute  tenderness  should  set  one  right.  Many  cases  of  scurvy  come  into 
the  hands  of  the  orthopaedic  surgeon  with  a  diagnosis  of  joint  or  spinal 
disease.  Where  the  swelling  was  mainly  of  one  limb  I  have  twice  known 
a  diagnosis  of  malignant  disease  to  be  made,  from  the  cachexia,  the 
shape  of  the  swelling,  the  discoloration,  and  the  pain.  I  have  known 
two  cases  to  be  operated  upon  by  eminent  surgeons,  once  with  a  diag- 
nosis of  sarcoma  and  once  of  ostitis  of  both  tibiae.  Not  until  the  sub- 
periosteal haemorrhages  and  epiphyseal  separation  were  discovered  was 
the  nature  of  the  trouble  suspected. 

The  diagnosis  of  scurvy  seldom  presents  any  difficulties  to  one  who 
has  once  seen  a  case.  No  one  need  err  if  the  essential  features  of  the  dis- 
ease are  kept  in  mind :  the  extreme  soreness  of  the  legs,  spongy,  swollen 
gums,  swelling  near  the  large  joints,  a  tendency  to  haemorrhages,  and 
usually  a  history  of  the  prolonged  use  of  some  proprietary  infant  food, 
or  sterilised  or  condensed  milk.  The  epiphysitis  of  hereditary  syphilis 
has  many  symptoms  in  common  with  scurvy,  but  it  usually  occurs  at  an 
earlier  age  (before  the  fifth  month)  and  other  evidences  of  syphilis  are 
usually  present.  If  any  doubt  exists,  this  will  be  removed  by  the  prompt 
improvement  and  generally  rapid  cure  following  an  anti-scorbutic  diet. 


240  NUTRITION. 

Prognosis. — This  is  invariably  good  if  the  disease  is  recognised  early. 
No  patients  with  symptoms  so  serious  improve  with  such  marvellous 
rapidity  as  do  the  great  majority  of  those  witii  scurvy,  under  proper 
management.  The  figures  of  the  Society's  report  on  this  point  are 
interesting.  The  average  duration  of  the  disease  before  treatment  was 
begun  in  over  three  hundred  cases  was  somewhat  over  three  weeks.  In 
eighty  per  cent  striking  improvement  was  noticed  during  the  first  week 
of  treatment,  and  in  forty  per  cent  within  three  days.  Over  two-thirds 
of  these  cases  were  well  within  three  weeks,  and  nearly  one-third  within 
one  week,  after  the  beginning  of  treatment. 

It  is  only  when  the  disease  is  of  long  standing,  wlien  the  malnutri- 
tion is  severe,  or  when  serious  complications,  usually  involving  the 
digestive  tract,  are  present  that  the  symptoms  persist  and  the  issue 
becomes  doubtful.  It  is  difficult  to  tell  what  the  exact  mortality  of 
scurvy  is.  Any  case  allowed  to  go  on  may  result  fatally.  The  younger 
the  infant  the  more  likely  is  this  to  occur.  I  have  seen  four  deaths 
in  nearly  one  hundred  cases.  In  one  of  my  patients  death  resulted  from 
haemorrhage  which  followed  an  incision  into  an  epiphyseal  swelling  at 
the  lower  end  of  the  femur,  made  before  I  saw  the  patient,  and  which 
persisted  despite  all  treatment.  Barlow's  early  article  included  thirty- 
one  cases  with  seven  deaths.  It  is  rare  that  scurvy  leaves  any  permanent 
effects.  Recovery  is  not  only  rapid  but  complete.  Relapses  are  ex- 
tremely rare  and  have  been  observed  only  in  one  or  two  cases,  where 
chronic  indigestion  existed  of  so  extreme  a  character  that  proper  feeding 
was  impossible.  The  after-effects  are  usually  the  result  of  prolonged  mal- 
nutrition, of  which  the  attack  of  scurvy  w^as  only  one  manifestation. 

Treatment. — This  is  remarkably  simple — viz.,  to  discontinue  all  pro- 
prietary foods,  condensed  milk  or  sterilised  milk,  and  to  substitute  a 
diet  of  fresh  cow's  milk,  modified  to  suit  the  child's  digestion.  With 
this  treatment  alone  improvement  will  soon  begin  and  gradually  com- 
plete recovery  takes  place.  However,  when  fresh  fruit  juice  is  added 
improvement  is  much  more  rapid.  It  should  always  be  combined  with 
the  change  in  diet.  Orange  juice  is  to  be  preferred,  but  the  juice  of 
any  fresh  ripe  fruit  will  answer  the  purpose.  Oranges  should  be  sweet 
and  fresh.  From  two  to  four  ounces  a  day  are  required,  best  in 
divided  doses,  given  about  one  hour  before  the  milk-feeding.  It  may 
be  given  plain,  or  diluted  with  water.  In  some  cases,  when  not  well 
tolerated  by  the  stomach,  it  is  better  given  at  night,  when  no  food  is 
taken.  Potato  also  has  marked  anti-scorbutic  properties,  and  may  be 
given  in  the  form  of  a  puree  to  infants  as  young  as  eight  or  ten  months. 
The  only  really  difficult  cases  to  manage  are  those  in  which  the  general 
condition  approaches  one  of  marasmus,  or  when  scurvy  is  accompanied 
by  marked  gastric  or  intestinal  disturbance.  When  an  intestinal  catarrh 
is  present,  with  the  bowels  moving  five  or  six  times  a  day,  one  may  hesi- 


RICKETS.  241 

tate  to  give  the  fruit  juice  for  fear  of  increasing  these  symptoms.  In 
a  number  of  instances  I  have  seen  intestinal  symptoms,  which  had  re- 
sisted ordinary  measures,  immediately  improved  by  the  fruit  juice,  thus 
establishing  their  intimate  connection  with  the  scorbutic  condition. 

Other  things  of  value  are  fresh  beef  juice,  and  for  older  children 
all  fresh  vegetables,  especially  potato.  The  anaemia  and  malnutrition 
call  for  iron,  cod-liver  oil,  and  other  tonics,  which  should  be  given  after 
active  symptoms  of  the  disease  have  disappeared.  Infants  with  scurvy 
should  be  handled  as  little  as  possible,  and  should  be  particularly  pro- 
tected againt  exposure  in  their  extremely  susceptible  condition.  The 
affected  limbs  should  be  immobilised  by  splints  during  the  period  of 
marked  symptoms,  always  if  epiphyseal  separation  has  taken  place,  and 
in  many  other  severe  cases. 

RICKETS   (Rachitis). 

Eickets  is"  a  chronic  disease  of  nutrition.  While  the  only  important 
anatomical  changes  are  found  in  the  bones,  it  is  not  to  be  regarded  as  a 
bone  disease;  but  as  a  very  complex  pathological  process,  the  result  of 
disturbed  metabolism,  which  affects  chiefly  the  bones,  but  also  muscles, 
ligaments,  mucous  membranes,  and  nearly  all  the  organs  of  the  body, 
particularly  the  nervous  system.  It  occurs  especially  between  the  ages 
of  six  and  eighteen  months.  It  is  not  very  common  in  the  country,  but 
is  exceedingly  frequent  in  most  large  cities.  While  not  a  fatal  disease 
per  se,  rickets  adds  very  greatly  to  the  danger  from  all  acute  diseases 
in  infancy,  and  even  to  some  degree  also  to  those  of  later  life.  Under 
proper  conditions  of  diet  and  hygiene  it  tends  to  spontaneous  recovery. 

Etiology. — Certain  facts  in  the  causation  of  rickets  are  well  known. 
It  is  closely  related  to  improper  feeding  and  bad  hygienic  surroundings. 
It  is  not  common  in  nursing  children  unless  lactation  is  unduly  pro- 
longed,^ as,  for  example,  where  nursing  is  continued  for  fifteen  to 
eighteen  months  without  other  food.  Artificially  fed  children  are  much 
more  prone  to  the  disease,  especially  those  who  are  badly  fed.  The  diet 
in  these  cases  is  most  frequently  deficient  in  fat,  and  often  at  the  same 
time  in  protein,  while  it  is  apt  to  contain  an  excess  of  carbohydrates. 
It  is  somewhat  difficult  to  separate  the  effects  which  these  different  fac- 
tors produce.  It  appears,  however,  that  the  most  important  factor  is 
the  deficiency  in  fat.  Rickets  is  exceedingly  common  in  children  reared 
upon  the  proprietary  foods,  nearly  all  of  which  are  very  low  in  fat 
and  contain  an  excess  of  carbohydrates.  It  is  also  common  in  chil- 
dren who  are  reared  upon  sweetened  condensed  milk,  and  for  precisely 

'  An  exception  to  this  statement  must  be  made  in  the  case  of  Italian  and  Negro 
children.    In  this  class  as  observed  in  New  York  it  is  not  uncommon  to  see  marked 
rickets  in  those  getting  nothing  but  the  breast. 
17 


242  NUTRITION. 

the  same  reason.  When  both  fat  and  protein  are  low,  rickets  is  more 
likely  to  result  than  when  only  the  fat  is  deficient. 

Certain  experiments  have  been  made  which  show,  that  a  condition  of 
the  bones  resembling  rickets  may  be  produced  in  animals  by  a  diet  de- 
ficient in  calcium  salts,  and  furthermore  that  this  may  be  cured  simply 
by  the  addition  of  these  salts  to  the  food.  The  conclusion  can  not,  how- 
ever, be  drawn  that  rickets  in  children  is  produced  in  this  manner.  In 
the  first  place  the  bony  condition  in  the  artificial  disease  is  not  histolog- 
ically the  same  as  that  seen  in  rickets;  again,  rickets  in  the  child  is  not 
cured  simply  by  the  administration  of  calcium  salts ;  and,  finally,  rickets 
develops  where  these  elements  have  not  been  deficient  in  the  food. 

Hygienic  surroundings  are  next  in  importance  to  diet.  Although,  as 
previously  stated,  rickets  is  essentially  a  disease  of  cities,  being  most 
often  seen  in  children  living  in  crowded  tenements  where  the  effects  of 
improper  food  are  most  strikingly  shown,  yet  even  here  the  disease  is  rare 
in  those  who  get  a  plentiful  supply  of  good  breast-milk. 

Distribution  of  Rickets. — According  to  Palm,  the  disease  is  almost 
unknown  in  the  extreme  north — Greenland,  Iceland,  Norway,  and  Den- 
mark. It  is  also  very  rare  in  China,  Japan,  Greece,  Turkey,  and  the 
southern  portions  of  Italy  and  Spain.  Its  greatest  frequency  is  in  the 
temperate  zone.  The  general  immunity  of  children  in  southern  latitudes 
appears  to  be  due  to  the  out-of-door  life,  and  the  almost  universal  custom 
of  maternal  nursing.  In  the  cities  of  America  no  race  is  exempt  from 
the  disease.  In  New  York  the  greatest  susceptibility  is  among  the 
Negroes  and  the  Italians.  The  extreme  cases  of  rickets  seen  are  almost 
invariably  in  one  of  these  nationalities.  It  is  exceptional  to  see  in  a 
dispensary  or  hospital  a  child  of  either  of  these  races  who  does  not  show, 
to  a  greater  or  less  degree,  the  signs  of  rickets.  These  two  southern  races 
seem  to  bear  very  badly  the  climate  and  the  confined  life  of  the  northern 
cities.  So  far  as  my  observations  are  concerned,  there  is  no  peculiarity 
in  the  food  of  these  people  which  explains  the  prevalence  of  rickets 
among  them,  and  this  must  be  attributed  to  a  race  peculiarity.  In  the 
country,  the  immunity  from  rickets  is  due  partly  to  the  more  prevalent 
custom  of  maternal  nursing,  and  partly  to  the  better  surroundings;  the 
increased  resistance  of  the  children  rendering  them  much  less  suscep- 
tible to  the  influences  of  bad  feeding  than  is  seen  in  the  cities.  In  New 
York  among  dispensary  and  hospital  patients,  rickets  is  exceedingly  com- 
mon, and  is  seen  chiefly  in  the  foreign  elements  of  the  population. 

Heredity. — There  is  no  evidence  that  rickets  is  hereditary.  Any 
cachexia  in  the  parents,  such  as  syphilis,  tuberculosis,  or  alcoholism, 
may,  however,  by  diminishing  the  child's  resistance,  be  a  predisposing 
cause  of  rickets.  The  later  children  in  a  family  are  more  likely  to  be 
affected  than  the  earlier  ones,  especially  when  the  interval  between  the 
pregnancies  has  been  short. 


RICKETS.  243 

Previous  Disease. — Rickets  not  infrequently  develops  in  syphilitic 
children;  the  connection,  however,  seems  to  be  no  closer  than  with  any 
other  cachexia.  Chronic  disorders  of  the  digestive  tract  sometimes  pre- 
cede and  often  follow  the  development  of  rickets.  There  is  no  sufficient 
ground  for  believing  that  rickets  exerts  any  protective  influence  against 
tuberculosis;  on  the  contrary,  the  thoracic  deformity  of  rickets  may  be 
a  predisposing  cause. 

Rickets  affects  both  sexes  with  equal  frequency.  The  symptoms  usu- 
ally manifest  themselves  between  the  sixth  and  eighteenth  months. 
Congenital  and  late  rickets  will  be  considered  separately. 

Nature  of  the  Disease. — Rickets  is  a  disorder  of  nutrition,  the  result 
of  some  disturbance  of  metabolism  in  which  calcium  plays  a  very  impor- 
tan  role.  The  exact  nature  of  this  disturbance  is  not  yet  understood. 
Three  theories  have  been  advanced  in  explanation  of  the  deficiency  of 
calcium  in  the  bones  which  is  the  only  constant  lesion  of  the  disease. 
The  first  one,  that  rickets  is  due  to  a  lack  of  calcium  in  the  food,  is  not 
supported  either  by  clinical  or  experimental  evidence.  The  second  theory 
is  that  the  disease  is  due  to  an  increased  excretion  of  calcium  as  a  result 
of  disturbances  of  digestion.  The  frequent  occurrence  of  rickets  after 
prolonged  disturbances  of  digestion  lends  some  support  to  this  view. 
The  third  theory  advanced  is  that  although  sufficient  salts  are  furnished 
in  the  food,  they  are  excreted  in  excess  because  the  bones  are  incapable 
of  assimilating  them. 

Lesions. — The  only  constant  and  characteristic  lesions  of  rickets  are 
found  in  the  bones;  these  changes  are  sufficiently  definite  to  give  it  a 
place  as  an  essential  disease  and  not  merely  a  form  of  malnutrition.  It 
is  still  a  matter  of  dispute  whether  these  bony  changes  are  to  be  consid- 
ered as  inflammatory,  or  simply  as  the  result  of  disordered  nutrition. 
Disordered  nutrition  and  chronic  inflammation  are  closely  allied,  and  it 
really  makes  but  little  difference  which  view  is  taken.  Occurring  at  a 
time  when  the  growth  of  bone  is  so  rapid,  the  effects  of  rickets  are  very 
striking  and  very  serious. 

In  order  to  appreciate  how  the  bones  are  affected  by  rickets,  it  must 
be  remembered  that  the  long  bones  grow  in  length  by  the  production  of 
bone  in  the  cartilage  between  the  epiphysis  and  the  shaft ;  that  the  shaft 
grows  in  thickness  by  the  production  of  bone  beneath  the  inner  layer  of 
the  periosteum ;  and  that  the  medullary  canal  is  continually  increasing  in 
size  by  the  absorption  of  the  inner  layers  of  the  bone.  In  rickets  there  is 
an  exaggerated  production  of  cartilage  at  the  epiphysis,  and  excessive 
cell-growth  beneath  the  periosteum,  while  the  process  of  ossification  in 
these  tissues  goes  forward  slowly  and  imperfectly,  or  is  entirely  arrested. 
At  the  same  time  the  absorption  of  the  medullary  layers  may  be  even 
more  rapid  than  normal.  In  health  the  growth  of  bone  in  length  is  much 
more  rapid  than  its  increase  in  diameter,  owing  to  the  greater  activity 


244  NUTRITION. 

of  the  changes  taking  place  at  the  epiphysis;  so,  in  rickets,  it  is  at  the 
extremities  of  the  long  bones  that  the  most  marked  changes  are  seen. 

One  of  the  most  striking  features  of  rachitic  bones  is  their  unnatural 
flexibility.  This  is  due  to  deficient  ossification  in  the  superficial  layers  of 
the  shaft  of  the  long  bones,  and  also  at  their  extremities.  Normally, 
bone  contains  about  one-third  organic  and  two-thirds  inorganic  matter. 
In  marked  rickets  the  proportions  are  reversed,  the  bones  often  contain- 
ing twice  as  much  organic  as  inorganic  matter.  Changes  are  seen  in  all 
the  long  bones,  but  all  are  not  affected  to  the  same  degree.  Sometimes 
those  most  affected  will  be  the  bones  of  the  leg,  sometimes  those  of  the 
forearm,  and  sometimes  the  ribs.  The  extent  varies  with  the  severity 
of  the  process. 

There  are  characteristic  changes  in  form.  The  most  constant  is  en- 
largement of  tbe  epiphyses  of  all  the  long  bones.  This  is  most  strikingly 
seen  iu  the  lower  extremities  of  the  radius  and  tibia.  The  enlargement 
may  be  so  marked  that  the  width  of  the  epiphysis  is  increased  by  one- 
half.  All  the  sharp  angles,  borders,  and  prominences  of  the  bones  are 
rounded  off.  The  curvatures  of  rachitic  bones  are  more  fully  described 
under  the  head  of  Symptoms.  They  may  be  due  to  a  variety  of  causes. 
Some  are  simply  an  exaggeration  of  the  normal  curves,  much  increased 
by  the  swelling  of  the  epiphyses;  others  are  due  to  muscular  action,  to 
atmospheric  pressure,  to  some  unnatural  posture,  such  as  the  cross-legged 
position,  to  the  weight  of  the  limbs,  or  to  the  weight  of  the  body.  The 
principal  change  in  the  form  of  the  flat  bones  consists  in  the  production 
of  large  bosses  or  prominences  due  to  thickening  of  the  bone,  usually 
about  the  centre  of  ossification.  These  bosses  are  soft  and  spongy.  Frac- 
tures are  not  uncommon.  The  bones  most  frequently  broken  are  the 
radius  and  ulna ;  next,  the  clavicle,  the  ribs,  the  humerus,  and  the  femur. 
The  fractures  are  usually  of  the  green-stick  variety.  There  is  a  bending 
of  the  outer  and  a  fracture  of  the  inner  layers  of  the  shaft  of  a  long 
bone.  This  results  in  more  or  less  impaction,  and  is  usually  followed 
by  the  production  of  considerable  callus.  The  epiphyseal  changes  result 
in  arrested  growth  in  length,  rachitic  bones  being  usually  much  shorter 
than  normal.  Increased  vascularity  is  seen  in  the  bosses  upon  the  flat 
bones,  at  the  extremities  of  the  long  bones  and  upon  stripping  the  peri- 
osteum from  the  shaft. 

In  a  longitudinal  section  of  one  of  the  long  bones,  the  principal 
change  seen  at  the  extremity  is  that  the  cartilaginous  layer  which  unites 
the  epiphysis  and  the  shaft  is  very  much  enlarged,  both  in  width  and 
thickness,  the  latter  being  sometimes  four  or  five  times  the  normal. 
This  cartilaginous  area  is  of  a  bluish  colour,  rather  softer  than  normal 
cartilage.  On  one  side  it  blends  with  the  cartilage  of  the  epiphysis,  on 
the  other  it  presents  an  irregular  dentated  border,  and  in  it  the  calcified 
areas  are  irregular  and  scattered.    The  epiphyseal  centres  of  ossification 


RICKETS.  245 

are  enlarged,  softer,  and  more  vascular  than  normal,  thus  increasing  the 
size  of  the  extremity  of  the  bone.  In  the  shaft,  the  outer  layers  of  bone 
are  thickened  and  soft,  like  decalcified  bone,  the  deeper  parts  being 
firmer,  while  the  deepest  layers  may  be  completely  ossified.  The  medul- 
lary canal  is  much  more  vascular  than  normal,  its  contents  resembling 
granulation  tissue.  Toward  the  extremities  the  trabecular  spaces  are 
much  increased  in  size,  so  that  the  bone  appears  unnaturally  porous. 
On  vertical  section  of  one  of  the  flat  bones — e.  g.,  one  of  the  bosses  upon 
the  skull — there  is  found  a  great  increase  in  the  size  of  the  trabecular 
spaces.  The  bosses  are  made  up  of  large  spongy  masses,  so  soft  as  to  be 
easily  indented  with  the  finger. 

Microscopical  Changes. — At  the  junction  of  bone  and  cartilage  at  the 
extremity  of  one  of  the  long  bones,  there  are  readily  traced  in  normal 
bone  (Fig.  34)  several  distinct  zones.  Next  to  the  hyaline  cartilage  (a) 
there  is  a  proliferating  zone  (b),  made  up  of  cartilage  cells  and  matrix, 
the  cells  having  no  orderly  arrangement,  Next  to  this  is  a  columnar 
zone  (c,  d),  in  which  the  cartilage  cells  arc  arranged  in  regular  rows  or 
columns.  Adjoining  this  is  the  zone  of  calcification  (e)  ;  and,  finally, 
there  is  the  zone  of  ossification  (/,  g),  where  true  bone  is  formed. 

In  rickets  (Plate  IV  and  Fig.  35),  the  principal  changes  are  seen  in 
the  proliferating  and  columnar  zones.  The  proliferating  zone  (Fig.  35, 
&)  is  increased  chiefly  by  the  multiplication  of  new  cells;  it  is  also  more 
vascular  than  normal.  The  columnar  zone  (c)  is  affected  in  a  similar 
way  and  to  a  much  greater  degree.  It  is  less  regular  in  its  formation, 
and,  instead  of  containing  but  few  vessels,  it  shows  large  vascular  chan- 
nels, sometimes  surrounded  by  medullary  spaces  (e).  The  ossification 
zone,  instead  of  being  narrow  and  sharply  outlined,  is  broad  and  very 
irregular.  Calcified  areas  (/)  may  be  seen  in  the  midst  of  regions  which 
are  cartilaginous,  while  masses  of  cartilage  (h)  occupy  areas  which 
should  be  completely  calcified.  In  some  places  there  appears  to  be  a 
transformation  of  cartilage  into  bone-tissue  of  an  inferior  sort  by  a  direct 
or  metaplastic  process.  In  the  shaft  there  is  seen  more  or  less  thicken- 
ing, and  an  increased  vascularity  of- the  periosteum.  Beneath  the  inner 
layer  there  is  excessive  cell-proliferation,  while  calcification  of  this  new 
tissue  is  imperfect  or  absent,  and  instead  of  hard,  compact  bone,  we  find 
irregular,  spongy  masses.  In  the  spongy  bone  there  is  considerable  thick- 
ening, with  an  erosion  of  bony  trabeculae,  which  results  in  the  formation 
of  large  medullary  spaces  filled  with  blood-vessels  and  connective  tissue 
rich  in  cells. 

Termination  of  the  Rachitic  Process. — After  a  variable  time,  usually 
from  three  to  fifteen  months,  the  active  proliferative  process  going  on  in 
the  cartilage  and  beneath  the  periosteum  ceases,  and  is  gradually  replaced 
by  ossification.  The  bone  becomes  less  vascular,  and  a  rapid  formation 
of  bone  takes  place  in  the  normal  way.     In  addition,  there  is  in  some 


246 


NUTRITION. 


places  a  direct  transformation  of  cartilage  into  bone.  Condensation  and 
contraction  take  place  in  the  spongy  masses  of  bone.  As  the  result  of 
this,  the  affected  bone  may  become  even  harder  tlian  normal ;  often  it  is 
ivory-like.  Its  structure,  however,  is  never  quite  like  that  of  healthy 
bone. 

In  the  long  bones  the  epiphyseal  swellings  slowly  diminish,  and  may 
quite  disappear;  the  slighter  curvatures  may  be  entirely  overcome,  and 


Fig.  34. — Section  Through  Ossification  Zone  of  Normal  Bone  (Ziegler).  a,  hyaline 
cartilage;  6,  zone  of  beginning  cartilage  proliferation;  c,  columns  of  cartilage  cells; 
d,  columns  of  hypertrophic  cartilage;  e,  zone  of  temporary  calcification;  /,  zone  of 
primary  medullary  space.s;  q,  zone  of  primary  bone  formation;  h,  fully  developed 
spongy  bone;  i,  blood-vessels;  k,  layer  of  osteoblasts. 


the  greater  ones  much  lessened.  The  beading  of  the  ribs  becomes  almost 
imperceptible;  the  bosses  upon  the  skull  shrink  very  markedly,  and  may 
leave  scarcely  a  trace  of  their  existence.  In  most  cases  the  active  process 
in  rickets  comes  to  an  end  by  the  time  the  child  is  two  and  a  half  years 
old,  often  at  two  years. 


PLATE  IV. 


Bone  in  Rickets. 

Longitudinal  section  of  a  rib  at  the  junction  of  the  costal  cartilage,  in  a  severe 
case  of  rickets  (slightly  magniiied).  C  =  costal  cartilage,  B  =  bone,  A  =  proliferating 
cartilage-zone,  which  is  much  widened.  Between  the  hypertrophied  cartilage  cell- 
columns  (a)  making  up  this  proliferating  zone,  are  seen  medullary  spaces  {b)  contain- 
ing blood-vessels.  In  this  zone  lie  masses  of  bone  (c)  not  calcified.  The  calcification 
zone  is  almost  wanting,  only  scattered  islands  (d)  of  calcified  cartilage-cells  being  seen. 

Beyond  this  proliferating  zone  (A)  is  a  layer  of  bony  tissue  (B)  made  up  of  small 
bands  of  which  only  a  few  have  a  nucleus  containing  lime  (e).  These  nuclei  appear 
black.  The  bony  bands  differ  both  in  form  and  arrangement  from  those  of  normal 
ossification.  Between  the  bony  masses  are  medullary  spaces  which  appear  light  in  the 
illustration.  At  (g)  the  beginning  of  cartilage  proliferation  is  seen.  Above  this  zone 
the  cartilage  is  normal.  iProm  Karg  and  Schmorl.) 


RICKETS. 


247 


Visceral  Lesions. — These  are  not  infrequent,  but  are  not  essential  to 
rickets.    In  the  lungs  they  are  due  to  deformities  of  the  chest  wall  and 


FiQ.  35. — Rachitic  Bone  (Ziegler).  Longitudinal  Section  Through  Ossification 
Zone  of  the  Upper  Diaphysis  of  the  Femur  of  a  Moderately  Rachitic 
Child  One  Year  Old  (highly  magnified),  a,  unchanged  hyaline  cartilage;  b,  be- 
ginning cartilage  proliferation';  c,  columns  of  proliferated  cartilage  cells;  d,  col- 
umns of  proliferated  hypertrophic  cells;  e,  medullary  spaces  containing  blood-ves- 
sels lying  within  the  cartilage;  /,  calcified  cartilage;  g,  bony  tissue;  h,  remains  of 
cartilage  within  the  bony  tissue ;  i,  point  of  uncalcified  bony  tissue ;  k,  calcified  bony 
tissue. 


to  complications.  Beneath  the  deep  lateral  furrows  which  are  so  com- 
mon, there  is  found  a  part  of  the  lung  in  a  state  of  more  or  less  complete 
collapse.     This  is  accompanied  by  emphysema  of  the  portion  just  ante- 


248  NUTRITION. 

rior  to  it.  Acute  and  chronic  bronchitis  and  broncho-pneumonia  are 
exceedingly  frequent.  A  low  grade  of  chronic  catarrhal  inflammation 
of  the  stomach  and  intestines  is  common,  and  is  often  associated  with 
dilatation  of  these  organs.  The  spleen  is  enlarged  in  most  cases  during 
the  period  of  active  symptoms.  This  is  usually  moderate  in  degree, 
although  marked  enlargement  is  not  at  all  rare.  The  swelling  of  the 
spleen  is  chiefly  due  to  simple  hyperplasia.  Enlargement  of  the  liver 
is  less  frequent,  and  may  occur  with  or  without  that  of  the  spleen. 
There  are  "no  constant  changes  in  the  structure  of  these  organs.  The 
lymph  nodes  are  frequently  enlarged.  Eachitic  patients  are  more  prone 
to  these  swellings  than  are  other  children.  They  are  due  to  simple  hyper- 
plasia, and  have  no  close  connection  with  rickets.  Cerebral  changes  are 
rare,  and  those  described  are  rather  of  accidental  occurrence  than  de- 
pendent upon  the  rachitic  process.  As  stated  under  Symptoms,  enlarge- 
ment of  the  head  is  usually  due  to  thickening  of  the  cranial  bones.  Al- 
though hydrocephalus  is  occasionally  seen,  it  is  extremely  doubtful 
whether  it  is  more  frequent  than  in  patients  not  rachitic.  Hypertrophy 
of  the  brain  has  been  described  in  connection  with  rickets,  but  as  yet 
this  does  not  seem  to  be  established  by  sufficient  pathological  evidence. 
The  muscles  are  flabby  from  imperfect  nutrition,  and  sometimes  atrophied 
from  disuse,  but  no  essential  anatomical  changes  have  been  demonstrated 
in  them. 

Symptoms. — A  well-marked  case  of  rickets  makes  a  striking  picture 
(Plate  V),  and  one  not  easily  mistaken.  There  are  seen  the  large  head, 
beaded  ribs,  narrow  chest,  prominent  abdomen,  symmetrical  swellings  of 
the  epiphyses  of  the  wrists  and  ankles,  and  curvatures  of  the  extremities. 
The  beginning  of  symptoms  is  nearly  always  insidious,  and  the  patient 
does  not  usually  come  under  observation  until  they  have  existed  for  sev- 
eral weeks,  often  several  months. 

Early  Symptoms. — The  most  constant  early  symptoms  are  sweating 
of  the  head,  extreme  restlessness  at  night,  constipation,  beading  of  the 
ribs,  and  cranio-tabes.  The  head-sweating  is  rarely  absent,  and  may  con- 
tinue for  several  months.  It  is  especially  profuse  during  sleep,  the  per- 
spiration standing  out  in  large  drops  upon  the  forehead,  often  being 
sufficient  to  wet  the  pillow.  This  is  one  of  the  causes  of  the  nasal  and 
bronchial  catarrhs  so  common  in  rachitic  infants.  There  is  marked  rest- 
lessness during  sleep :  the  children  tossing  about  the  crib,  kicking  off  the 
clothes,  and  never  having  the  quiet,  natural  slumber  of  healthy  infants. 
This  may  be  due  to  many  causes,  but  when  persistent  and  associated  with 
marked  perspiration  of  the  head,  rickets  should  be  suspected.  In  many 
rachitic  infants  more  serious  nervous  symptoms  appear  early ;  there  may 
be  tetany,  laryngismus  stridulus,  or  general  convulsions.  Constipation  is 
frequently  seen  as  an  early  symptom,  although  it  is  more  marked  in 
the  later  stages  of  the  disease. 


PLATE  V. 


Typical  Rickkts. 

Showing  the  large  head,  narrow  chest,  prominent  abdomen,  marked  enlargement 
of  the  epiphyses  at  the  wrists  and  ankles.  There  are  also  curvatures  of  the  forearms 
and  legs  which  are  not  so  well  shown. 

The  patient  a  child  two  and  a  half  years  old. 


RICKETS.  249 

The  beading  of  the  ribs  is  almost  invariably  the  first  appreciable 
change  in  the  bones,  and  it  is  well-nigh  constant.  This  forms  the  so- 
called  "rachitic  rosary,"  consisting  of  nodules  at  the  line  of  junction  of 
the  costal  cartilages  and  the  ribs.  It  may  be  slight,  or  there  may  be  a 
row  of  knobs  as  large  as  small  marbles.  In  many  cases  with  marked 
thoracic  deformity,  little  or  no  beading  of  the  ribs  is  seen  externally. 


FiQ.  36. — Rachitic  Skull.     From  coloured  child  two  years  old,  horizontal  section,  inner 
surface;  showing  thickening  of  the  bones,  especially  the  frontal,  and  open  fontanel. 

although  at  autopsy  it  is  found  to  be  very  marked  upon  the  internal  sur- 
face of  the  chest  (Plate  VI).  Beading  of  the  ribs  was  noted  in  all  but 
two  of  one  hundred  and  forty-four  successive  cases  of  rickets,  at  the  time 
of  the  first  examination.  In  infants  under  six  months  there  may  be 
found  soft  spots  in  the  cranium,  usually  over  the  occipital  or  posterior 
portions  of  the  parietal  bones.  These  are  from  one-fourth  to  one  inch  in 
diameter,  and  there  are  usually  several  of  them  present.  By  pressure 
with  the  finger  they  give  a  sort  of  parchment-crackling  sensation.  This 
condition  is  known  as  cranio-tabes.  Cranio-tabes  is  believed  to  be  more 
frequent  when  syphilis  is  associated  with  rickets,  and  it  is  seen  also  in 
syphilitic  cases  which  are  not  rachitic.    A  rachitic  cachexia  is  not  usually 


250 


NUTRITION. 


present  until  the  symptoms  have  existed  for  several  months,  and  in  many 
cases  it  is  not  seen  at  all. 

Deformities. — The    deformities    of   rickets    are    almost    invariably 
symmetrical   in   character,   and   usually   numerous.      In   extreme   cases 

almost  every  bone  in  the  body 
is  affected. 

Head. — This  usually  appears 
to  be  too  large,  and  although  it 
may  not  be  greater  in  circum- 
ference than  that  of  a  healthy 
child  of  the  same  age,  it  is  out 
of  proportion  to  the  rest  of  the 
body.  In  marked  cases  the  in- 
crease in  circumference  may  be 
one  or  two  inches.  The  enlarge- 
ment is  chiefly  due  to  tbicken- 
ing  of  the  cranial  bones.  In  one 
case  with  marked  deformity,  I 
found  the  skull  over  the  parietal 
bones  half  an  inch  in  thickness 
\f^  (Fig.  36).  This  thickening  di- 
'^  '-  «L       minishes  with  recovery,  but  in 

Fig.  37.-RACHITIC  Head.    Italian  chUd  two         ^^^^    ^^^^    ^j^g    ],ead    remains 
years  old;  square,  prominent  forehead  and  ,    tp      i 

flat  vertex.  throughout  lite  larger  than  it 


Fig.  38. — Rachitic  Skull  from  a  Child  One  Year  Old. 
Showing  frontal  and  parietal  bosses  and  wide  fontanel. 


RICKETS  251 

should  be.  The  shape  of  the  rachitic  head  is  somewhat  square  (Fig.  37), 
owing  to  the  formation  of  large  bosses  over  the  parietal  and  frontal  emi- 
nences. It  is  flattened  at  the  occiput  from  pressure,  and  flattened  also  at 
the  vertex.  In  extreme  cases,  the  jjrominences  upon  tlie  frontal  and 
parietal  bones  may  be  so  great  as  to  produce  quite  a  marked  furrow  along 
the  line  of  the  sagittal  and  frontal  sutures,  and  one  at  right  angles  to  this 
along  the  coronal  suture  (Fig.  38).  This  condition  gives  unusual  promi- 
nence to  the  forehead.  Marked  deformity  of  the  head  has  been  observed 
in  thirty-three  per  cent  of  my  cases.  The  sutures  may  remain  open  for  an 
unnatural  time,  occasionally  until  the  end  of  the  first  year.  The  fontanel 
is  late  in  closing,  being  frequently  found  open  at  two  and  a  half,  and 
sometimes  even  at  three  years.  Often  at  eighteen  or  twenty  months 
the  fontanel  is  two  inches  in  diameter.  The  veins  of  the  scalp  are 
often  prominent,  and  the  hair  is  frequently  worn  from  the  occiput, 
owing  to  restlessness  during  sleep.  Occasionally  rickets  and  hydrocepha- 
lus are  associated,  but  the  latter  is  the  least  frequent  of  all  causes  of  the 
enlargement  of  the  head. 

Chest. — Beading  of  the  ribs  has  already  been  mentioned.    This  is  the 
most  characteristic  feature,  but  in  the  majority  of  cases  there  are,  in 


Fig.  39. — A,  Horizontal  Section  of  a  Rachitic  Chest,  child  two  years  old,  showing 
lateral  furrow.s;  B,  Section  of  Chest  of  Healthy  Child  of  the  Same  Age. 

addition,  lateral  depressions  over  the  lower  third  of  the  chest,  at  the  line 
of  junction  of  the  cartilages  with  the  ribs,  with  eversion  of  the  lower 
borders  of  the  ribs.  In  severe  cases  these  depressions  or  furrows  are  so 
great  as  to  cause  serious  deformity  (Plate  VI).  Usually  there  is  a 
great  diminution  in  the  transverse,  and  an  increase  in  the  antero-posterior, 
diameter  of  the  chest.  Fig.  39  shows  the  outline  of  the  chest  of  a  rachitic 
child  of  two  years,  compared  with  that  of  a  healthy  child  of  the  same 
age.  Another  frequent  deformity  is  the  "  rachitic  girdle,"  which  con- 
sists in  a  transverse  depression  about  two  inches  broad,  extending  from 
one  side  of  the  chest  to  the  other,  just  above  its  lower  border.     A  less 


252 


NUTRITION. 


frequent  deformity  is  the  "  funnel  chest,"  a  deep  central  depression  over 
the  ensifonn  cartilage.  This  is  sometimes  nearly  an  inch  and  a  half  in 
depth.  Marked  thoracic  deformity  was  seen  in  twenty  per  cent  of  my 
cases,  and  in  only  a  small  proportion  was  the  chest  normal. 

The  factors  in  the  production  of  the  thoracic  deformity  are  the  con- 
traction of  the  diaphragm,  atmospheric  pressure,  and  soft  chest  walls, 
these  sinking  in  at  the  point  where  they  have  least  resistance,  viz.,  at  the 
junction  of  the  costal  cartilages  and  the  ribs.  When  there  exists  any 
obstruction  to  the  entrance  of  air,  as  with  bronchitis,  hypertrophied  ton- 
sils, or  adenoid  growths  of  the  pharynx,  the  thoracic  deformities  are  exag- 
gerated. Irregular  chest  deformities  depend  upon  the  co-existence  of 
pathological  conditions  in  the  lungs.  Pigeon-breast  is  occasionally  seen, 
but  it  is  doubtful  if  this  depends  upon  rickets  alone. 

Spine. — In  very  many  of  the  milder  cases  this  is  normal.  The  most 
characteristic  deformity  consists  in  a  posterior  curve  (kyphosis),  (see  Fig. 
40),  which  is  a  general  one,  usually  extending  from  the  mid-dorsal  to 

the  sacral  region.  This  existed  in  forty-six 
per  cent  of  my  cases.  In  the  early  part  of 
the  disease  it  disappears  entirely  on  sus- 
pending the  child,  or  making  extension  upon 
the  extremities;  but  in  cases  of  long  stand- 
ing it  may  not  disappear  entirely  by  these 
tests.  Very  much  less  frequently  there  is 
seen  a  rotary  curvature.  This,  in  my  expe- 
rience, has  been  more  frequently  with  the 
convexity  to  the  left  side  than  to  the  right — 
the  opposite  of  the  common  form  of  lateral 
curvature  seen  in  young  girls.  Marked  lat- 
eral curvature  in  children  under  three  years 
is  usually  rachitic. 

The  clavicle  is  affected  only  in  severe 
cases.  The  usual  deformity  consists  in  an 
exaggeration  of  the  anterior  curve  at  the 
inner  third  of  the  bone,  which  is  somewhat  shortened  and  its  extremities 
enlarged.     It  is  not  infrequently  the  seat  of  green-stick  fracture. 

Deformities  of  the  pelvis  belong  to  obstetrics  rather  than  to  paedi- 
atrics. The  most  common  rachitic  change  is  a  diminution  of  the  antero- 
posterior diameter  and  a  narrowing  of  the  subpubic  arch. 

Extremities. — Deformities  of  the  upper  extremities  are  usually  sym- 
metrical. The  humerus  is  affected  only  in  severe  cases.  It  has  a  forward 
and  outward  curve,  although  rarely  a  very  marked  one.  Both  the  epiphy- 
ses are  enlarged,  although  the  upper  one  can  not  well  be  made  out 
unless  the  child  is  very  thin.  The  radius  and  ulna  are  frequently 
affected.    They  present  a  convexity  upon  their  extensor  surfaces  (Plate 


Fig.  40. — Rachitic  Curvature 
OF  THE  Spine. 


PLATE  VI. 


Deformity  of  the  Chest  in  Severe  Rickets. 

In  the  upper  picture,  giving  the  external  view,  is  shown  a  deep  oblique  furrow  at 
the  junction  of  the  ribs  and  costal  cartilages,  these  meeting  at  an  acute  angle. 

In  the  lower  picture  the  ribs  have  been  separated  from  the  spine  and  spread  open, 
showing  the  same  deformity  as  it  appears  from  within,  looking  forwards. 

From  a  coloured  child  ten  months  old. 


RICKETS. 


253 


V),    which    in    some    ca.ses    is    very    marked,    particularly    in    children 
who  have  been  creeping.     Green-stick  fractures  here  are  (piite  frecpient 


A  B 

Fig.  41. — Multiple  Fractures  in  Rickets. 
Showing  both  arms  of  the  same  patient ;  fractures  also  of  both  femora. 


as  they  are  also  in  the  femora.  They  are  frecpently  multiple  and 
occur  from  very  slight  causes,  sometimes  apparently  from  muscular 
contraction.  Cases  with  such  fractures 
are  sometimes  classed  as  osteomalacia. 
Kachitic  changes  at  the  epiphyses  are 
more  common  than  in  the  shaft,  en- 
largement of  the  epiphyses  at  the  wrist 
being  one  of  the  most  constant  bony  de- 
formities of  rickets  (Plate  V).  It  was 
present  in  ninety-five  per  cent  of  my 
cases.  Less  frequently  similar  swellings 
are  seen  at  the  elbow.  Enlargement  of 
the  ends  of  the  metacarpal  bones  or  the 
phalanges  I  have  seen  but  seldom  and 
only  in  extreme  cases. 

The  dower  extremities  are  rather 
more  frequently  affected  than  the  upper, 
but  in  a  similar  way.  The  femur  is  in- 
volved only  in  severe  cases ;  it  commonly 
presents  a  general  forward  and  outward 
curve,  which  is  mainly  due  to  the  weight 
of  the  legs  as  the  child  sits.  Occasion- 
ally there  is  also  an  outward  rotation 
of  the  femur,  where  children  have  been 
allowed  to  sit  much  in  a  cross-legged  posture.  When  such  children  begin 
to  walk,  the  toes  are  turned  very  far  outward.    The  principal  deformities 


Fig.  42. — Typical  Bow-legs  of 
-   Severe  Form. 


254 


NUTRITION. 


of  the  lower  extremity  are  bow-legs  (Fig.  42)  and  knock-knees  (Fig. 
43).  Knock-knees  are  more  common  in  females,  and  are  believed  to 
be  due  to  an  overgrowth  of  the  inner  condyles  of  the  femur.  Enlarge- 
ment of  both  condyles  can  be 
demonstrated  in  most  of  the 
marked  cases  of  rickets.  The 
cases  of  slight  bow-legs  may 
be  due  simply  to  swelling  of 
the  epiphyses,  the  shaft  of 
the  bone  being  quite  normal. 
This  point  I  have  verified 
by  post-mortem  observations. 
Such  are  probably  most  of 
the  deformities  which  dis- 
appear spontaneously.  The 
most  severe  cases  of  bow- 
legs are  often  associated  with 
some  degree  of  antero- 
posterior  curvature, 
and  the  latter  may  be 
the  principal  deform- 
ity. Enlargement  of 
tlie  epiphyses  at  the 
ankles  is  usually  pres- 
ent when  it  is  seen  at 
the  wrists,  and  nearly  to  the  same  degree.  Enlargement  of  the  upper 
epiphyses  of  the  tibia  and  the  fibula  is  seen  only  in  severe  cases.  The 
cause  of  the  deformities  of  the  leg  is  not,  primarily,  at  least,  walking 
too  early,  since  they  are  common  in  children  who  have  never  walked; 
slight  deformities,  however,  may  be  aggravated  by  early  walking.  A 
change  which  has  not  been  sufficiently  emphasised  is  the  arrested  growth 
of  the  long  bones ;  this  is  one  of  the  most  characteristic  features  of  rickets. 
A  rachitic  child  of  three  years  often  measures  in  height  five  or  six 
inches  less  than  a  healthy  child  of  the  same  age,  the  difference  being 
almost  entirely  in  the  lower  extremities. 

All  the  ligaments,  but  particularly  those  about  the  large  joints,  are 
lax  and  frequently  elongated.  This  may  lead  to  the  deformity  known  as 
weak  ankles,  or  to  an  over-extension  at  the  knee  {genu  recurvatum) ; 
also  to  unnatural  mobility  at  the  hips,  shoulders,  elbows,  and  wrists. 
The  condition  of  the  ligaments  plays  an  important  part  in  the  produc- 
tion of  spinal  deformities. 

Muscles. — The  muscular  symptoms  of  rickets  are  almost  as  constant 
and  as  characteristic  as  those  of  the  bones.  The  muscles  are  small,  very 
flabby,  and  poorly  developed;  hence  rachitic  children  are  unable  to  sit 


Fig.  43. — Knock-knees. 


RICKETS.  255 

erect,  or  to  stand  or  walk  at  the  proper  age.  Of  one  hundred  and  fifty- 
one  cases  in  which  the  date  of  walking  alone  was  investigated,  only 
twenty-seven,  or  eighteen  per  cent,  walked  before  the  fifteenth  month; 
forty-seven  per  cent  were  not  walking  at  the  eighteenth  month ;  twenty 
per  cent,  not  at  two  years ;  and  ten  per  cent,  not  at  two  and  a  half  years. 
Late  walking  is  one  of  the  most  common  symptoms  for  which  advice 
is  sought  by  parents  with  rachitic  children.  The  muscular  power  in  the 
extremities  is  sometimes  so  feeble  as  to  suggest  paralysis.  I  have  seen 
a  number  of  cases  in  which  the  symptoms  so  resembled  paralysis,  that 
even  expert  diagnosticians  were  unable  to  differentiate  rickets  from  pol- 
iomyelitis except  by  the  electrical  reactions,  those  in  rickets  being  usually 
normal  or  exaggerated.  In  other  cases  the  symptoms  may  suggest 
cerebral  palsy  of  the  flaccid  type.  The  muscular  symptoms  may  be  marked 
when  the  bony  changes  are  slight,  and  conversely.  As  no  lesions  of  the 
muscles  have  been  demonstrated,  the  symptoms  are  probably  due  to 
imperfect  nutrition.  Two  other  symptoms  depend  chiefly  upon  the 
condition  of  the  muscles,  viz.,  pot-])elly  and  constipation. 

Pot-belly  is  quite  an  early  symptom,  and  in  most  cases  a  very  marked 
one  (Plate  V).  It  was  noted  in  sixty  per  cent  of  my  cases.  The  en- 
largement of  the  abdomen  is  uniform.  It  is  everywhere  tympanitic,  and 
it  may  be  as  tense  as  a  drumhead.  It  is  due  to  a  loss  of  tone  in  the 
abdominal  muscles,  and  in  the  muscular  walls  of  the  stomach  and  in- 
testine. It  is  aggravated  by  chronic  indigestion  and  excessive  intestinal 
putrefaction.  The  enlargement  is  thus  mainly  from  tympanites.  There 
may  be  a  marked  degree  of  dilatation  both  of  the  stomach  and  the  colon. 
To  a  very  small  degree  only,  does  the  large  abdomen  depend  upon  swell- 
ing of  the  liver  or  spleen. 

The  constipation  of  rickets,  as  already  suggested,  depends  upon  the 
loss  of  tone  in  the  muscular  walls  of  the  intestines.  It  may  alternate 
with  diarrhoea.  It  rarely  happens  that  a  rachitic  child  has  habitually 
normal  evacuations  from  the  bowels.  Hard,  dry,  constipated  stools  fre- 
quently set  up  a  condition  of  chronic  catarrh  of  the  colon  in  which  large 
masses  of  mucus  are  discharged. 

Fever. — According  to  some  observers  there  is  a  febrile  movement 
which  belongs  to  the  active  stage  of  rickets,  but  I  have  never  been  able  to 
satisfy  myself  of  the  truth  of  this  observation. 

Dentition. — As  a  rule,  dentition  is  late  and  apt  to  be  difficult,  i.  e., 
it  is  associated  with  attacks  of  indigestion  or  other  disturbances  which 
may  be  serious.  Individual  cases,  however,  present  great  variations  in 
regard  to  this  symptom.  A  study  of  the  progress  of  dentition  in  one 
hundred  and  fifty  rachitic  children  gave  the  following  results:  in  fifty 
per  cent  the  first  teeth  were  cut  on  or  before  the  eighth  month;  twenty 
per  cent  of  the  cases  had  no  teeth  at  twelve  months,  and  in  eight  per 
cent  none  had  appeared  at  fifteen  months.     Even  though  the  first  teeth 


256  NUTRITION. 

come  at  the  usual  time,  the  progress  of  dentition  is  usually  retarded  by 
the  development  of  rickets.  The  character  of  the  teeth  in  rickets  is 
usually  good.  This  is  in  striking  contrast  to  hereditary  syphilis,  where 
the  tendency  to  early  decay  is  constantly  seen. 

General  Appearance. — Children  suffering  from  marked  rickets 
are  almost  always  ansemic.  The  majority  are  fat  and  flabby.  The  tissues 
are  soft  and  have  but  little  resistance.  Karely,  they  may  be  thin,  like 
patients  suffering  from  marasmus. 

Rachitic  patients  are  very  prone  to  suffer  from  hypertrophied  tonsils, 
adenoid  growths  of  the  pharynx,  and  enlargements  of  the  lymph  nodes 
of  the  neck.  In  all  forms  of  acute  illness  the  feeble  resistance  of  these 
patients  is  very  evident.  This  is  especially  true  of  acute  disease  of  the 
lungs. 

The  mucous  membranes  are  very  vulnerable  in  all  rachitic  patients. 
From  the  slightest  indiscretion  in  diet  an  attack  of  acute  indigestion  or 
diarrhoea  may  be  brought  on,  and  from  a  very  insignificant  exposure, 
catarrlial  inflammation  of  the  upper  or  lower  air  passages  is  excited. 
In  rachitic  patients  all  such  attacks  are  prone  to  run  a  protracted  course. 
Inflammation  of  the  trachea  and  larger  bronchi  is  likely  to  lextend  to  the 
smaller  bronchi  and  the  lungs. 

The  downward  displacement  of  the  liver  and  spleen  from  contraction 
of  the  chest  should  not  be  mistaken  for  enlargement  of  these  organs. 
Moderate  enlargement  of  the  spleen  is  very  common  during  the  stage 
of  most  active  symptoms,  i.  e.,  from  the  sixth  to  the  twelfth  month. 
Great  enlargement  of  either  liver  or  spleen  is  infrequent. 

Blood. — Anaemia  is  present  in  most  of  the  marked  cases,  its  intensity 
varying  with  the  severity  of  the  rachitic  process.  The  blood  picture  is 
usually  that  of  an  ordinary  secondary  ansemia.  Leucocytosis  is  often 
present;  it  is  more  marked  in  cases  attended  by  an  enlarged  spleen. 

Nervous  Syhiptgms  are  among  the  most  frequent  manifestations  of 
rickets.  Restlessness  at  night  has  already  been  mentioned  as  a  prominent 
early  symptom.  Pain  and  tenderness  are  rare.  A  disposition  to  mus- 
cular spasm  is  seen  in  many  cases.  There  may  be  laryngismus  stridulus, 
tetany,  or  general  convulsions.  While  in  all  infants,  owing  to  the  ir- 
ritability of  the  nervous  centres,  convulsions  are  easily  excited  from 
relatively  slight  causes,  in  those  who  are  rachitic  this  susceptibility  is 
greatly  intensified.  As  a  predisposing  cause  of  convulsions  in  infancy, 
rickets  takes  the  first  place.  The  younger  the  child  and  the  more  active 
the  rachitic  process,  the  more  frequently  do  convulsions  occur.  They 
belong  especially  to  the  first  year,  being  most  frequent  between  the  third 
and  sixth  months.  The  exciting  cause  of  convulsions  in  these  cases  is 
usually  to  be  found  in  the  stomach  or  intestine. 

Course  and  Tennination. — Rickets  is  essentially  a  chronic  disease,  and 
its  course  is  measured  by  months.     The  active  symptoms  in  most  cases 


RICKETS.  257 

continue  from  three  to  fifteen  months.  That  active  symptoms  cease 
when  a  child  reaches  the  age  of  eighteen  months  or  two  years,  is  no 
doubt  due  largely  to  the  fact  that  at  this  age  the  diet  is  more  general, 
and  is  more  likely  to  furnish  what  the  child  needs,  and  that  more  fresh 
air  is  likely  to  be  secured  than  at  an  earlier  age. 

The  earliest  symptoms  of  improvement  are  a  diminution  in  the 
nervous  symptoms,  especially  in  the  restlessness  at  night;  increased 
muscular  power,  as  shown  by  a  disposition  to  stand  or  walk;  diminution 
in  the  head-sweats;  disappearance  of  the  cranio-tabes ;  and  improvement 
in  the  anaemia.  The  changes  in  the  deformities  are  very  slow,  and  from 
month  to  month  almost  imperceptible.  When  improvement  once  begins, 
however,  it  usually  goes  steadily  forward. 

Types  of  Rickets. — Congenital  Rickets. — Infants  may  present  at  birth 
the  characteristic  deformities  of  rickets,  and  there  may  be  found  even 
the  minute  bone  changes  of  the  disease.  Such  cases  are  reported  to  be 
common  in  Vienna  ^and  other  large  cities  of  Europe,  where  mothers  dur- 
ing pregnaiicy  have  lived  under  unfavourable  conditions.  In  America, 
however,  congenital  rickets  is  a  very  rare  disease.  Single  cases  have 
been  reported  by  several  writers;  but  it  must  be  remembered  that  cretin- 
ism and  chondro-dystrophy  have  often  been  improperly  included  under 
this  head, 

Late  Rickets. — Rare  instances  have  been  reported  of  bony  deformities 
in  all  respects  like  those  of  rickets,  developing  in  children  from  six  to 
twelve  years  old.  A  number  of  such  cases  have  been  observed  in  England. 
I  have  not  seen  this  disease,  nor  has  a  case  been  seen  during  the  past 
twenty  years  at  the  Hospital  for  Euptured  and  Crippled,  New  York, 
where  more  deformities  come  under  observation  than  anywhere  else  in 
this  country. 

Acute  Rickets. — Although  from  time  to  time  cases  have  been  reported 
with  this  title,  from  a  study  of  the  histories  it  is  clear  that  the  great 
majority,  if  not  all  of  them,  were  cases  of  infantile  scurvy.  It  is  doubt- 
ful whether,  strictly  speaking,  there  is  such  a  thing  as  acute  rickets. 

Diagnosis. — The  diagnosis  of  rickets  is  not  usually  difficult.  The 
most  important  early  symptoms  for  diagnosis  are  sweating  of  the  head, 
cranio-tabes,  great  restlessness  at  night,  delayed  dentition,  and  enlarged 
fontanel.  All  these,  taken  separately,  may  mean  something  else,  but 
collectively  they  can  mean  nothing  but  rickets.  In  the  later  stages  some 
of  the  characteristic  deformities  are  usually  present;  the  most  constant 
are  beading  of  the  ribs,  enlargement  of  the  epiphyses  of  the  wrists  and 
ankles,  and  bow-legs. 

Special  symptoms,  when  unusually  prominent,  may  give  rise  to  diffi- 
culty in  diagnosis.  The  enlargement  of  the  head  may  be  mistaken  for 
hydrocephalus.  The  delayed  dentition  and  large  fontanel  of  the  cretin 
may  be  mistaken  for  rickets.  Muscular  weakness  may  be  so  great,  espe- 
18 


258  NUTRITION. 

cially  when  affecting  the  legs,  as  to  make  it  easy  to  mistake  a  rachitic 
pseudo-paralysis  for  actual  paralysis  due  to  a  cerebral  or  spinal  lesion. 
When  walking  is  much  delayed,  rickets  may  be  passed  over  as  simple 
backwardness.  In  nearly  all  of  the  last-mentioned  group  of  cases  the 
diagnosis  may  be  cleared  up  by  a  careful  search  for  the  bony  changes, 
and  by  the  fact  that  in  rickets  there  is  only  a  general  weakness  of  all 
the  muscles,  and  not  actual  paralysis  of  any  limb  or  group  of  muscles. 
The  greatest  difficulty  is  usually  found  where  the  muscular  symptoms 
are  marked  and  the  bony  changes  slight,  as  is  not  infrequently  the  case. 
Here  the  question  is,  whether  rickets  is  sufficient  to  explain  all  the  symp- 
toms, or  whether  in  addition  some  other  condition  is  present.  The 
electrical  reactions  will  decide  the  question  of  poliomyelitis,  while  the 
presence  of  cerebral  symptoms,  exaggerated  knee-jerks,  and  rigidity  of 
the  legs,  will  usually  mark  a  cerebral  birth-palsy.  The  bony  enlarge- 
ments of  syphilis  may  be  confounded  with  those  of  rickets.  The  bone 
changes  of  early  syphilis,  although  affecting  the  epiphyses  are  seen  at 
an  earlier  age  and  are  generally  accompanied  by  pain  and  tenderness, 
sometimes  by  epiphyseal  separation,  none  of  which  are  seen  in  rickets. 
The  bone  changes  of  late  syphilis  affect  the  shaft  rather  than  the  ex- 
tremities of  the  long  bones;  where  the  bone  is  enlarged  near  the  joint 
it  is  usually  upon  one  side  only.  In  syphilis  there  may  be  necrosis,  while 
in  rickets  breaking  down  of  bone  is  never  seen.  From  scurvy,  rickets  is 
differentiated  by  the  absence  of  marked  hypersesthesia,  ecchymoses,  and 
other  haemorrhages,  the  changes  in  the  gums,  and  most  of  all  by  the 
fact  that  anti-scorbutic  diet  produces  no  immediate  change  in  the  symp- 
toms. The  diagnosis  of  rachitic  curvature  of  the  spine  from  vertebral 
caries  will  be  considered  in  connection  with  the  latter  disease. 

Prognosis. — Eickets  per  se  is  seldom,  if  ever,  a  cause  of  death.  It 
is,  however,  a  large  factor  in  the  mortality  of  the  first  two  years,  as  it 
predisposes  strongly  to  many  forms  of  acute  disease.  It  is  an  important 
etiological  factor  in  certain  serious  nervous  conditions,  especially  con- 
vulsions. Eickets  adds  very  greatly  to  the  danger  from  all  acute  diseases 
of  infancy,  particularly  those  of  the  respiratory  tract.  The  encroach- 
ment upon  the  capacity  of  the  lungs  by  a  marked  thoracic  deformity, 
may  in  itself  be  enough  to  keep  a  child  in  a  delicate  condition  and 
retard  its  growth.  At  the  same  time  such  a  condition  is  a  constant 
invitation  to  acute  attacks  of  bronchitis  or  pneumonia.  The  effect  of 
rickets  upon  the  future  health  of  the  child  depends  chiefly  upon  the 
presence  and  extent  of  the  thoracic  deformity.  When  this  is  absent, 
although  children  may  remain  somewhat  dwarfed  on  account  of  their 
short  legs,  in  other  respects  they  may  be  as  well  as  if  they  had  never 
been  the  subjects  of  rickets. 

Prophylaxis. — As  rickets  is  primarily  due  to  improper  food  or  feed- 
ing, and  secondarily  to  bad  surroundings,  it  may  largely  be  prevented 


RICKETS.  259 

by  the  observance  of  proper  rules  of  feeding  as  laid  down  elsewhere,  and 
by  removing  children  from  their  faulty  surroundings.  Especial  care 
should  be  given  to  the  later  children  of  a  family  where  the  earlier  ones 
have  shown  even  the  mildest  symptoms  of  rickets,  as  the  predisposition 
is  sure  to  increase  with  each  successive  child. 

Treatment. — In  considering  the  treatment  of  rickets,  the  natural 
course  of  the  disease  is  to  be  kept  in  mind,  viz.,  that  active  symptoms 
frequently  continue  only  until  the  end  of  the  first  year,  rarely  longer  than 
the  eighteenth  or  twentieth  month.  The  most  important  period  for 
treatment,  therefore,  and  the  one  in  which  it  is  most  effective,  is  from  the 
sixth  to  the  eighteenth  month.  The  earlier  the  treatment  is  begun  the 
better  will  be  its  results.  General  treatment  after  the  eighteenth  month, 
has  very  little  effect  upon  the  disease,  for  by  this  time  most  of  the 
harm  has  been  done.  The  course  of  the  disease  when  untreated  is  toward 
spontaneous  recovery,  from  the  changes  in  diet  and  life  which  are  usually 
made  when  children  have  reached  the  latter  half  of  the  second  year.  Most 
of  the  cases  seen  in  private  practice  are  of  a  mild  type  and  recover 
without  special  treatment,  often  no  diagnosis  being  made  until  later 
in  life,  when  the  bony  deformities  or  stunted  growth  indicate  the  pre- 
vious existence  of  rickets.  The  first  step  in  treatment  is  to  remove  the 
cause,  and  is  therefore  to  be  directed  to  the  diet  and  hygiene  of  the 
patient.  The  results  will  depend  upon  how  completely  these  causes  can 
be  discovered  and  removed. 

Diet. — Such  disorders  of  digestion  as  are  present  must  be  treated 
on  general  principles.  The  most  frequent  dietetic  error  in  rachitic 
patients  being  an  excess  of  carbohydrates  and  an  insufficient  supply  of 
fat,  it  follows  that  condensed  milk,  proprietary  infant  foods,  and  large 
amounts  of  farinaceous  foods  of  every  description  should  be  stopped.  A 
suitably  modified  cow's  milk  should  be  substituted  or  for  young  infants 
a  wet-nurse  should  be  secured.  Most  infants,  however,  are  eight  to  ten 
months  old  before  rachitic  symptoms  are  observed;  to  them  beef  juice, 
raw  eggs,  and  fruit  juice  should  be  given  in  addition  to  milk.  Cream, 
though  desirable,  is  very  often  badly  borne  and  some  other  form  of  fat 
must  be  substituted.  For  many  infants  olive  oil  will  be  found  useful 
and  may  be  given,  one  teaspoonful  three  times  a  day  for  long  periods. 
The  fat  of  crisp  bacon  upon  stale  bread  or  zwieback  among  the  poor 
may  serve  as  well.  All  these  articles  are  to  be  given  according  to  the 
rules  laid  down  in  the  chapters  on  Infant  Feeding. 

Hygiene. — In  large  cities  it  is  almost  impossible  to  secure  for  rachitic 
patients  the  surroundings  they  require.  Whenever  possible,  such  chil- 
dren should  be  sent  to  the  country ;  but  where  this  is  out  of  the  question, 
much  may  be  accomplished  by  frequent  excursions  upon  the  water  or 
into  the  country,  by  keeping  children  as  much  as  possible  in  the  parks 
and  open  squares  of  the  city,  and  securing  plenty  of  fresh  air  in  sleeping 


260  NUTRITION. 

rooms.  Cold  sponge-baths  given  every  morning,  do  much  to  lessen  this 
susceptibility.  Sunshine,  though  difficult  to  obtain  in  large  cities,  is  a 
most  efficient  therapeutic  agent.  The  establishment  of  suburban  hospitals 
and  homes  for  these  cases  would  do  more  than  anything  else  to  lessen 
the  mortality  from  rickets. 

Medicinal  Treatment. — In  a  disease  which  tends  so  uniformly  to 
recovery  when  causal  conditions  are  removed,  it  is  difficult  to  estimate, 
by  clinical  observations,  the  real  value  of  medicinal  treatment.  Arsenic 
and  iron  are  valuable  in  the  treatment  of  rickets,  the  special  indication 
for  their  use  being  the  presence  of  marked  anaemia.  Profuse  sweating 
may  be  relieved  by  small  doses  of  atropine,  i.  e.,  gr.  -g-^^,  three  or  four 
times  a  day,  to  a  child  of  six  months.  The  special  remedies  most  used 
are  cod-liver  oil,  phosphorus,  and  preparations  of  calcium. 

The  various  preparations  of  calcium,  the  phosphate,  lactophosphate, 
and  hypophosphite,  have  long  been  employed  with  the  belief  that  they 
could  supply  lime  to  the  tissues.  It  is  now  practically  certain  that  they 
do  not  do  so,  although  at  times,  they  may  be  useful  as  tonics  in  this  con- 
dition. The  two  important  remedies  for  rickets  are  cod-liver  oil  and 
phosphorus.  No  remedy  for  rickets  has  held  its  place  so  long  as  has 
cod-liver  oil.  Phosphorus,  popularised  in  the  treatment  of  this  disease 
by  Kassowitz,  has  also  some  value;  its  most  striking  results  are  seen  in 
the  early  cases  and  when  nervous  symptoms  are  marked.  The  best  results 
are  obtained  by  a  combination  of  these  two  remedies.  The  officinal  oil 
of  phosphorus  is  used  in  combination  with  cod-liver  oil,  gr.  -5^  to  ^J-j- 
is  given  three  times  a  day  with  one-half  drachm  to  one  drachm  of  the  oil. 
Striking  confirmation  of  the  clinical  observations  regarding  the  value 
of  this  combination  is  furnished  by  the  metabolism  experiments  of 
Schabad  who  found  the  percentage  of  calcium  retention  enormously  in- 
creased by  the  use  of  cod-liver  oil  and  phosphorus. 

Treatment  of  the  Rachitic  Deformities. — The  deformities  of  the 
chest  are  less  amenable  to  treatment  than  most  of  the  others.  After  the 
third  year  something  can  be  done  by  gymnastics  to  develop  the  chest 
muscles  and  to  increase  the  pulmonary  expansion.  The  employment  of 
the  pneumatic  cabinet,  in  which  it  is  sought  to  overcome  these  deform- 
ities by  the  use  of  rarefied  air,  has  never  been  given  the  trial  which  it 
deserves.  From  the  very  meagre  reports  published,  this  appears  to  be 
of  considerable  value. 

The  deformity  of  the  spine  (kyphosis)  may  usually  be  overcome  by 
postural  treatment.  The  patient  should  lie  upon  a  hard  bed ;  no  pillow 
should  be  allowed  under  the  head,  but  in  severe  cases  one  should  be 
placed  beneath  the  back,  so  that  the  head  and  buttocks  are  slightly  lower 
than  the  lumbar  spine.  While  sitting,  the  shoulders  should  be  kept  back 
and  the  trunk  supported.  Por  a  few  minutes  each  day  the  child  should 
be  placed  upon  the  face,  and  the  deformity  overcome  by  raising  the  but- 


RICKETS.  261 

tocks  while  pressure  is  made  upon  the  spine.  In  severe  cases,  an 
apparatus  for  giving  spinal  support,  either  by  a  steel  brace  or  a  plaster- 
of-Paris  jacket,  may  be  worn  a  few  hours  each  day  when  the  child  is 
sitting  up.  Other  means  should  be  employed,  especially  friction  and 
massage,  to  develop  the  spinal  muscles. 

In  very  many  cases  slight  deformities  of  the  extremities  are  outgrown 
when  the  general  treatment  can  be  properly  carried  out.  Where  these 
exist,  the  physician  should  take  tlie  curve  of  the  legs  liy  seating  the 
child  upon  a  flat  surfaces  and  tracing  their  outline  with  a  pencil  held 
perpendicularly.  A  fresh  tracing  should  be  taken  once  a  month.  If  the 
deformity  is  not  very  great  and  no  increase  takes  place,  it  is  safe  to 
continue  with  general  treatment  only.  If  the  deformity  is  marked  or  if 
it  increases  in  spite  of  the  constitutional  treatment,  braces  should  be 
applied.  Something  may  be  done  toward  straightening  the  bones  by 
intelligent  manipulation.  Walking  should  be  discouraged  until  the  bones 
are  quite  firm.  Friction  of  the  extremities  and  massage  will  do  very 
much  to  increase  muscular  development.  The  habit  of  sitting  cross- 
legged — a  very  common  one  in  rachitic  children — should  be  prevented, 
and  in  fact  any  other  habitual  posture,  on  account  of  the  danger  of 
increasing  certain  deformities.  But  little  is  to  be  expected  from  the 
use  of  apparatus  for  the  correction  of  rachitic  deformities  after  the  child 
is  two  and  a  half  years  old;  since  at  this  time,  and  often  even  at  two 
years,  the  bones  are  so  firm  that  no  amount  of  pressure  from  a  steel 
brace  will  have  any  effect. 

Without  going  fully  into  the  question  of  the  surgical  treatment  of 
rachitic  deformities,  for  which  the  reader  is  referred  to  text-books  of 
general  and  orthopaedic  surgery,  I  will  only  state  that  osteotomy  seems 
to  me  to  offer  decided  advantages  over  the  other  means  of  treating  severe 
deformities.  The  best  results  in  osteotomy  are  obtained  when  the  opera- 
tion is  delayed  until  the  fourth  or  fifth  year,  by  which  time  the  bones  are 
sufficiently  firm  and  solid.  Operations  in  the  second  year  are  generally 
unsatisfactory,  and  those  in  the  third  year  often  so,  because  of  the  bend- 
ing of  the  bones  which  takes  place  subsequently.  The  deformities  which 
require  operation  are  bow-legs  and  knock-knees,  less  frequently  the  cur- 
vatures of  the  femur  of  the  bones  of  the  forearm. 


SECTION  III. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CHAPTER    I. 
DISEASES  OF   THE  LIPS,    TONGUE,   AND  MOUTH. 

MALFORMATIONS. 

Harelip. — This  is  one  of  the  most  frequent  congenital  deformities. 
It  is  caused  by  an  incomplete  fusion  of  the  central  process  with  one  or 
both  of  the  lateral  processes  from  which  the  upper  half  of  the  face  is  de- 
veloped. This  deformity  may  be  single  or  double ;  the  fissure  is  never  in 
the  median  line,  but  usually  just  beneath  the  centre  of  the  nostril.  There 
may  be  simply  a  slight  indentation  in  the  lip,  or  the  fissure  may  extend 
to  the  nostril.  Both  single  and  double  harelip — more  frequently  the  lat- 
ter— may  be  complicated  by  fissure  of  the  palate.  Double  harelip  is 
usually  accompanied  by  a  fissure  between  the  intermaxillary  and  the 
superior  maxillary  bone  of  each  side. 

Cleft  Palate. — This  is  second  in  frequency  to  harelip.  It  may  involve 
the  soft  palate  only,  or  the  fissure  may  extend  into  the  hard  palate,  pro- 
ducing a  wide  gap  in  the  roof  of  the  mouth.  The  most  frequent  form 
is  that  in  which  only  the  soft  palate  is  affected. 

For  the  surgical  treatment  of  both  these  deformities  the  reader  is  re- 
ferred to  text-books  upon  surgery.  As  to  the  time  of  operation,  in  cases 
of  harelip  with  a  vigorous  child  of  eight  or  nine  pounds,  operation  in 
the  early  days  of  life  is  to  be  preferred.  With  a  small  and  delicate  infant 
it  is  best  to  wait  until  it  is  well  started  in  its  growth — usually  the  sec- 
ond month — and  in  cleft  palate  during  the  second  year.  The  medical 
treatment  of  these  cases  consists  in  the  care  of  the  mouth  and  in  the 
nutrition  of  the  patient.  The  mouth  in  all  cases  must  be  kept  scrupu- 
lously clean,  but  the  greatest  care  is  necessary  not  to  injure  the  epi- 
thelium. A  camel's-hair  brush  and  plain  lukewarm  water,  or  a  weak 
alkaline  solution,  are  to  be  recommended.  Both  these  deformities  are 
exceedingly  likely  to  be  complicated  by  thrush.  This  is  a  serious  menace 
to  the  success  of  any  operation,  and  even  to  the  life  of  the  patient.  The 
nutrition  is  always  a  matter  of  much  difficulty,  and  a  very  large  number 
of  these  cases  die  of  inanition  or  marasmus.  In  cases  of  harelip,  if  the 
262 


DISEASES  OF  THE   LIPS.  263 

fissure  is  so  great  as  to  interfere  with  nursing,  the  child  may  be  fed 
with  a  spoon  or  a  medicine  dropper  until  the  operation  can  be  done. 
In  cleft  palate  there  may  be  attached  to  the  rubber  nipple  of  the  nursing 
bottle  a  flap  of  thin  sheet-rubber  in  such  a  way  that  it  closes  the  fis- 
sure in  the  mouth  when  once  the  nipple  is  in  place.  This  flap  should  be 
shaped  like  a  leaf,  one  extremity  being  sewed  to  the  neck  of  the  rubber 
nipple  and  the  other  end  left  free.  In  many  cases,  both  before  and 
immediately  after  operation,  gavage  may  be  resorted  to  with  the  greatest 
benefit  and  with  very  little  inconvenience. 

Congenital  Hypertrophy  of  the  Tongue. — This  is  usually  due  to  dis- 
ease of  the  lymphatics,  and  is  to  be  regarded  as  a  lymphangioma.  In  a 
few  cases  hypertrophy  of  the  muscular  fibres  has  been  present.  The 
tongue  may  reach  an  enormous  size,  so  that  it  is  impossible  for  it  to  be 
contained  within  the  cavity  of  the  mouth,  and  it  may  thus  interfere  with 
nursing,  deglutition,  and  even  with  respiration.  The  treatment  is  sur- 
gical. Cases  like  the  above  are  to  be  distinguished  from  those  of  enlarge- 
ment of  the  tongue  seen  in  sporadic  cretinism.  In  this  disease  the 
tongue  is  considerably  enlarged  and  may  protrude  slightly  from  the 
mouth,  but  it  is  rarely,  if  ever,  large  enough  to  cause  other  symptoms. 
It  diminishes  notably  under  treatment  with  thyroid  extract. 

Bifid  Tongue. — These  cases  are  extremely  rare.  Brothers  has  re- 
ported to  the  New  York  Pathological  Society  a  case  of  cleft  tongue  in  a 
child  of  one  month.    There  was,  in  addition,  a  fissure  of  the  soft  palate. 

Tongue-tie. — This  deformity  is  due  to  such  a  shortening  of  the  fre- 
num  that  it  is  impossible  to  protrude  the  tongue  to  a  normal  extent.  It 
differs  considerably  in  degree  in  different  cases.  In  some,  the  tongue 
can  not  be  protruded  beyond  the  gums.  Tongue-tie  may  interfere  with 
articulation,  and  even  with  sucking.  The  treatment  consists  in  liberat- 
ing the  tongue  by  dividing  the  frenum  with  scissors  and  completing  the 
operation  with  the  finger  nail.  This  should  be  done  in  every  case  unless 
the  child  is  a  bleeder.  In  many  cases  the  mother  may  think  the  tongue 
tied  when  the  frenum  is  of  normal  length. 

Bifid  Uvula. — This  is  not  very  uncommon.  It  usually  occurs  in  con- 
nection with  cleft  palate,  but  is  occasionally  seen  when  there  is  no  other 
deformity  present.  It  may  be  complete  or  partial,  and  it  does  not  of  it- 
self require  treatment. 

DISEASES  OF  THE  LIPS. 

Herpes. — Herpes  labialis  is  an  exceedingly  common  affection  in  chil- 
dren, occurring  in  acute  febrile  diseases,  particularly  pneumonia,  and 
sometimes  alone.  It  is  the  familiar  "  fever  sore  "  or  "  cold  sore  "  of 
domestic  medicine.  The  appearance  is  similar  to  herpes  in  other  parts 
of  the  body.  There  is  first  a  group  of  vesicles,  then  rupture  and  the 
formation  of  crusts.    It  is  often  quite  difficult  to  cure  on  account  of  the 


264  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

disposition  of  children  to  pick  the  lip  with  the  fingers.  Although  it  heals 
without  treatment,  recovery  is  facilitated  by  the  use  of  some  antiseptic 
lotion,  such  as  dilute  boric  acid,  followed  by  a  dusting  powder  of  zinc 
oxide  and  boric  acid.  This  treatment  is  generally  more  successful  than 
the  use  of  ointments.  Young  children  should  wear  mittens  or  elbow 
splints  at  night,  to  prevent  picking  at  the  crusts. 

Eczema  of  the  Lip. — This  is  an  exceedingly  common  condition,  and 
a  very  troublesome  one.  The  vermilion  border  is  dry  and  rough,  and 
prone  to  deep  cracks  or  fissures.  These  are  usually  seen  at  the  angles  of 
the  mouth  or  in  the  median  line.  When  severe  they  are  exceedingly 
painful,  bleed  freely,  and  are  the  cause  of  very  great  discomfort,  es- 
pecially in  the  cold  season.  The  lips  should  be  covered  at  night  by  a 
simple  ointment,  and  this  should  be  used  as  much  as  possible  during  the 
day.  Where  deep  fissures  form,  they  should  be  touched  with  burnt  alum, 
or  with  the  solid  stick  of  nitrate  of  silver.  Syphilitic  fissures  are  con- 
sidered with  the  symptoms  of  that  disease. 

Perleche  (French,  pcrUcher  =i  to  lick). — This  name  was  first  given 
by  Lemaistre,  in  1886,  to  a  form  of  ulceration  occurring  usually  at  the 
angle  of  the  mouth.  It  begins  in  most  cases  as  a  small  fissure,  which,  by 
constant  licking  and  irritation,  to  which  there  is  usually  added  infection, 
may  produce  an  intractable  ulcer  of  considerable  size.  It  often  resem- 
bles the  mucous  patch  of  hereditary  syphilis.  The  ulcer  is  of  a  grayish 
colour,  is  quite  painful,  and  is  associated  with  considerable  swelling  of 
the  lip.  It  lasts  from  two  to  four  weeks.  The  treatment  is  the  same  as 
in  simple  fissure — viz.,  the  use  of  burnt  alum  or  nitrate  of  silver,  and 
covering  the  part  with  bismuth  or  oxide  of  zinc. 

DISEASES  OF  THE  TONGUE. 

Epithelial  Desquamation. — This  is  a  disease  of  the  lingual  epithe- 
lium, which  is  characterised  by  the  appearance  upon  the  dorsum  or 
margin  of  the  tongue,  of  circular,  elliptical,  or  crescentic  red  patches, 
with  gray  margins  which  are  slightly  elevated.  The  gray  margins  are 
apparently  due  to  thickening  of  the  epithelial  layer  and  the  red  areas 
to  desquamation  of  the  epithelium.  It  is  sometimes  improperly  called 
psoriasis  of  the  tongue.  It  is  quite  a  common  condition,  and  is  prob- 
ably congenital. 

As  usually  seen,  there  exist  upon  the  tongue  from  two  to  half  a  dozen 
of  these  red  patches  surrounded  by  a  gray  border,  which  is  about  one- 
twelfth  of  an  inch  wide,  and  slightly  elevated.  The  outline  of  the  patch 
is  nearly  always  crescentic  (see  Fig.  44).  From  day  to  day  tlie  con- 
figuration of  the  patches  changes;  the  gray  lines  advance  across  the 
tongue  from  side  to  side,  or  from  base  to  tip,  disappearing  as  they  reach 
the  border  or  the  extremity.     They  are  followed  by  the  red  patches, 


DISEASES  OF  THE  TONGUE.  265 

and  as  the  old  ones  fade  away  new  ones  form  and  run  the  same  course. 
The  red  patches  are  of  a  bright  colour  nearest  the  border,  gradually 
shading  off  into  the  normal  colour  of  the  tongue.  Only  the  epithelium  is 
involved,  the  deeper  structures  being  unaf- 
fected. The  duration  of  the  disease  is  indefi- 
nite; it  usually  lasts  for  years.  Guinon 
reports  several  cases  which  recovered  dur- 
ing an  intercurrent  attack  of  measles  or 
scarlet  fever. 

The  cause  is  unknown.  The  condition 
occurs  rather  more  frequently  in  females 
than  in  males,  and  Gubler  has  reported  an 
instance  of  several  members  of  the  same 
family  being  affected.  The  condition  has 
been  thought  to  depend  upon  nearly  every 
disease  of  childhood.  It  is  not  accom- 
panied by  pain,  salivation,  or  by  other  symp-  Fig.  44.— Epithelial  Desqua- 
toms  of  stomatitis,  and  is  of  little  practical  ^^?°^   °^  ^"^      ongue. 

'  ^  (Guinon.) 

importance.     Its   S3'mptoms   are   so   charac- 
teristic that  it  can  hardly  be  mistaken  for  any  other  condition.     Treat- 
ment is  unnecessary. 

Two  other  forms  of  epithelial  desquamation  have  been  observed, 
both  much  more  rare  than  that  described.  In  one  of  these  the  red  de- 
nuded portion  occupies  the  margin  of  the  tongue,  while  the  centre  is 
gray  or  white;  the  irregular  wavy  outline  which  separates  the  two  sug- 
gests strongly  an  outline  map,  and  the  condition  is  sometimes  called  the 
"  geographical  tongue."  This  term  is  frequently  employed  to  designate 
the  common  form.  In  another  variety  nearly  the  whole  organ  may  be 
uniformly  red,  from  loss  of  the  epithelium,  there  being  no  borders  or 
patches.  Both  these  varieties  are  of  much  shorter  duration  than  the 
more  common  form,  usually  lasting  only  a  few  weeks. 

Glossitis. — Inflammation  of  the  tongue  is  not  very  common  in  chil- 
dren. It  is  usually  of  traumatic  origin.  The  injury  may  be  due  to  bit- 
ing the  tongue  in  a  fall  or  in  an  epileptic  seizure.  Glossitis  is  sometimes 
excited  by  the  irritation  of  a  sharp  tooth,  causing  a  wound  which  may  be 
the  avenue  of  infection;  or  it  may  result  from  taking  into  the  mouth 
irritant  or  caustic  poisons.  In  a  small  number  of  cases  no  cause  can  be 
found.  The  symptoms  are  marked  swelling  of  the  tongue,  so  that  it  may 
protrude  from  the  mouth ;  and  it  may  even  be  so  great  as  to  cause  severe 
dyspnoea.  There  are  also  profuse  salivation,  difficulty  in  swallowing  and 
in  articulation,  and  often  considerable  local  pain.  There  may  be  a 
rise  of  temperature  to  102°  or  103°  F.  The  treatment  consists  in  the 
use  of  fluid  food,  which  in  severe  cases  may  be  introduced  through 
the  nose  by  means  of  a  catheter.     Ice  may  be  used  externally,  or,  bet- 


266  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

ter  still,  pieces  of  ice  may  be  kept  in  the  mouth  continually.  If  there 
is  obstruction  to  respiration,  and  in  all  severe  cases,  scarification  should 
be  done  on  the  dorsum  of  the  tongue  along  the  side  of  the  raphe. 

The  acute  swelling  of  the  tongue  and  lips  occurring  in  some  cases  of 
urticaria  may  be  mentioned  in  this  connection.  This  is  a  rare  condi- 
tion in  children,  but  it  may  develop  rapidly  and  to  such  a  degree  as  to 
cause  alarming  symptoms.  The  treatment  consists  in  the  use  of  ice 
locally,  free  purgation  by  salines,  and,  in  extreme  cases,  needle  punc- 
tures to  relieve  the  oedema. 

Tongue-swallowing. — This  term  is  used  to  describe  a  rare  condition 
seen  in  infants,  in  which  the  tongue  is  turned  backward  into  the 
pharynx,  so  as  to  obstruct  respiration.  It  may  be  drawn  quite  into 
the  oesophagus.  Several  marked  cases  have  been  collected  by  Hennig.* 
While  most  frequently  occurring  with  paroxysms  of  pertussis,  tongue- 
swallowing  has  been  seen  in  other  diseases.  This  should  not  be  forgot- 
ten as  one  of  the  explanations  of  sudden  asphyxia  in  a  young  infant. 
The  conditions  necessary  for  its  production  are  a  somewhat  relaxed  organ 
or  a  long  frenum.  In  none  of  the  fatal  cases  reported,  however,  had  the 
frenum  been  divided.  In  some  weak  infants,  falling  back  of  the  tongue, 
so  that  its  base  partly  covers  the  epiglottis,  produces  asphyxia,  precisely 
as  it  occurs  in  adult  life  under  full  anaesthesia.  The  recognition  of  the 
condition  is  a  very  easy  one,  and  its  treatment  is  to  relieve  the  obstruc- 
tion by  drawing  the  tongue  forward  by  the  finger  or  forceps. 

TTlcer  of  the  Frenum. — The  friction  against  the  sharp  edges  of  the 
lower  central  incisors  frequently  causes  an  ulcer  of  the  frenum  in  in- 
fants. I  have  never  seen  it  in  older  children.  It  usually  occurs  in 
pertussis,  but  is  seen  in  other  conditions.  In  some  it  appears  to  be  pro- 
duced by  friction  of  the  teeth  during  nursing  from  the  breast  or  bottle. 
It  is  more  often  seen  in  children  who  are  delicate  or  cachectic  than  in 
those  who  are  healthy  and  well  nourished.  The  ulcer  may  be  confined 
to  the  frenum,  or  it  may  extend  quite  deeply  into  the  tongue.  It  is 
usually  about  one-fourth  of  an  inch  in  diameter,  and  of  a  yellowish-gray 
colour.  When  not  readily  cured  by  touching  with  alum  or  nitrate  of 
silver,  the  child  may  be  fed  by  gavage  for  several  days,  or  the  teeth  may 
be  covered  by  a  bit  of  absorbent  cotton. 

DENTAL  CARIES. 

Although  the  teeth  do  not  strictly  belong  to  the  province  of  the  physi- 
cian they  have  an  important  influence  upon  the  general  health.  The 
pernicious  effects  of  dental  caries  have  only  recently  been  appreciated. 
Routine  examinations  of  public-school  children,  made  in  various  cities, 
have  shown  that  fully  80  per  cent  have  extensive  dental  caries.     Among 


*  Jahrbuch  fiir  Kinderheilkunde,  xi,  299. 


ALVEOLAR  ABSCESS.  267 

the  inmates  of  institutions  the  proportion  is  fully  as  great  as  this,  possi- 
bly greater,  unless,  as  in  a  few  modern  institutions,  special  attention  is 
given  to  this  subject. 

Among  the  causes  of  dental  caries  the  most  important  without  doubt 
is  want  of  cleanliness — the  almost  entire  neglect  of  the  toothbrush 
among  the  children  of  the  poor.  This  leads  to  decomposition  of  food 
and  secretions,  acid  fermentation,  erosions  of  the  enamel,  etc.  But  not 
all  caries  of  the  teeth  can  be  ascribed  to  this  cause.  Diet  has  certainly 
much  to  do  with  it.  It  is  my  own  belief  that  the  opinion  commonly  held, 
that  excessive  indulgence  in  sweets  is  responsible  for  dental  caries,  is 
well  founded.  Malnutrition  and  improper  food,  especially  in  early 
childhood,  certainly  affect  the  teeth.  In  some  children  a  congenitally 
defective  enamel  is  present.  Hereditary  syphilis  is  also  a  cause,  and  in 
children  with  congenital  mental  defects  the  teeth  are  prone  to  early 
decay. 

The  symptoms  are  both  local  and  general.  Locally,  as  a  result  of 
decomposition  and  infection,  there  are  present  foul  breath,  gingivitis, 
alveolar  abscess,  ulcerative  stomatitis,  toothache,  etc.  The  lymph  nodes 
in  the  neighbourhood  frequently  become  enlarged  and  sometimes  tuber- 
culous. The  tuberculosis  of  the  submaxillary  and  submental  lymph 
nodes  is  nearly  always  the  result  of  infection  through  the  teeth  or  the 
gums.  Whether  the  cervical  lymph  nodes  are  infected  in  the  same  way 
is  very  doubtful.  The  general  symptoms  result  in  part  from  improper 
mastication  of  food  and  in  part  from  sepsis  from  the  local  condition. 
Thus  we  may  have  attacks  of  indigestion,  failing  nutrition,  loss  of  appe- 
tite, and  anaemia.  From  the  local  irritation  various  nervous  symptoms 
may  arise.  The  most  common  are  habit  spasm,  facial  chorea,  headaches, 
and  according  to  some  writers  even  epileptiform  convulsions.  The  pres- 
ence of  carious  teeth  is  a  menace  to  the  general  health.  They  certainly 
predispose  to  local  tuberculosis.  Many  persons  assume  that  if  the  teeth 
affected  belong  to  the  first  set,  it  matters  little.  However,  the  perma- 
nent teeth  are  often  injured  by  extensive  decay  of  the  deciduous  set. 
The  treatment  of  this  condition  belongs  to  the  dentist.  But  the  physician 
should  appreciate  the  importance  of  the  subject  and  urge  parents  and 
others  in  charge  of  children  to  give  proper  attention  to  cleanliness  and  to 
see  that  carious  teeth  of  the  first  set  are  either  filled  or  removed. 


ALVEOLAR  ABSCESS. 

This  is  common  in  children,  especially  among  the  class  of  hospital 
and  dispensary  patients,  in  whom  little  or  no  attention  is  given  to  the 
care  of  the  teeth.  It  causes  severe  pain  and  acute  swelling,  which  may  be 
limited  to  the  gum,  or  it  may  involve  to  a  considerable  extent  the  perios- 
teum of  the  jaw  and  even  cause  swelling  of  the  whole  side  of  the  face. 


268  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

If  there"  is  retention  of  pus,  there  may  be  quite  severe  constitutional 
symptoms,  such  as  a  chill  and  high  temperature;  but  in  most  of  the 
cases  these  are  wanting.  The  abscess  usually  opens  spontaneously  into 
the  mouth,  but  it  may  open  externally  if  the  molar  teeth  are  the  ones 
affected.  It  may  even  lead  to  necrosis  of  the  jaw.  If  its  site  is  the  upper 
jaw,  the  pus  may  find  its  way  into  the  nasal  cavity  or  into  the  maxillary 
sinus. 

The  treatment  is,  in  the  first  place,  prophylactic.  This  requires  atten- 
tion to  the  teeth  to  prevent  decay,  and  the  removal  of  old  carious  fangs, 
which  are  a  constant  menace  to  the  health  of  the  child.  The  free  use 
of  the  toothbrush  and  some  antiseptic  mouth-wash  will,  in  the  great 
majority  of  cases,  prevent  the  occurrence  of  this  disease.  It  is  impor- 
tant that  the  abscess  be  opened  early  and  free  drainage  secured.  If 
there  is  a  carious  tooth  it  should  be  drawn. 


DIFFICULT  DENTITION. 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  in- 
fancy is  one  which  has  given  rise  to  much  discussion.  From  a  very  early 
period  the  view  has  descended,  that  a  large  number  of  the  diseases  occur- 
ring between  the  ages  of  six  months  and  two  years  are  due  to  difficult 
dentition.  The  list  of  such  diseases  is  a  long  one,  but  year  by  year  it  has 
been  shortened  as  one  after  another  has  been  shown  to  depend  upon 
other  causes,  dentition  being  only  a  coincidence. 

At  the  present  time  many  good  observers  deny  that  dentition  is  ever 
a  cause  of  symptoms  in  children;  some  even  going  so  far  as  to  say  that 
the  growth  of  the  teeth  causes  no  more  symptoms  than  the  growth  of  the 
hair.  Without  doubt  the  usual  mistake  made  in  practice  is  to  overlook 
disease  of  the  brain,  ears,  lungs,  stomach,  and  intestines,  because  of  the 
firm  belief  that  the  child  was  "only  teething."  The  physician  who 
starts  out  with  the  idea  that  in  infancy  dentition  may  produce  all  symp- 
toms usually  gets  no  further  than  this  in  his  etiological  investigations. 
Although  no  doubt  the  importance  of  dentition  as  an  etiological  factor 
in  disease  has  been  in  the  past  greatly  exaggerated,  the  careful  and 
candid  observer  must  admit  that,  particularly  in  delicate,  highly  nervous 
children,  dentition  may  produce  many  reflex  symptoms,  some  even  of 
quite  an  alarming  character. 

Speaking  from  general  impressions  not  from  statistics,  I  should  say 
that  in  my  experience  fully  one-half  of  the  healthy  children  cut  their 
teeth  without  any  visible  symptoms,  local  or  general;  in  the  remainder 
some  disturbance  is  usually  seen,  and  though  in  most  cases  it  is  slight 
and  of  short  duration,  it  may  last  for  several  days  or  even  a  week.  The 
symptoms  most  commonly  seen  are  disturbed  sleep,  or  wakefulness  at 
night  and  fretfulness  by  day,  so  that  children  often  sleep  only  one-half 


DIFFICULT   DENTITION.  269 

the  usual  time.  There  is  loss  of  appetite,  and  much  less  food  than  usual 
is  taken.  There  is  often,  but  not  always,  an  increase  in  the  salivary 
secretion,  a  slight  amount  of  catarrhal  stomatitis,  and  a  constant  dispo- 
sition on  the  part  of  the  child  to  put  the  fingers  into  the  mouth.  The 
bowels  are  often  constipated  or  there  may  be  slight  diarrhoea.  The  ther- 
mometer may  show  a  slight  elevation  of  temperature  to  100°  or  101.5° 
F.  The  weight  often  remains  stationary  for  a  week  or  two,  and  there 
may  even  be  a  loss  of  a  few  ounces.  The  duration  of  these  symptoms  in 
most  cases  is  but  a  few  days,  and  they  require  no  special  treatment.  If 
the  food  is  forced  beyond  the  child's  inclination,  attacks  of  indigestion 
with  vomiting  and  diarrhoea  are  easily  excited. 

Symptoms  more  severe  than  the  above,  are  rare  in  healthy  children, 
but  are  not  infrequent  in  those  who  are  delicate  or  rachitic.  In  such 
susceptible  children,  even  so  slight  a  thing  as  dentition  may  be  an  excit- 
ing cause  of  quite  serious  disturbances.  Often  there  is  some  other 
factor  in  the-  case,  such  as  bad  feeding  or  feeble  digestion.  In  delicate 
or  rachitic  children  there  may  be  seen  the  symptoms  already  mentioned 
as  occurring  in  healthy  infants,  but  in  greater  severity;  and  in  addition 
there  may  be  severe  attacks  of  acute  indigestion.  Occasionally  there  is 
an  elevation  of  temperature  to  102°  or  103°  F.,  lasting  usually  only  two 
or  three  days,  and  accompanied  by  no  symptoms  except  almost  complete 
anorexia.  Convulsions  which  could  fairly  be  attributed  to  dentition  I 
have  seen  but  two  or  three  times ;  they  are  more  apt  to  occur  in  rachitic 
and  highly  nervous  children.  In  cases  of  eczema  the  symptoms  often 
undergo  a  distinct  exacerbation  with  the  eruption  of  each  group  of 
teeth.  As  regards  almost  all  the  other  diseased  conditions  which  are 
commonly  attributed  to  dentition,  I  believe  that  it  is  a  delusion  to  ascribe 
them  to  this  cause. 

The  physician  should  watch  a  child  carefully,  and  examine  it  fre- 
quently, to  be  sure  that  he  is  not  overlooking  some  serious  local  or  con- 
stitutional disease  before  he  allows  himself  to  make  the  diagnosis  of 
difficult  dentition.  Probably  in  ninety-five  per  cent  of  the  cases  in  which 
symptoms  are  present,  they  are  due  to  some  cause  other  than  dentition. 
When,  however,  symptoms  such  as  any  of  those  mentioned  disappear 
immediately  when  the  teeth  come  through,  and  when  we  see  them 
repeated  four  or  five  times  in  the  same  child  with  the  eruption  of  each 
group  of  teeth,  and  accompanied  by  red  and  swollen  gums,  I  think  we 
can  not  escape  the  conclusion  that  dentition  is  a  factor  in  their  pro- 
duction, though  perhaps  not  the  only  one. 

In  the  treatment  of  this  condition  drugs  occupy  but  a  small  place.  It 
should  be  remembered  that  infants  are  at  this  time  in  a  peculiarly  sus- 
ceptible condition  as  regards  the  digestive  tract,  and  attacks  of  indiges- 
tion, and  even  severe  diarrhoea,  are  readily  excited  from  slight  causes, 
especially  from  overfeeding.     Special  care  should  be  exercised  in  this 


270  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

respect.  The  strength  of  the  food  should  be  reduced,  as  well  as  the 
amount  given.  A  poor  appetite  indicates  a  feeble  digestion,  which 
should  not  be  overtaxed.  As  attacks  of  bronchitis  and  acute  nasal  ca- 
tarrh are  readily  induced,  even  slight  exposure  should  be  guarded 
against.  The  nervous  s3'mptoms,  when  severe,  may  be  relieved  by  the 
use  of  moderate  doses  of  the  bromides  or  by  phenacetine,  better  than  by 
opiates.  All  soothing  syrups  should  be  discountenanced.  All  the  vari- 
ous devices  for  making  dentition  easy  are  a  delusion.  In  a  small  num- 
ber of  cases  lancing  the  gums  is  of  value.  I  have  myself  seen  in  a  few 
rare  instances  marked  and  undoubted  relief  given  by  it.  This  is  likely 
to  be  the  case  where  the  gums  are  tense,  swollen,  and  very  red,  with  the 
teeth  just  beneath  the  mucous  membrane.  To  press  a  tooth  through  the 
gum  by  simply  rubbing  gently  with  the  finger  covered  with  sterile  gauze 
is  frequently  more  effective  than  an  incision.  It  is  seldom,  however, 
that  the  relief  expected  is  seen  from  any  of  these  measures. 

CATARRHAL   STOMATITIS. 

This  is  characterised  by  redness  and  swelling  of  the  mucous  mem- 
brane, and  by  increased  secretion  of  the  salivary  and  the  muciparous 
glands  of  the  mouth.  It  usually  involves  a  large  part  of  the  mucous 
membrane. 

Etiology. — Catarrhal  stomatitis  may  result  from  traumatism.  This 
injury  may  be  mechanical,  or  due  to  heat  or  any  irritant  accidentally 
taken  into  the  mouth.  It  frequently  occurs  at  the  time  of  the  eruption 
of  a  tooth.  It  complicates  measles,  scarlet  fever,  diphtheria,  influenza, 
and  many  other  infectious  diseases.  In  these  cases,  and  in  many  others, 
the  disease  is  probably  due  to  direct  infection. 

Lesions. — The  lesions  are  essentially  the  same  as  in  catarrhal  inflam- 
mations of  other  mucous  membranes.  There  are  congestion  with  des- 
quamation of  epithelial  cells,  and  sometimes  the  formation  of  superficial 
ulcers.  The  process  may  be  a  very  superficial  one,  or  it  may  extend  to 
the  submucous  tissue. 

S3miptoms. — The  mucous  membrane  is  intensely  injected,  all  the 
capillaries  are  dilated,  and  small  haemorrhages  easily  excited.  The  mu- 
cous membrane  is  swollen,  this  being  most  apparent  over  the  gums  or 
about  the  teeth.  There  may  be  some  swelling  of  the  lips.  The  mouth 
seems  hot,  and  the  local  temperature  is  certainly  increased.  There  is 
considerable  pain,  as  sho\\Ti  by  fretfulness,  but  particularly  by  the  disin- 
clination to  take  food :  infants,  though  evidently  hungry,  either  refusing 
the  breast  or  bottle  altogether,  or  dropping  it  after  a  few  moments.  The 
increase  in  secretion  is  sometimes  marked,  so  that  the  saliva  pours  from 
the  mouth,  irritating  the  lips  and  face  and  drenching  the  clothing.  In 
other  cases  the  saliva  is  swallowed.     On  close  inspection  there  may  be 


HERPETIC  STOMATITIS.  271 

seen  swelling  of  the  muciparous  follicles,  and  even  the  formation  of  tiny 
cysts  from  the  accumulation  of  secretion  within  them.  The  tongue  is 
usually  coated,  the  edges  reddened,  and  the  papillae  prominent.  In 
febrile  diseases,  such  as  typhoid,  etc.,  we  may  get  an  accumulation  of 
dead  epithelium  with  the  formation  of  cracks  and  fissures  of  the  tongue, 
and  the  lips  may  present  a  similar  condition.  The  neighbouring  lym- 
phatic glands  are  slightly  enlarged  and  tender.  The  constitutional  symp- 
toms accompanying  simple  stomatitis  are  not  severe,  but  some  disturb- 
ance is  almost  always  present.  There  may  be  derangement  of  digestion 
with  vomiting,  and  even  a  mild  attack  of  diarrhoea.  In  the  majority  of 
cases  the  disease  runs  a  short  course,  recovery  taking  place  in  a  few 
days  when  the  primary  cause  is  removed.  In  very  delicate  children  it 
may  be  prolonged,  and  from  the  interference  with  nutrition  may  even 
lead  to  serious  consequences. 

Treatment. — The  mouth  and  teeth  should  be  kept  clean.  Food  is 
more  acceptable  if  given  cold.  In  very  severe  cases,  where  food  is  refused, 
gavage  may  be  resorted  to  three  or  four  times  daily.  In  all  cases  chil- 
dren may  be  given  ice  to  suck.  This  is  refreshing,  both  on  account  of 
the  cold  and  from  the  relief  to  the  thirst.  The  mouth  should  be  kept 
clean  with  a  solution  of  boric  acid,  ten  grains  to  the  ounce,  or  an  alkaline 
solution,  such  as  Dobell's,  diluted  with  an  equal  amount  of  cold  boiled 
water;  or  plain  water  may  be  used.  In  the  severe  forms,  where  there  is 
much  swelling  and  slight  catarrhal  ulceration,  astringents  are  required. 
In  my  experience  alum  is  the  best;  this  may  be  applied  in  the  form  of 
the  powdered  burnt  alum  mixed  with  an  equal  amount  of  bismuth,  or  in 
solution,  ten  grains  to  the  ounce,  with  a  swab  or  brush.  Where  ulcers 
are  slow  in  healing  and  very  painful,  the  powdered  burnt  alum  or  the 
solid  stick  of  nitrate  of  silver  may  be  applied  directly. 

HERPETIC  STOMATITIS. 
(Aphthous,  Vesicular,  or  Follicular  Stomatitis.) 

In  this  form  of  stomatitis  we  have  the  appearance  first  of  small 
yellowish-white  isolated  spots,  and  subsequently  the  formation  of  super- 
ficial ulcers.  These  ulcers  are  first  discrete,  but  may  coalesce  and  form 
others  of  considerable  size.  It  is  a  self-limited  disease,  usually  running 
its  course  in  from  five  days  to  two  weeks. 

Etiology. — Very  little  is  as  yet  positively  known  regarding  the  cause 
of  herpetic  stomatitis.  It  is  not  common  in  the  first  year,  but  after  that 
is  very  frequently  seen  throughout  childhood.  It  occurs  in  the  strong  as 
well  as  in  the  delicate.  It  is  often  associated  with  some  disturbance  of 
the  stomach,  and  occasionally  with  dentition.  I  have  adopted  the  term 
herpetic  because  the  condition  is  analogous  to  herpes  of  the  lips  and 
face,  the  difference  in  appearance  being  due  chiefly  to  location.     It  is 


272  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

apparently  caused  by  something  which  acts  upon  terminal  nerve  fila- 
ments. 

Lesions. — The  generally  accepted  opinion  is  that  there  is  first  a  vesi- 
cle, followed  by  a  death  of  epithelial  cells  covering  it,  and  then  a  super- 
ficial ulcer.  The  white  appearance  is  due  to  the  fact  that  the  ulcers, 
being  on  a  mucous  membrane,  are  always  moist.  These  ulcers  may 
extend  superficially,  but  never  deeply;  they  heal  quickly  with  the  for- 
mation of  new  epithelial  cells,  leaving  no  cicatrices.  Herpetic  stoma- 
titis is  always  associated  with  more  or  less  catarrhal  inflammation. 

Symptoms. — The  disease  is  characterised  by  local  and  general  symp- 
toms. The  latter  are  quite  indefinite — general  indisposition,  loss  of 
appetite,  and  slight  fever.  The  local  symptoms  consist  in  the  develop- 
ment of  small,  shallow,  circular  ulcers,  usually  coming  in  successive 
crops.  While  most  frequent  at  the  border  of  the  tongue  and  the  inside 
of  the  lips,  they  may  be  found  upon  any  part  of  the  mucous  membrane 
of  the  mouth  or  the  pharynx.  There  may  be  only  half  a  dozen  present, 
or  the  mouth  may  be  filled  with  them.  They  are  first  of  a  yellowish 
colour,  and  on  an  average  about  one-eighth  of  an  inch  in  diameter.  By 
the  coalescence  of  several  smaller  ones  there  may  form  patches  of  con- 
siderable size,  sometimes  nearly  covering  the  lips.  The  older  ulcers  are 
apt  to  have  a  dirty  grayish  colour,  and  in  places  may  look  not  unlike  a 
diphtheritic  membrane.  The  smaller  ones  are  surrounded  by  a  red 
areola,  and  when  healing  the  margin  is  of  a  bright  red  colour.  Their 
appearance  is  often  more  like  that  of  an  exudation  upon  the  mucous 
membrane  than  an  excavation  into  it.  The  other  symptoms  are  much 
the  same  as  those  of  catarrhal  stomatitis,  but  usually  of  greater  severity. 
The  pain  is  particularly  intense,  it  being  often  difficult  to  induce  chil- 
dren to  take  anything  in  the  form  of  food.  The  tongue  is  frequently 
coated,  but  there  is  never  the  foul  breath  of  ulcerative  stomatitis.  The 
duration  of  the  disease  is  from  one  to  two  weeks,  and,  if  the  child  is  in 
good  condition,  complete  recovery  takes  place  even  without  any  special 
treatment.  In  badly  nourished  children  the  disease  may  last  for  two  or 
three  weeks;  relapses  may  occur,  and  the  condition  may  interfere  very 
seriously  with  the  child's  nutrition. 

Treatment. — This  is  the  same  as  in  catarrhal  stomatitis,  with  the 
addition  that  to  each  one  of  the  ulcers  finely  powdered  burnt  alum  should 
be  applied  with  a  camel's-hair  brush.  If  this  is  not  effective,  the  solid 
stick  of  nitrate  of  silver  may  be  used.  The  ulcers  will  usually  yield  rap- 
idly to  this  treatment.  In  my  experience,  drugs  given  with  the  purpose 
of  affecting  the  lesion  in  the  mouth  have  been  without  benefit. 

ULCERATIVE  STOMATITIS. 

Ulcerative  stomatitis  is  believed  to  occur  only  when  teeth  are  pres- 
ent.   It  is  characterised  by  an  ulcerative  process,  beginning  at  the  junc- 


ULCERATIVE   STOMATITIS.  273 

tion  of  the  teeth  and  the  gum,  and  extending  along  the  teetli;  it  occa- 
sionally involves  other  parts  of  the  mouth,  but  never  spreads  beyond  the 
buccal  cavity. 

Etiology. — A  form  of  ulcerative  stomatitis  is  produced  by  certain 
metallic  poisons,  especially  mercury,  lead,  and  phosphorus ;  but  all  these 
are  now  rare.  Ulcerative  stomatitis  also  occurs  in  scurvy;  and  it  seems 
probable  that  an  allied  disturbance  of  nutrition,  with  spongy,  swollen 
gums,  precedes  some  other  forms  of  ulcerative  stomatitis.  Bad  sur- 
roundings and  improper  food  act  as  predisposing  causes;  for  the  disease 
is  quite  common  in  institutions  for  children  and  in  hospital  and  dis- 
pensary patients,  although  rare  in  private  practice.  Local  causes  of  im- 
portance are  want  of  cleanliness  of  the  mouth  and  teeth  and  the  presence 
of  carious  teeth.  Conditions  which  produce  a  lowered  vitality  of  the 
gums  act  as  a  predisposing  cause,  and  infection  as  an  exciting  cause  of 
the  disease.  The  constant  clinical  features  of  ulcerative  stomatitis  and 
the  occasional  occurrence  of  epidemics  indicate  a  specific  cause  which  is 
probably  the  same  as  that  of  ulcero-membranous  tonsillitis.  The  two 
conditions  often  exist  at  the  same  time.  From  the  investigations  of  Vin- 
cent, Bernheim,  Plant  and  others  it  seems  probable  that  noma  is  also 
produced  by  the  same  organism  but  represents  a  more  virulent  infection. 

Lesions. — The  disease  may  begin  at  any  part  of  the  mouth,  but  most 
frequently  upon  the  outer  surface  of  the  gum  along  the  lower  incisor 
teeth.  From  this  point  it  extends  behind  the  teeth,  and  from  the  in- 
cisors to  the  canines  and  molars,  usually  of  one  side  only;  but  it  may 
involve  the  entire  gum  of  both  jaws.  From  the  gums  the  process  may 
spread  to  the  lips,  affecting  the  fold  of  mucous  membrane  between  the 
gum  and  the  lip,  and  also  to  the  inner  surface  of  the  cheek,  especially 
opposite  the  molar  teeth,  where  large  ulcers  often  form.  In  neglected 
cases  the  disease  may  extend  into  the  alveolar  sockets,  the  teeth  loosen- 
ing and  falling  out.  The  periosteum  of  the  alveolar  process  may  be  in- 
volved, and  even  superficial  necrosis  of  the  jaw  may  occur,  as  has  hap- 
pened in  several  cases  that  came  under  my  observation.  These  severe 
forms  are  met  with  in  institutions  chiefly  and  then  generally  follow 
measles  or  scarlet  fever. 

Ulcers  similar  in  appearance  may  also  be  present  in  other  parts  of 
the  mouth — i.  e.,  on  the  soft  palate  or  the  tonsils,  sometimes  even  when 
the  gums  are  not  involved. 

Symptoms. — The  first  things  noticed  are  the  very  offensive  breath 
and  the  profuse  salivation.  It  is  usually  for  one  of  these  symptoms  that 
the  patient  is  brought  for  treatment.  On  inspection  of  the  mouth,  there 
are  seen  in  the  mild  cases,  swollen,  spongy  gums  of  a  deep-red  or  purplish 
colour,  which  bleed  at  the  slightest  touch.  There  is  a  line  of  ulceration, 
usually  along  the  incisor  teeth,  most  marked  in  front,  which  may  ex- 
tend to  any  or  to  all  of  the  teeth;  sometimes  it  affects  only  the  gum 
19 


274  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

along  the  molar  teeth,  the  incisors  escaping.  At  the  junction  of  the 
teeth  and  gum  is  seen  a  dirty,  yellowish  deposit,  on  the  removal  of  which 
free  bleeding  takes  place.  The  diseased  parts  are  very  painful,  and  the 
child  cries  and  resists  any  attempt  at  examination.  In  the  more  severe 
cases  and  in  those  of  longer  duration  the  teeth  are  loosened,  sometimes 
being  so  loose  that  they  can  be  picked  from  the  gum.  There  may  be 
necrosis  of  the  jaw,  and  even  a  loose  sequestrum  may  be  found.  In 
these  cases  the  ulceration  along  the  gums  is  deeper,  and  there  may  be 
ulcers  in  the  cheek  opposite  the  molar  teeth,  or  inside  the  lip.  The 
swelling  may  be  so  great  that  the  teeth  are  almost  covered;  this  is  seen 
particularly  in  the  scorbutic  form.  The  saliva  pours  from  the  mouth, 
adding  greatly  to  the  discomfort  of  the  patient.  Beneath  the  jaw  are 
felt  the  large,  swollen  lymphatic  glands,  which  are  painful  and  tender  to 
the  touch,  but  show  no  tendency  to  suppurate.  The  tongue  is  somewhat 
swollen,  and  shows  at  the  edges  the  imprint  of  the  teeth;  it  has  a  thick, 
dirty  coating. 

The  disease  is  attended  by  little  or  no  fever  or  other  constitutional 
symptoms.  The  general  condition  of  these  patients  is  often  poor,  and 
there  may  be  quite  a  marked  cachexia.  Other  forms  of  stomatitis  may  be 
associated,  and  it  should  not  be  forgotten  that  the  gangrenous  form  may 
follow. 

When  not  recognised  or  not  properly  treated,  ulcerative  stomatitis 
may  last  for  months.  When  properly  treated  it  tends  in  all  recent  cases 
to  recovery,  usually  in  from  five  to  ten  days.  No  deformity. of  the  mouth 
is  left,  the  only  untoward  results  being  shrinking  of  the  gum,  sometimes 
loss  of  some  of  the  incisor  teeth,  and  more  rarely  a  superficial  necrosis 
of  the  alveolar  process.  All  these  are  quite  uncommon.  Ulcerative 
stomatitis  can  hardly  be  confounded  with  any  other  form,  and  not  only 
should  a  diagnosis  of  the  lesion  be  made,  but  the  condition  upon  which 
it  depends  should,  if  possible,  be  discovered;  scorbutus,  particularly, 
should  not  be  overlooked. 

Treatment. — The  first  thing  to  be  done  is  to  remove  the  cause.  When 
dependent  upon  metallic  poisoning  the  source  should  be  discovered. 
Scorbutic  cases  should  have  the  usual  anti-scorbutic  diet.  Cleanliness  of 
the  mouth  is  of  great  importance,  and  this  may  best  be  accomplished  by 
the  use  of  peroxide  of  hydrogen  diluted  with  from  one  to  four  parts  of 
water.  It  should  be  followed  by  thorough  rinsing  with  plain  water,  and 
repeated  several  times  a  day.  In  other  cases  a  solution  of  alum,  five 
grains  to  the  ounce,  or  a  mouth-wash  of  chlorate  of  potash,  three  grains 
to  the  ounce,  may  be  employed.  The  only  objection  to  the  last  men- 
tioned is  the  pain  which  it  usually  produces. 

The  specific  remedy  for  ulcerative  stomatitis  is  chlorate  of  potash. 
The  best  method  of  administration  is  to  give  two  grains,  or  one-half  tea- 
spoonful  of  a  saturated  solution,  largely  diluted,  every  hour  during  the 


THRUSH.  275 

day  for  the  first  twenty-four  hours  and  subsequently  every  two  hours; 
when  improvement  occurs  the  dose  may  be  still  further  reduced. 
Marked  benefit  is  usually  seen  in  one  or  two  days  even  in  cases  that  have 
lasted  for  several  weeks.  If  the  case  does  not  yield  readily  to  this  treat- 
ment there  is  probably  disease  at  the  roots  of  the  teeth,  and  when  loose 
these  should  be  removed,  and  the  jaw  examined  to  see  if  there  is  necro- 
sis. Occasionally  when  there  is  no  disposition  to  heal,  the  shreds  of 
necrotic  tissue  should  be  carefully  removed,  and  burnt  alum  or  nitrate 
of  silver  applied. 

The  constitutional  and  dietetic  treatment  in  all  these  cases  should 
be  the  same  as  that  employed  in  scurvy — i.  e.,  plenty  of  fruit,  fresh  vege- 
tables, and  sometimes  the  internal  administration  of  mineral  acids,  espe- 
cially aromatic  sulphuric  acid.     Iron  is  indicated  in  most  of  the  cases. 

Ulceration  of  the  Hard  Palate. — This  is  usually  seen  in  the  first  few 
weeks  of  life,  but  may  occur  in  any  child  suffering  from  marasmus.  The 
primary  cau§e  may  be  the  injury  inflicted  in  cleansing  the  mouth.  In 
other  cases  it  is  due  to  the  friction  of  the  rubber  nipple,  or  some  other 
object  which  the  child  is  allowed  to  suck.  In  still  others  it  is  appar- 
ently produced  by  the  habit  of  tongue-sucking  frequently  observed  in 
these  young  infants.  The  appearances  are  quite  characteristic :  there  is 
found,  rather  far  back  upon  the  hard  palate,  usually  in  the  middle  line, 
a  superficial  ulcer,  from  a  fourth  to  a  half  inch  in  diameter.  There  are 
no  signs  of  acute  inflammation.  Thrush  may  coexist,  but  it  has  no  rela- 
tion to  the  production  of  the  disease.  Spontaneous  recovery  usually  oc- 
curs in  from  one  to  three  weeks,  provided  the  cause  can  be  removed.  In 
children  suffering  from  marasmus  these  ulcers  are  very  intractable,  and 
in  many  instances  their  cure  is  practically  impossible.  It  is  therefore 
especially  important  to  prevent,  if  possible,  their  formation  by  care  in 
cleansing  the  mouth,  and  in  avoiding  the  other  causes  referred  to.  When 
ulcers  have  appeared  they  should  be  treated  as  in  cases  of  herpetic  stoma- 
titis. 

THRUSH. 
(Sprue;  German,  Soar;  French,  Muguet.) 

Thrush  is  a  parasitic  form  of  stomatitis  characterised  by  the  appear- 
ance upon  the  mucous  membrane,  usually  of  the  tongue  or  of  the  cheeks, 
of  small  white  flakes  or  larger  patches.  It  is  common  in  infants  of  the 
first  two  or  three  months,  and  in  all  the  protracted  exhausting  diseases 
of  early  life. 

Etiology. — The  exact  class  to  which  the  vegetable  parasite  which 
produces  thrush  belongs  has  not  yet  been  definitely  settled.  Robin's 
opinion  was  long  accepted  that  it  was  the  o'idium  albicans;  the  view  of 
Grawitz,  that  it  is  the  saccharotnyces  albicans,  is  now  more  generally 
adopted.     If  a  little  of  the  exudate  from  the  mouth  is  placed  upon  a 


276 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


Fig.  45. — Thrush  Fungus  (highly  magnified). 
a,  mycelium;  b,  spores;  c,  epithelial  cells 
from  the  mouth;  d,  leucocytes;  e,  detritus, 
(v.  Jaksch.) 


slide  and  a  drop  of  liquor  potassfe  added,  the  structure  of  the  fungus  is 
readily  seen.  With  the  low  power  of  the  microscope  there  can  be  made 
out  fine  threads  (the  mycelium)  and  small  oval  bodies  (the  spores). 
With  a  high  power  the  threads  can  be  seen  to  be  made  up  of  a  number 

of  shorter  rods,  at  the  ends  of 
which  the  spore  formation 
takes  place  (Fig.  45).  The 
mycelium  is  produced  from 
the  spores.  The  spores  of  this 
fungus  are  of  very  common 
%\H^u^^^^^^^^<^^^^^K^;;-f^i!^s>-  occurrence  in  the  atmosphere. 
^»~~^^'^^^^'=-^A^rriC<yC-M;M:'M^^^  It    is    difficult    or    impossible 

for  thrush  to  develop  upon 
a  healthy  mucous  membrane. 
Its  growth  is  favoured  by 
slight  abrasions,  such  as  are 
often  produced  by  rough 
methods  of  cleansing  the 
mouth ;  also  by  catarrlial  sto- 
matitis, a  scanty  salivary  se- 
cretion and  want  of  cleanli- 
ness. The  nature  of  the  process  which  it  produces  is  in  all  probability  a 
sugar  fermentation,  the  acid  reaction  of  the  mouth  being  the  result  of  the 
growth  rather  than  its  cause.  Infection  may  come  from  another  patient 
by  means  of  a  rubber  nipple  or  a  cloth  which  has  been  used  for  the 
infected  mouth,  from  the  nipple  of  the  nurse,  or  directly  from  the  air. 
Its  production  is  favoured  by  a  scanty  secretion  of  saliva,  hence  it  is 
frequent  in  the  first  two  or  three  months  of  life;  also  by  an  altered 
secretion  such  as  is  seen  in  protracted  wasting  diseases,  entero-colitis, 
marasmus,  typhoid,  tuberculosis,  etc.  It  is  very  common  in  infants  suf- 
fering from  harelip  or  any  other  deformity  of  the  mouth.  The  disease 
is  frequently  seen  in  foundling  asylums,  in  all  places  where  many  young 
infants  are  crowded  together,  and  where  cleanliness  of  mouths,  bottles, 
etc.,  is  neglected. 

Lesions. — The  spores  lodge  between  the  epithelial  cells  and  gradu- 
ally separate  the  different  layers.  This  occurs  before  the  formation  of 
the  white  pellicle.  Later  the  disease  spreads  on  the  surface  of  the 
mucous  membrane,  and  also  penetrates  the  deeper  structures.  It  may 
invade  the  blood-vessels  and  cause  thrombosis  or  even  be  carried  to  dis- 
tant parts.  Although  the  saccharomyces  albicans  is  commonly  found 
upon  flat  epithelium,  its  growth  is  not  confined  to  it.  It  usually  l)egins 
at  many  distinct  points  upon  the  mucous  membrane,  and  gradually 
spreads  until  coalescence  takes  place;  a  continuous  membrane  may  be 
thus  formed.     No  pus  is  produced  by  the  process. 


THRUSH.  277 

The  usual  seat  is  the  margin  of  the  tongue,  the  inside  of  the  lips  and 
cheeks,  and  the  hard  palate,  but  not  infrequently  it  involves  the  pillars 
of  the  fauces,  and  the  pharynx.  Further  extension  in  the  digestive  tract 
than  this  is  rare,  although  the  stomach,  and  even  the  intestines,  may  be 
invaded.  I  have  seen  it  but  once  or  twice  in  the  oesophagus  and  never 
in  the  stomach,  and  I  know  of  but  two  reported  cases  in  this  country  in 
which  thrush  has  been  found  there.  Cases  involving  the  oesophagus  and 
the  stomach  appear  from  reports  to  be  much  more  common  in  Europe. 
In  several  cases  in  the  Babies'  Hospital  the  saccharomyces  albicans  has 
been  found  in  the  lungs  of  infants  suffering  from  broncho-pneumonia. 
There  are  several  reported  cases  of  general  blood  infection  from  this 
organism. 

Symptoms. — The  essential  symptoms  of  thiush  are  the  appearance 
upon  the  mucous  membrane  of  the  mouth — usually  beginning  upon  the 
tongue  or  the  inner  surface  of  the  cheek — of  small  white  flakes  which 
resemble  deposits  of  coagulated  milk,  but  which  differ  from  them  in  the 
fact  that  they  can  not  be  wiped  off.  If  forcibly  removed,  they  usually 
leave  a  number  of  bleeding  points.  There  may  be  only  a  few  scattered 
patches,  or  the  mouth  and  pharynx  may  be  covered.  The  mouth  is  gen- 
erally dry,  the  tongue  coated;  food  may  be  refused  on  account  of  pain, 
and  there  may  be  some  difficulty  in  swallowing.  The  otlier  symptoms 
depend  upon  the  conditions  with  which  the  thrush  is  associated. 

Diagnosis. — This  is  rarely  difficult.  The  deposit  may  be  mistaken  for 
coagulated  milk,  but  is  distinguished  by  the  features  just  mentioned. 
When  existing  upon  the  pharynx  and  fauces  it  has  been  confounded  with 
diphtheria,  although  this  mistake  can  hardly  be  made  if  all  the  facts 
of  the  case  are  taken  into  consideration — the  age  of  the  patient,  the 
involvement  of  the  lips  and  tongue,  the  dry  mouth,  the  absence  of  gland- 
ular enlargement,  etc.  In  any  case  of  doubt  the  examination  of  the 
deposit  under  the  microscope  at  once  reveals  its  true  nature. 

Prognosis. — Thrush  is  not  in  itself  a  dangerous  disease,  except  in  the 
very  rare  instances  where  it  may  obstruct  the  oesophagus,  and  this  can 
hardly  occur  except  in  a  condition  of  exhaustion  which  is  necessarily 
fatal.  In  a  feeble  and  delicate  infant,  or  in  one  with  harelip  or  cleft 
palate,  thrush  may  be  a  serious  complication.  With  proper  treatment 
most  of  the  cases  involving  only  the  mouth  are  readily  cured. 

Treatment. — Thrush  may. usually  be  prevented  by  due  attention  to 
cleanliness  of  the  mouth,  rubber  nipples,  bottles,  cloths,  etc.  In  infants 
with  deformities  of  the  mouth  in  institutions,  it  frequently  develops 
despite  all  precautions.  All  rubber  nipples  should  be  kept  in  a  solution 
of  boric  acid  and  the  child's  mouth  should  be  cleansed  several  times  a 
day.  On  no  account  should  a  feeding-bottle  be  passed  from  one  child 
to  another. 

In  the  treatment  of  the  disease  the  essential  things  are  cleanliness, 


278  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  the  use  of  some  mild  antiseptic  mouth-wash.  The  best  routine  treat- 
ment is  to  cleanse  the  mouth  carefully  after  every  feeding  or  nursing 
with  a  solution  of  bicarbonate  of  soda,  and  to  apply  twice  a  day  a  one- 
per-cent  solution  of  formalin.  All  applications  should  be  carefully  made, 
so  as  not  to  injure  the  epithelium.  The  best  method  of  cleansing  is  by 
a  small  swab  made  with  a  wooden  toothpick  and  absorbent  cotton.  Ap- 
plications to  be  especially  avoided  are  those  mixed  with  honey  or  any 
syrup.  In  hospital  cases  the  disease  seems  to  be  prolonged  by  the  irrita- 
tion of  the  rubber  nipple  of  the  feeding-bottle.  In  such  it  has  been 
our  practice  to  feed  by  gavage  for  two  or  three  days,  as  some  cases  im- 
proved much  more  rapidly  when  this  was  done. 

GONORRHCEAL   STOMATITIS. 

There  has  been  described  by  Dohrn  and  Rosinski  a  form  of  stomatitis 
in  the  newly  born,  due  to  a  gonorrhoeal  infection.  This  is  not  likely  to 
take  place  unless  the  epithelium  has  been  removed.  The  infection  in  all 
cases  occurred  from  the  mother.  The  lesion  consists  in  the  formation  of 
yellowish-white  patches  upon  the  tongue  or  hard  palate — regions  in 
which  the  epithelium  is  liable  to  be  injured  by  rough  attempts  at  cleans- 
ing the  mouth.  There  may  be  other  evidences  of  gonorrhoeal  infection, 
especially  ophthalmia.  The  diagnosis  rests  upon  the  discovery  of  the 
gonococcus  in  the  exudate.  In  all  the  cases  cited  the  general  health  was; 
not  affected,  and  recovery  followed  in  the  course  of  a  week  or  ten  days. 

The  treatment  consists  in  thorough  cleanliness  and  in  the  application 
of  a  saturated  solution  of  boric  acid,  as  in  thrush. 

SYPHILITIC   STOMATITIS. 

The  buccal  symptoms  of  hereditary  S3^hilis  are  important  both  from 
a  diagnostic  and  a  therapeutic  standpoint.  Tlie  most  frequent  lesions  are 
fissures,  ulcers,  and  mucous  patches.  Fissures  are  found  upon  the  lips, 
most  frequently  at  the  angle  of  the  mouth,  and  are  usually  multiple. 
They  may  be  quite  deep  and  cause  frequent  haemorrhages.  Mucous 
patches  are  superficial  ulcers  developing  from  papules  which  form  upon 
the  mucous  or  muco-cutaneous  surfaces.  In  cases  of  acquired  syphilis 
in  children  the  primary  sore  may  be  seen  upon  the  tongue,  the  lip,  or  the 
tonsil.  All  these  symptoms  are  more  fully  considered  in  the  chapter  on 
Syphilis. 

DIPHTHERITIC   STOMATITIS. 

In  severe  cases  of  diphtheria  the  membrane  is  found  not  only  upon 
the  pharynx  and  tonsils,  but  it  may  appear  anywhere  upon  the  buccal 
mucous  membrane  or  the  lips.  It  is  questionable  whether  the  diphther- 
itic process  ever  begins  on  the  mucous  membrane  of  the  mouth,  or  is 


GANGRENOUS  STOMATITIS.  279 

ever  limited  to  this  part.  In  my  own  experience  diphtheritic  stomatitis 
has  always  been  associated  with  deposits  upon  the  tonsils  and  pharynx. 
It  is  seen  only  in  the  severest  cases,  and  in  those  which,  from  other  con- 
ditions present,  are  almost  necessarily  fatal.  Bearing  in  mind  the  above 
points,  it  can  hardly  be  mistaken  for  any  otlicr  variety  of  stomatitis, 
although  not  infrequently  the  mistake  is  made  of  regarding  as  diph- 
theritic, cases  of  herpetic  stomatitis  in  which  the  ulcers  have  coalesced. 
The  treatment,  so  far  as  the  mouth  is  concerned,  consists  in  cleanliness 
by  frequent  gargling  or  irrigation  with  a  hot  saline  solution.  Forcible 
removal  of  the  membrane  is  not  to  be  advised. 

GANGRENOUS  STOMATITIS— NOMA. 

(Cancrum  oris.) 

The  term  noma  is  used  to  designate  all  forms  of  spontaneous  gan- 
grene occurring  in  children,  which  involve  mucous  membranes  or  muco- 
cutaneous orifices.  The  most  frequent  situation  being  the  mouth,  noma 
and  gangrenous  stomatitis  are  often  used  synonymously.  ISToma  may, 
however,  affect  the  nose,  external  auditory  canal,  vulva,  prepuce,  or  anus. 
It  is  a  rare  disease,  and  usually  terminates  fatally. 

Etiology. — Noma  is  seldom  seen  outside  of  institutions  for  children, 
where  small  epidemics  are  not  uncommon.  It  is  usually  secondary  to 
some  of  the  infectious  diseases,  most  frequently  following  measles,  and 
next  to  this  scarlet  fever,  typhoid,  or  whooping-cough.  While  it  may 
occur  at  any  age,  most  of  the  cases  are  in  children  under  five  years,  and 
in  those  of  poor  general  condition.  Noma  seldom  attacks  parts  previ- 
ously healthy.  In  the  mouth  it  may  be  preceded  by  catarrhal,  or  more 
often  by  ulcerative  stomatitis;  in  the  auditory  canal,  by  a  chronic  otitis 
media.  There  seems  little  doubt  that  the  disease  is  contagious.  In 
1899  I  saw  five  cases  in  a  single  ward,  all  beginning  in  the  auditory 
canal,  which  were  apparently  produced  by  the  use  of  the  same  syringe 
to  clean  the  ears  without  proper  disinfection.  All  these  children  were 
suffering  from  whooping-cough  at  the  time. 

It  is  now  quite  well  established  that  the  exciting  cause  of  noma  is  the 
same  as  that  of  ulcerative  stomatitis  (q.  v.).  The  pathological  process 
in  one  case  is  of  a  mild  type  occurring  in  patients  of  considerable 
resistance.  In  the  other  it  is  of  a  severe  or  malignant  type  occurring  in 
patients  of  feeble  resistance  as  a  result  of  previous  acute  disease.  In 
the  gangrenous  tissue  pyogenic  cocci  and  putrefactive  bacteria  are 
abundant.  In  the  border  zone,  and  extending  into  the  adjacent  healthy 
tissue  the  specific  organisms  of  the  disease  are  found. 

Lesions. — The  process  is  one  of  slowly  spreading  gangrene.  In  most 
of  the  cases  there  are  thrown  out  inflammatory  products  in  quite  large 
amount,  but  there  is  little  or  no  tendency  to  limitation  of  the  disease. 


280  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

This  usually  advances  steadily  until  death  occurs.  In  a  small  number  of 
cases  a  line  of  demarcation  finally  forms,  and  the  slough  separates,  leav- 
ing a  large  area  to  be  partially  filled  in  by  granulation  and  cicatrisation. 
Other  infectious  processes  are  likely  to  accompany  the  disease,  partic- 
ularly broncho-pneumonia. 

S3rinptoins. — The  constitutional  symptoms  are  not  usually  severe  until 
the  local  disease  has  existed  for  several  days.  Then  those  of  marked 
prostration  and  sepsis  develop,  sometimes  quite  rapidly.  The  tempera- 
ture is  usually  elevated  to  102°  or  103°  ¥.,  and  sometimes  to  104°  or 
105°  F.  There  are  dulness,  apathy,  feeble  pulse,  muscular  relaxation, 
and  very  often  diarrhoea.  Before  death  the  temperature  may  be  sub- 
normal. 

Of  the  local  symptoms,  often  the  first  to  attract  attention  is  the  odour 
of  the  breath;  sometimes  it  is  the  dusky  spot  on  the  cheek  or  lip.  On 
examination  of  the  mouth,  there  usually  is  found  upon  the  gum  or  inside 
of  the  cheek  a  dark,  greenish-black  necrotic  mass,  surrounded  by  tissues 
which  are  swollen  and  cedematous,  so  that  the  cheek  or  lips  may  be 
two  or  three  times  their  normal  thickness.  Externally  the  parts  are 
tense  and  brawny  from  the  swelling,  this  infiltration  always  extending 
for  some  distance  beyond  the  gangrenous  part.  As  the  process  extends, 
the  teeth  loosen  and  fall  out;  there  may  be  necrosis  of  the  alveolar  process 
of  the  jaw  and  perforation  of  one  or  both  cheeks  or  lower  lip.  Ex- 
tensive sloughing  of  the  face  may  take  place,  usually  upon  one  side, 
sometimes  upon  both,  giving  the  patient  a  horrible  appearance,  as  shown 
in  Fig.  46.  In  this  patient  the  process  began  in  the  right  cheek,  subse- 
quently involving  the  left;  perforation  occurred  in  both  cheeks,  and  be- 
fore death  a  large  part  of  the  face  was  gangrenous.  The  odour  from 
a  severe  case  is  very  offensive,  and,  in  spite  of  all  efforts  at  disinfection, 
it  may  fill  the  ward  or  even  the  house.  Pain  is  rarely  severe,  and  in  many 
cases  it  is  absent.    Extensive  haemorrhages  are  rare. 

I  have  notes  of  seven  eases  in  which  noma  affected  the  car,  being 
preceded  by  chronic  otitis  media  in  every  instance.  The  disease  began 
in  the  deeper  structures  of  the  canal,  the  first  symptom  noticed  usually 
being  a  nodular  swelling  just  beneath  the  ear,  crowding  the  lobe  upward. 
Shortly  afterward  there  appeared  the  dirty  brown  discharge  with  a  gan- 
grenous odour.  Later,  the  gangrenous  circle  surrounded  the  meatus, 
which  gradually  extended,  until  in  some  cases  the  whole  side  of  the  face 
and  head  were  involved.  A  probe  could  readily  be  passed  into  the  cra- 
nial cavity.    All  these  cases  ended  fatally. 

The  usual  duration  of  the  disease  is  from  five  to  ten  days.  If 
recovery  takes  place,  there  is  first  seen  a  line  of  demarcation;  then  the 
slough  is  thrown  off,  and  granulation  and  cicatrisation  begin,  but  require 
a  long  time,  usually  leaving  an  unsightly  deformity. 

The  prognosis  is  grave,  fully  three-fourths  of  the  cases  proving  fatal. 


GANGRENOUS  STOMATITIS. 


281 


The  results  depend  not  only  upon  the  disease  itself,  but  upon  the  con- 
dition of  the  patient  with  which  it  is  associated. 

Gangrenous  stomatitis  can  hardly  be  mistaken  for  any  other  form  of 
disease  occurring  in  the  mouth,  and  early  recognition  is  of  great  impor- 
tance, since  only  early  treatment  is  likely  to  be  successful. 


X 


Fig.  46. — Gangrenous  Stomatitis,  following  Measles. 
(From  a  photograph  lent  by  Dr.  Henry  Moffat.) 


Treatment. — Much  can  be  done  to  prevent  the  disease  by  careful 
attention  to  all  the  milder  forms  of  stomatitis,  particularly  to  the  ulcera- 
tive variety.  Frequent  and  thorough  cleansing  of  the  mouth  in  all  acute 
infectious  diseases  is  a  part  of  the  treatment  which  is  too  often  neglected. 
This  should  be  a  matter  of  routine  in  every  severe  illness  in  a  young 
child.  Recognising  the  malignant  nature  of  gangrenous  stomatitis,  its 
treatment  should  be  radical  from  the  very  outset.  Of  the  measures 
which  have  been  proposed,  that  which  seems  to  offer  the  best  chance  of 


282  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

arresting  the  process  is  excision  with  cauterisation.  This  should  be 
done  under  anassthesia.  In  excising,  one  should  go  some  distance  into 
tissues  apparently  liealthy,  for  the  reason  that  the  process  has  always 
advanced  farther  in  the  subcutaneous  tissues  than  in  the  skin.  The 
edges  of  the  wound  should  then  be  thoroughly  cauterised,  best  by  the 
Paquelin  cautery.  Of  the  other  means  employed,  the  use  of  strong  car- 
bolic acid  immediately  followed  by  alcohol  is  probably  the  best.  This  is 
to  be  used  after  excising  or  curetting  the  necrotic  tissue.  The  mouth 
sliould  be  kept  as  clean  as  possible  by  the  use  of  peroxide  of  hydrogen. 
The  general  treatment  should  be  supporting  and  stimulating.  As  the 
possibility  of  contagion  exists,  every  case  should  be  isolated. 


CHAPTER    II. 

DISEASES  OF   THE  PHARYNX. 
ACUTE   PHARYNGITIS. 

Acute  pharyngitis  may  exist  as  a  primary  disease,  or  with  any  of  the 
infectious  diseases,  particularly  scarlet  fever,  measles,  diphtheria,  or 
influenza.  Secondary  pharyngitis  will  be  considered  in  connection  with 
these  different  diseases. 

Certain  children  have  a  constitutional  predisposition  to  attacks  of 
acute  pharyngitis,  and  contract  it  upon  the  slightest  provocation.  In 
some  of  them  there  is  a  strongly  marked  rheumatic  diathesis."  Attacks 
of  acute  pharyngitis  often  follow  exposure.  In  many  cases  they  are 
associated  with  acute  disturbances  of  digestion.  All  of  the  above  causes 
probably  act  by  producing  local  and  general  conditions  favourable  to 
the  development  of  micro-organisms  already  present  in  the  mouth.  The 
bacteria  most  frequently  associated  with  severe  attacks  are  the  staphylo- 
coccus, the  pneumococcus,  the  streptococcus,  and  less  frequently,  the 
bacillus  influenzae. 

In  acute  catarrhal  pharyngitis  the  inflammation  may  involve  the  en- 
tire mucous  membrane  of  the  tonsils,  fauces,  uvula,  posterior  and  lateral, 
pharyngeal  walls,  or  any  part  of  it.  It  may  exist  alone,  or  in  connection 
with  a  similar  inflammation  in  the  rhino-pharynx  or  in  the  larynx.  In 
the  beginning  there  is  seen  an  acute  redness,  usually  involving  the  entire 
pharynx.  This  may  entirely  subside  after  twenty -four  hours,  or  it  may 
be  followed  by  the  usual  changes  of  acute  catarrhal  inflammation — 
dryness,  swelling,  and  oedema.  Later  there  is  increased  secretion  of 
mucus,  and  finally  there  may  be  muco-pu8.  Occasionally  slight  haemor- 
rhages are  present. 

There  is  pain  at  the  angle  of  the  jaws,  which  is  increased  by  swallow- 


TTVULITIS.  283 

ing,  also  a  sensation  of  dryness  and  rouglmess  in  the  pharynx,  and  often 
an  irritating  cough.  There  may  be  slight  swelling  of  tiie  neighlwuring 
lymphatic  glands.  The  constitutional  symptoms  in  young  children  are 
often  severe.  Not  infrequently  there  is  a  sudden  onset  with  vomiting, 
and  a  rise  of  temperature  to  102°  or  even  101°  F.  These  symptoms  are 
usually  of  short  duration,  frequently  less  than  twenty-four  hours,  and  in 
two  or  three  days  the  patient  may  be  entirely  well.  In  other  cases  the 
pharyngitis  may  be  accompanied  or  followed  by  laryngitis. 

Acute  primary  pharyngitis  is  to  be  distinguished  from  scarlet  fever, 
diphtheria,  measles,  and  influenza.  A  positive  diagnosis  from  scarlet 
fever  is  impossible  until  a  sufficient  time  has  elapsed  for  the  eruption  to 
appear,  and  the  patient  should  be  closely  Avatched  for  the  first  sign  of 
this.  If  scarlet  fever  is  prevalent,  a  child  with  the  symptoms  of  severe 
pharyngitis  should  at  once  be  isolated  while  waiting  for  the  diagnosis 
to  be  settled.  There  is  commonly  less  difficulty  in  excluding  measles 
because  of  the  absence  of  Koplik's  sign  on  the  buccal  mucous  membrane, 
and  of  the  accompanying  catarrh  of  the  eyes  and  nose.  Catarrhal  diph- 
theria can  be  excluded  only  by  culture. 

The  first  step  in  the  treatment  of  acute  ])l:aryngitis  is  to  open  the 
bowels  freely  by  means  of  calomel,  castor  oil,  or  magnesia.  The  child 
should  be  kept  in  bed,  and  the  diet  should  be  fluid,  or,  in  the  case  of 
infants,  the  amount  of  food  should  be  much  reduced.  Pieces  of  ice  may 
be  swallowed  frequently  for  the  relief  of  pain  and  thirst.  Internally 
there  may  be  given  two  grains  of  phenacetine  every  four  hours  to  a  child 
of  three  years.  It  is  important  at  the  outset  to  induce  free  perspira- 
tion. The  disease  is  not  serious,  and  the  indications  are  to  make  the 
child  as  comfortable  as  possible  during  the  short  attack.  I  have  seen 
but  little  benefit  from  the  use  of  aconite,  although  for  years  I  saw  it 
used  as  a  routine  treatment. 


UVULITIS. 

Acute  inflammation  of  the  uvula,  with  swelling  and  oedema,  occurs 
as  a  part  of  the  lesion  in  acute  pharyngitis.  In  rare  instances  the  u\Tila 
may  be  the  principal  or  the  only  seat  of  inflammation.  Huber  (New 
York)  has  reported  two  cases,  one  of  which  is  unique.  An  infant  ten 
months  old  was  apparently  well  until  two  hours  before  it  was  seen,  when 
there  was  noticed  a  constant  irritating  cough,  accompanied  by  consider- 
able gagging.  Later  there  could  be  seen  in  the  mouth  a  prominent  red 
mass,  the  enlarged  and  elongated  uvula.  It  was  accompanied  by  par- 
oxysms of  coughing,  which  interfered  both  with  nursing  and  deglutition. 
The  general  symptoms  were  quite  alarming.  The  uvula  was  found  to  be 
fully  one  inch  long  and  half  an  inch  wide,  red  and  oedematous ;  in  other 
respects  the  throat  was  normal.    The  symptoms  were  relieved  by  multiple 


284  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

needle  punctures  and  the  use  of  ice.  In  such  conditions  the  greatest 
relief  is  often  afforded  by  the  application  of  adrenalin,  or  its  use  as  a 
spray  or  gargle. 

ELONGATED  UVULA. 

Probably  this  is  primarily  a  congenital  condition.  It  is  increased  by 
repeated  attacks  of  acute  or  subacute  inflammation.  The  degree  of 
elongation  varies  in  different  cases;  in  some  it  may  reach  an  inch  in 
length.  Only  the  mucous  membrane  is  involved  in  the  elongation.  The 
symptoms  are  those  of  local  irritation,  especially  a  cough  upon  lying 
down,  and  the  sensation  of  a  foreign  body  in  the  pharynx.  In  some 
cases  it  may  be  a  reflex  cause  of  asthma,  or,  more  frequently,  of  catar- 
rhal spasm  of  the  larynx.  The  diagnosis  is  very  easily  made'  by  in- 
specting the  throat.  The  treatment  consists  in  grasping  the  tip  of  the 
uvula  with  forceps  and  cutting  off  the  excess  with  the  scissors,  or  a 
uvulatome.  Care  should  be  taken  not  to  cut  off  too  much  of  the  uvula, 
or  severe  liaBmorrhage  may  occur. 

RETRO-PHARYNGEAL  ABSCESS. 

Two  distinct  varieties  are  seen :  ( 1 )  The  so-called  idiopathic  abscesses 
which  belong  to  infancy,  and  (2)  abscesses  secondary  to  caries  of  the 
cervical  vertebrae. 

Retro-pharyngeal  Abscess  of  Infancy. — All  of  the  later  investigations 
regarding  this  disease  go  to  show  that  primarily  it  is  not  a  cellulitis, 
but  a  suppurative  inflammation  of  the  lymph  nodes  (lymphatic  glands) 
with  a  surrounding  cellulitis.  The  retro-pharyngeal  lymph  nodes  form  a 
chain  on  either  side  of  the  median  line  between  the  pharyngeal  and  the 
prevertebral  muscles.  These  nodes  are  said  to  undergo  atrophy  after 
the  third  year,  and  in  some  cases  to  disappear  entirely.  Retro-pharyngeal 
abscess — or,  more  properly,  retro-pharyngeal  lymphadenitis,  since  the 
process  does  not  invariably  go  on  to  suppuration — is  probably  never 
primary,  but  secondary  to  infectious  catarrhs  of  the  pharynx,  and  is  set 
up  by  the  entrance  of  pyogenic  bacteria,  usually  the  staphylococcus  or 
streptococcus.  Its  pathology  is  the  same  as  the  more  frequent  sup- 
purative inflammation  of  the  external  cervical  lymph  nodes,  with  which 
it  is  sometimes  associated.  Usually  only  a  single  node  is  involved,  but 
sometimes  two  or  three  are  affected,  and  these  may  be  situated  upon 
opposite  sides.  I  have  frequently  seen  retro-pharyngeal  lymphadenitis 
so  severe  as  to  give  rise  to  marked  local  symptoms,  although  it  did  not 
go  on  to  suppuration.  Kormann's  observations,  however,  show  that 
swelling  of  these  glands  in  diseases  of  the  mouth  and  throat  is  very 
much  more  common  than  is  generally  supposed.  Similar  abscesses  from 
suppurative  inflammation  of  other  lymph  nodes  in  the  neighbourhood 


RETRO-PHARYNGEAL  ABSCESS.  285 

of  the  pharynx  may  occur.  I  have  seen  one  situated  between  the  epiglot- 
tis and  the  base  of  the  tongue. 

Etiology. — These  cases  almost  invariably  occur  in  infancy.  Fully 
three-fourths  of  those  that  have  come  under  my  observation  have  been  in 
patients  under  one  year.  Bokai  (Buda-Pesth)  reports  that  of  sixty  cases 
observed,  forty-two  occurred  during  the  first  year,  eleven  during  the 
second  year,  and  only  seven  at  a  later  period.  The  primary  disease  is 
usually  a  severe  rhino-pharyngitis,  or  an  attack  of  epidemic  influenza, 
but  rarely  it  occurs  as  a  sequel  of  scarlet  fever  or  measles.  In  six  hun- 
dred and  sixty-four  cases  of  scarlet  fever,  Bokai  noted  retro-pharyngeal 
abscess  in  seven  cases.  After  measles  it  is  even  more  rare.  Retro- 
pharyngeal abscess  usually  occurs  in  winter  or  spring,  on  account  of  the 
prevalence  of  the  diseases  upon  which  it  depends.  It  is  seen  in  children 
previously  robust,  but  more  often  in  those  who  are  delicate  and  who  in 
consequence  are  prone  to  severe  catarrhal  affections. 

Symptoms. — The  early  symptoms  in  most  cases  are  merely  those  of 
an  ordinary  rhino-pharyngeal  catarrh.  After  this  has  subsided  the  tem- 
perature may  remain  slightly  elevated,  often  for  a  week  or  more,  before 
local  symptoms  are  noticeable.  Sometimes,  without  any  distinct  history 
of  previous  catarrh,  there  are  seen  quite  high  temperature,  from  102°  to 
104°  F.,  loss  of  flesh,  and  prostration.  A  careful  examination  may  be 
required,  and  sometimes  observation  for  a  day  or  two,  before  the  ex- 
planation of  these  constitutional  symptoms  is  discovered.  In  other  cases 
the  early  constitutional  symptoms  are  so  slight  as  to  escape  notice,  and 
the  local  symptoms  are  the  only  ones  present.  Although  usually  these 
are  not  severe,  retro-pharyngeal  abscess  may  cause  dyspnoea,  which  in  a 
short  time  assumes  an  alarming  character.  The  duration  of  the  inflam- 
matory process  before  abscess  forms  is  generally  five  or  six  days,  but  it 
may  be  several  weeks.  The  temperature  is  invariably  elevated,  usually 
from  100°  to  103°  F.;  occasionally  it  may  be  104°  or  105°  F.,  with 
symptoms  of  prostration  seemingly  out  of  all  proportion  to  the  local 
disease,  but  which  are  to  be  explained  by  the  tender  age  and  feeble  re- 
sistance of  the  patient. 

The  most  characteristic  local  symptoms  are  the  posture,  the  head 
being  drawn  far  backward  to  relieve  pressure  on  the  larynx,  the  noisy 
respiration  with  the  mouth  open,  and  difficulty  in  deglutition.  Some- 
times the  first  thing  to  attract  notice  is  a  sudden  attack  of  dyspnoea 
severe  enough  to  cause  asphyxia.  This  is  due  to  the  pressure  forward 
of  the  abscess  encroaching  upon  the  larynx.  The  mouth  may  be  dry,  or 
there  may  be  a  copious  secretion  of  pharyngeal  mucus.  The  dyspnoea 
is  in  most  cases  greater  on  inspiration,  and  in  some  it  is  noticed  only 
then,  expiration  being  normal.  The  difficulty  in  swallowing  is  greater 
when  the  tumour  is  low.  The  child  may  find  it  impossible  to  swallow, 
and  in  consequence  may  refuse  to  nurse;  or  the  difficulty  in  nursing 


286  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

may  depend  upon  the  nasal  obstruction.  Sometimes  there  is  regurgita- 
tion of  food  through  the  nose  oi*  mouth.  The  voice  is  usually  nasal. 
Generally  there  is  no  hoarseness,  but  a  peculiar  short  cry  which  is  quite 
characteristic.  There  may  be,  although  rarely,  aphonia.  Usually  there 
is  some  swelling  to  be  seen  externally,  just  below  the  angle  of  the  jaw 
in  front  of  the  sterno-mastoid  muscle;  exceptionally  this  may  be  more 
prominent  than  the  internal  swelling.  In  one  or  two  cases  I  have  no- 
ticed torticollis  as  an  early  symptom. 

A  positive  diagnosis  is  made  by  an  examination  of  the  throat.  On 
inspection  there  is  seen  a  distinct  bulging  of  the  lateral  wall  of  the 
pharynx,  usually  a  little  above  the  base  of  the  tongue.  The  swelling  may 
be  so  great  as  to  crowd  the  uvula  to  one  side  and  nearly  fill  the  pharynx. 
It  is  rarely  if  ever  in  the  median  line.  There  is  usually  redness  of  the 
mucous  membrane  and  oedema  of  the  uvula  and  of  the  adjacent  parts. 
On  digital  examination  the  swelling  is  made  out  even  better  than  by  in- 
spection. It  may  be  situated  so  low  down  as  not  to  be  visible  at  all. 
In  the  early  stage  there  may  be  felt  only  a  localised  induration  or 
a  somewhat  diffuse  swelling,  but  by  the  time  the  swelling  is  large 
enough  to  produce  marked  symptoms,  fluctuation  can  generally  be  dis- 
covered. 

Prognosis. — When  left  to  itself  the  abscess  may  open  into  the  pharynx, 
the  pus  being  swallowed  or  expectorated.  The  cavity  may  close  rapidly 
by  granulation,  and  in  a  few  days  the  patient  be  entirely  well;  or  the 
abscess  may  refill.  External  opening  I  have  never  known  to  take  place. 
It  is  rare  for  much  burrowing  to  occur.  In  young  or  very  delicate  in- 
fants the  constitutional  symptoms  may  be  so  severe  that  the  child  con- 
tinues to  fail  even  after  the  evacuation  of  the  abscess,  and  dies  usually 
from  broncho-pneumonia. 

Death  may  occur  from  asphyxia  due  to  pressure  upon  the  larynx, 
to  oedema  of  the  glottis,  or  from  rupture  of  the  abscess  into  the  air 
passages,  especially  if  this  occurs  during  sleep.  Carmichael,  Bokai,  and 
others  have  reported  deaths  from  ulceration  into  the  carotid  artery,  or 
one  of  its  large  branches.  Carmichael's  patient  was  only  five  weeks  old. 
The  general  mortality  is  from  five  to  ten  per  cent;  many  deaths  are 
due  to  a  failure  to  make  the  diagnosis.  Gautier  has  collected  ninety- 
five  cases,  with  forty-one  deaths.  In  my  experience  death  has  most  fre- 
quently resulted  from  late  broncho-pneumonia ;  in  one  case  it  was  due  to 
a  secondary  retro-cesophageal  abscess. 

Diagnosis. — Retro-pharyngeal  abscess  is  to  be  suspected  if  in  an  in- 
fant there  is  difficulty  in  swallowing,  noisy  dyspnoea,  mouth-breathing, 
and  the  head  drawn  backward.  A  positive  diagnosis  is  possible  only  by 
a  digital  examination  of  the  pharynx.  The  mistake  most  often  made 
is,  that  the  physician,  called  to  a  young  child  suffering  from  great 
dyspnoea,  has  jumped  at  a  diagnosis  of  laryngeal  stenosis,  and  forth- 


EETRO-PHARYNGEAL  ABSCESS.  287 

with  performed  tracheotomy  or  intubation,  without  taking  the  trouble 
to  get  the  history  or  to  make  a  careful  examination  of  the  pharynx. 
Many  such  cases  are  reported  in  which  the  child  has  died  during  the 
operation  or  immediately  afterward,  the  autopsy  first  revealing  the 
nature  of  the  disease.  A  sudden  attack  of  dyspnoea  like  that  caused 
by  the  rupture  of  an  abscess  might  be  produced  by  the  lodgment  of  a 
foreign  body  in  the  pharynx  or  larynx.  A  digital  examination  would  aid 
in  the  diagnosis.  I  once  saw  in  an  infant  a  sarcoma  of  the  pharyn- 
geal lymph  glands  which  gave  an  external  and  internal  tumour  exactly 
like  that  of  a  retro-pharyngeal  abscess. 

Treatment. — Before  the  abscess  has  pointed,  hot  applications  may  be 
made  to  the  throat  to  relieve  the  symptoms  and  to  hasten  the  formation 
of  pus,  since  resolution  is  not  to  be  expected.  Spontaneous  opening 
should  never  be  waited  for,  on  account  of  the  danger  of  the  rapid  devel- 
opment of  serious  symptoms  from  pressure  or  oedema,  or  of  suffocation 
from  an  opening  into  the  air  passages,  especially  during  sleep. 

As  soon  as  the  diagnosis  is  made  the  case  should  be  carefully  watched, 
and  as  soon  as  a  point  of  superficial  fluctuation  is  detected,  but  not  before, 
the  pus  should  be  evacuated.  External  incision  has  its  advocates,  but 
the  internal  opening  is,  to  my  mind,  much  to  be  preferred.  In  opening 
through  the  mouth  the  patient  should  be  seated  in  an  upright  position 
and  the  head  firmly  held.  The  use  of  a  mouth-gag  may  cause  asphyxia. 
With  the  finger  as  a  guide,  a  bistoury,  which  has  been  guarded  to  its 
point,  is  introduced  and  the  abscess  opened  at  its  thinnest  portion,  the 
incision  being  made  toward  the  median  line.  The  head  should  then  be 
bent  forward,  to  allow  the  pus  to  escape  through  the  mouth.  It  is  well 
to  insert  the  finger  into  the  cavity  to  enlarge  the  opening  and  break 
down  any  septa ;  for  after  a  simple  puncture  the  abscess  may  refill.  In- 
cision, although  usually  easy,  in  some  cases  may  be  quite  difficult  on 
account  of  the  swelling  and  the  small  pharynx  of  the  infant.  For  the 
past  few  years  I  have  adopted  the  plan  of  opening  these  abscesses  with 
the  finger  nail,  sharpened  to  a  point,  a  procedure  simple,  efficient,  and 
free  from  danger.  I  have  seldom  seen  a  case  in  which  this  was  difficult. 
The  amount  of  pus  evacuated  is  from  one  drachm  to  half  an  ounce.  In 
the  majority  of  cases  no  after-treatment  is  required.  The  relief  of  the 
dyspnoea  and  dysphagia  is  immediate,  and,  except  in  young  infants, 
recovery  usually  rapid. 

Retro-pharyngeal  Abscess  from  Pott's  Disease. — This  form  is  rare  in 
comparison  with  that  just  described,  and  under  three  years  of  age  it  is 
extremely  so.  These  abscesses  are  usually  larger,  and  the  amount  of 
pus  contained  may  be  from  four  to  eight  ounces.  They  form  very  much 
more  slowly,  often  lasting  for  months,  and  as  with  other  secondary 
abscesses,  the  constitutional  symptoms  are  seldom  severe.  The  swelling 
is  frequently  in  the  median  line,  and  is  not  so  circumscribed  as  in  the 


288  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

idiopathic  cases.  The  pus  often  burrows  along  the  spine  for  several 
inclies. 

The  symptoms  of  Pott's  disease  of  the  cervical  region  are  usually 
present  for  several  months  before  the  appearance  of  the  abscess.  Some- 
times the  abscess  precedes  the  deformity,  and  it  may  be  the  first  intima- 
tion of  the  existence  of  bone  disease.  The  local  symptoms  resemble 
those  of  the  idiopathic  cases,  but  they  develop  more  slowly,  and  sudden 
attacks  of  fatal  asphyxia  are  very  rare.  External  swelling  is  usually 
seen,  and  it  may  be  quite  large,  extending  almost  from  one  ear  to  the 
other,  forming  a  distinct  collar.  On  digital  exploration  there  may  be 
found  an  irregularity  of  the  anterior  surface  of  the  cervical  vertebrae, 
and  occasionally  a  marked  angular  prominence. 

When  left  to  themselves  these  abscesses  may  open  externally  in  front 
of  the  sterno-mastoid  muscle  just  below  the  jaw,  sometimes  nearly  as  low 
as  the  clavicle;  they  may  rupture  internally  into  the  pharynx,  the 
cesophagu-,  or  the  air  passages;  or  they  may  burrow  a  long  distance  in 
front  of  the  spine.  Death  may  result  from  pressure  upon  the  larynx, 
or  from  rupture  into  the  larynx,  trachea,  or  pleura;  all  these,  however, 
are  rare.  The  abscesses  not  infrequently  refill  after  they  are  evacuated, 
and  occasionally  a  discharging  sinus  is  left  for  many  months. 

Treatment. — These  abscesses  should  be  opened  as  soon  as  they  are 
large  enough  to  give  rise  to  local  symptoms.  Tiie  external  incision  just 
in  front  of  the  sterno-mastoid  muscle  is  generally  to  be  preferred  to 
opening  through  the  mouth,  since  it  gives  better  drainage,  and  the  after- 
treatment  is  more  easily  carried  on;  and  a  sinus  opening  externally  is 
less  objectionable  than  one  opening  into  the  pharynx. 

ADENOID   VEGETATIONS   OF  THE  VAULT  OF  THE   PHARYNX. 

This  is  a  very  common  condition  and  one  much  neglected  by  the 
general  practitioner.  It  is  the  source  of  more  discomfort  and  the  origin 
of  more  minor  ailments  than  almost  any  other  pathological  condition  of 
childhood. 

There  is  a  mass  of  lymphoid  tissue  situated  at  the  vault  of  the 
pharynx  which  in  structure  closely  resembles  the  tonsils.  It  is  often 
spoken  of  as  the  "  pharyngeal  tonsil."  Like  the  faucial  tonsils,  this  may 
become  greatly  hypertrophied,  so  as  to  form  a  tumour  large  enough  to 
fill  the  rhino-pharynx  completely.  These  tumours  have  a  broad  attach- 
ment which  is  sometimes  more  to  the  roof,  and  sometimes  more  to  the 
posterior  wall  of  the  pharynx.  The  term  adenoid  vegetations  was  given 
to  them  by  Meyer,  who  first  described  them  in  18G8.  In  infancy  these 
growths  are  soft,  vascular,  and  spongy;  in  older  children  they  become 
firm,  dense,  and  more  fibrous.  Their  appearance  is  well  shown  in  Fig. 
47.    Adenoid  vegetations  are  associated  with  hypertrophy  of  the  faucial 


ADENOID  VEGETATIONS  OF  THE   PHARYNX.  289 

tonsils  in  about  one-third  of  the  cases.  Growths  large  enough  to  cause 
decided  nasal  obstruction  may  in  time  produce  changes  in  the  facial 
bones  amounting  to  positive  deformity.  Tlie  bony  palate  may  be  dome- 
shaped  or  even  acutely  arched;  the  dental  arch  of  the  upper  jaw  be- 


FiG.  47. — Adenoid  Vegetations,  Natural  Size.  (1)  From  child  eight  months  old; 
(2)  from  child  twenty-two  months  old ;  (3)  from  child  two  and  one-half  years  old ;  (4) 
from  child  two  and  one-half  years  old;  (5)  from  child  three  years  old.  With  the  ex- 
ception of  (5)  all  were  removed  with  a  single  sweep  of  the  curette.  Although  the 
growths  represented  are  somewhat  larger  than  the  average  for  the  ages  mentioned, 
just  such  ones  are  constantly  met  with  in  practice. 

comes  almost  V-shaped.     Deformities  of  the  thorax  also  occur,  which 
will  be  described  with  the  symptoms. 

Etiology. — Hereditary  influences  certainly  play  some  part  in  the 
production  of  this  condition.  I  have  frequently  known  every  one  of  a 
large  family  of  children  to  be  affected,  and  often  the  parents  have  suf- 
fered from  the  same  condition.  In  many  cases  adenoid  growths  are  con- 
genital. Eachitic  children  are  somewhat  oftener  affected  than  others, 
but  no  connection  with  syphilis  has  been  traced.  Much  interest  has 
lately  been  awakened  regarding  the  relation  of  adenoid  growths  to  tuber- 
culosis. Of  945  cases  collected  by  Lewin  in  which  specimens  of  adenoids 
were  examined,  tuberculosis  was  present  in  five  per  cent.  Though  this 
proportion  is  no  doubt  much  higher  than  will  be  found  in  private  prac- 
tice, the  fact  is  an  important  one;  for  it  is  highly  probable  that  this  is 
the  channel  of  infection  in  not  a  few  cases  of  tuberculosis.  Adenoids 
20 


290  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

are  most  common  in  damp,  changeable  climates.  Their  first  symptoms 
often  follow  an  attack  of  measles,  scarlet  fever,  or  diphtheria.  The  re- 
peated head  colds  are  more  often  a  result  than  a  cause  of  the  condition. 

S3rinptoms. — The  symptoms  of  adenoid  growths  are  usually  first  no- 
ticed when  children  are  from  eighteen  months  to  three  years  old;  but 
they  may  be  present  almost  from  birth.  I  have  in  several  instances  seen 
them  to  a  marked  degree  in  infants  only  a  few  months  old.  The  symp- 
toms generally  increase  in  severity  as  age  advances,  being  always  better 
in  summer  and  worse  in  winter,  until  the  age  of  six  or  seven  is  reached. 
The  chief  symptoms  are  those  which  relate  to  (1)  chronic  rhino-pharyn- 
geal  catarrh,  (2)  mechanical  obstruction,  (3)  otitis  and  other  aural 
conditions,  (4)  general  malnutrition  and  ansemia,  (5)  reflex  nervous 
phenomena. 

The  rhino-pharyngeal  catarrh  shows  itself  by  a  persistent  nasal  dis- 
charge, frequently  recurring  acute  attacks,  or  head  colds,  during  the 
entire  winter  season.  In  susceptible  children  these  attacks  are  often  the 
beginning  of  a  bronchitis,  which  may  keep  a  young  child  indoors  almost 
the  entire  winter. 

The  obstructive  symptoms  are  inability  to  blow  the  nose,  mouth- 
breathing  constantly  or  only  during  sleep,  and  a  nasal  voice.  The 
difficulty  in  breathing  is  increased  when  the  child  lies  upon  the  back. 
In  consequence  of  this,  children  sleep  in  all  sorts  of  positions — lying 
upon  the  face,  sometimes  upon  the  hands  and  knees,  and  often  toss 
restlessly  about  the  crib  in  the  vain  endeavour  to  find  some  position  in 
which  respiration  is  easy.  The  attacks  of  dyspnoea  at  night  may  amount 
almost  to  asphyxia,  and  are  the  explanation  of  many  of  the  so-called 
night-terrors  from  which  children  suffer.  When  the  obstruction  has 
existed  from  infancy  there  are  often  deformities  of  the  chest;  tiiese  are 
most  marked  in  rachitic  subjects.  The  most  frequent  one  consists  in 
deep  lateral  depressions  of  the  lower  part  of  the  chest,  with  a  promi- 
nence of  the  sternum.  The  deformity  is  due  to  interference  with  pul- 
monary expansion. 

There  is  often  seen  a  flattening  at  the  root  of  the  nose,  and  some- 
times a  prominence  of  the  transverse  vein  in  this  region. 

Some  impairment  of  hearing  exists  in  a  large  proportion  of  the  cases. 
Blake  (Boston)  found  this  to  be  true  in  39  out  of  47  cases  examined; 
in  35  of  these  marked  improvement  in  the  hearing  followed  removal 
of  the  adenoid  growths.  Deafness  may  be  due  to  tubal  catarrh  or  to 
otitis.     Often  a  history  is  given  of  several  attacks  of  suppurative  otitis. 

The  reflex  symptoms  associated  with  adenoid  growths  are  many. 
One  of  the  most  important  is  catarrhal  spasm  of  the  larynx,  or  the  famil- 
iar spasmodic  croup.  In  my  experience  the  majority  of  young  children 
who  are  subject  to  such  attacks  have  adenoids,  the  removal  of  which 
is  frequently  followed  by  their  complete  cessation.     Other  respiratory 


ADENOID   VEGETATIONS  OF  THE   PHARYNX.  291 

symptoms  associated  with  adenoids  are  intractable  coughs,  frequently 
of  a  spasmodic  character,  without  bronchial  symptoms  or  signs,  and  per- 
sistent hoarseness,  lasting  for  months  or  even  years,  and  recurring  every 
cold  season.  Both  these  conditions  are  often  cured  by  the  removal  of 
the  adenoids  after  all  other  treatment  has  been  without  effect.  To  these 
growtlis  bronchial  asthma  also  is  very  frequently  due.  Their  relation  to 
incontinence  of  urine  is  often  an  intimate  one ;  the  two  coexist  in  a  large 
number  of  patients,  and  in  a  certain  number  removal  of  the  adenoids 
cures  the  incontinence.  Headaches  are  very  common ;  stammering  may 
be  present ;  chorea  and  even  epileptiform  seizures  have  been  attributed  to 
adenoids,  although  I  have  never  seen  either. 

The  general  health  of  patients  suffering  from  adenoids  may  be  im- 
paired from  lack  of  oxygen  due  to  obstructed  respiration,  from  loss  of 
sleep,  and  from  confinement  to  the  house,  necessitated  by  attacks  of 
bronchitis  or  head  colds.  Marked  ansemia  is  often  present.  In  old  and 
neglected  cases  of  a  severe  character,  children  may  be  stunted  in  growth, 
and  their  facial  expression  dull  and  stupid.  They  are  languid,  listless, 
often  depressed,  and  this  with  their  deafness  frequently  causes  them  to 
be  regarded  in  school  as  children  who  are  somewhat  deficient  mentally. 

These  patients  are  always  better  in  summer  and  worse  in  winter. 
The  natural  course  of  the  growths  if  left  to  themselves  is  to  increase  up 
to  a  certain  point,  and  then  to  remain  stationary  until  puberty,  when 
they  usually  undergo  atrophy.  This,  with  the  marked  increase  in  the 
capacity  of  the  rhino-pharynx  which  occurs  at  this  time,  results  in  a  dis- 
appearance of  the  most  aggravated  symptoms.  The  removal  of  the  pa- 
tient to  an  elevated  region  with  a  dry  atmosphere  will  often  result  in  a 
relief  from  all  the  symptoms,  and  a  diminution  in  the  size  of  the  growth, 
but  unless  such  a  change  in  residence  is  permanent  the  symptoms  are 
liable  to  return.  Under  ordinary  circumstances  there  is  little  or  no 
tendency  to  spontaneous  recovery..  In  children  with  adenoid  growths 
attacks  of  diphtheria,  scarlet  fever,  measles,  and  whooping-cough  are  all 
likely  to  be  more  severe. 

Diagnosis. — In  a  well-marked  case  the  condition  is  usually  evident 
from  the  history,  and  can  scarcely  be  overlooked.  The  intractable  nasal 
catarrh,  upon  which  no  treatment,  local  or  general,  has  more  than  a  tem- 
porary influence,  the  mouth-breathing,  the  disturbed  sleep,  and  the 
slight  deafness — all  are  characteristic.  In  some  even  of  the  marked 
cases,  attention  may  be  drawn  to  the  larjmx,  bronchi,  or  ears  as  the  seat 
of  disease.  At  other  times  the  patients  come  tor  treatment  on  account 
of  the  general  symptoms — the  nervous  depression,  the  headaches,  or  the 
anaemia.  In  r^re  cases  the  leading  symptom  may  be  epistaxis.  The 
symptoms  do  not  always  depend  upon  the  size  of  the  growth,  for  in  a 
small  throat  quite  a  small  growth  may  cause  very  marked  symptoms. 

Although  the  history  is  in  most  cases  clear,  only  an  examination  can 


292  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

make  us  certain  that  an  adenoid  growth  exists.  The  best  method  of  ex- 
amination consists  in  a  digital  exploration  of  the  pharynx;  but  this 
requires  a  little  practice  before  it  is  very  satisfactory.  The  head  is  stead- 
ied by  one  hand,  and  the  forefinger  of  the  other  is  passed  up  behind  the 
soft  palate.  The  growth  is  ordinarily  felt  as  an  irregular,  granular,  soft, 
velvety  mass,  or  sometimes  as  a  firm  tumour  completely  blocking  the 
passage;  and  the  finger,  when  withdrawn,  is  almost  invariably  covered 
with  blood.  By  posterior  rhinoscopy,  the  growth  in  older  children  can 
often  be  seen. 

Treatment. — The  disappearance  of  adenoid  growths  is  possible  only 
when  they  are  small.  This  is  aided  by  removal  to  a  warm,  dry  climate 
for  the  winter  season.  All  possible  means  should  be  employed  to  prevent 
these  patients  from  taking  cold,  such  as  proper  clothing,  cold  sponging, 
cod-liver  oil,  etc.  With  the  larger  growths  these  methods  may  improve 
the  catarrlial  symptoms,  but  can  hardly  affect  the  obstructive  ones.  The 
reduction  of  tumours  of  any  considerable  size  by  local  applications  is,  I 
think,  a  delusion;  every  marked  case  that  has  come  to  my  notice  has 
been  relieved  only  by  operation. 

Kemoval  of  adenoid  growths  is  indicated :  ( 1 )  When  the  obstructive 
symptoms — habitual  mouth-breathing,  disturbed  sleep,  nasal  voice,  chest 
deformities,  etc. — are  marked;  (2)  for  a  chronic  nasal  discharge,  con- 
stantly recurring  head  colds,  particularly  when  these  tend  to  attacks 
of  bronchitis  or  laryngitis;  (3)  where  there  is  asthma  or  repeated  at- 
tacks of  catarrhal  spasm  of  the  larynx;  (4)  with  deafness,  chronic  otitis, 
or  repeated  attacks  of  acute  otitis;  (5)  for  certain  nervous  symptoms — 
enuresis,  stammering,  chorea,  headaches,  night-terrors,  etc.  Although 
striking  improvement  is  not  infrequent,  one  should  be  cautious  about 
promising  too  much  from  operation,  especially  as  regards  the  nervous 
conditions;  also  in  older  children  when  there  is  deafness  or  asthma. 

The  preferable  time  for  operation  is  the  late  spring  or  early  summer, 
in  order  that  during  the  warm  months  the  mucous  membranes  may  have 
an  opportunity  to  regain  their  normal  condition;  however,  operation 
may  be  done  at  any  time  except  during  attacks  of  acute  catarrh.  Unless 
the  symptoms  are  very  marked,  I  prefer  to  defer  operation  until  a  child 
is  at  least  two  years  old. 

Removal  of  adenoids  by  scraping  with  the  finger  nail  is  at  best  a  very 
uncertain  method,  and  is  not  to  be  advised,  except  in  the  case  of  chil- 
dren under  two  or  two  and  a  half  years  old,  where  the  growths  are  gen- 
erally small  and  the  patients  easily  handled.  The  operation  is  preferably 
done  with  general  anaesthesia :  first,  for  the  sake  of  thoroughness;  sec- 
ondly, to  avoid  the  fright  and  pain  which  so  bloody  an  operation  is  apt  to 
cause  in  those  who  are  older,  and  especially  in  very  nervous  children.  So 
many  deaths  from  operations  for  adenoids  or  tonsils  under  chloroform 
have  now  been  reported,  and  so  many  narrow  escapes  have  occurred  that 


ADENOID  VEGETATION  S  OF  THE  PHARYNX.       293 

have  not  been  reported^  that  chloroform  anaesthesia  should,  I  think,  be 
given  up  altogether.  My  preference  is  for  ether ;  in  older  children  it  may 
with  advantage  be  preceded  by  nitrous  oxide,  and  sometimes  with  such 
patients  the  nitrous  oxide  alone  may  be  used ;  but  this  is  not  to  be  advised 
with  very  young  children.  Deep  anaesthesia  is  not  usually  necessary,  and 
if  the  semi-erect  position  is  assumed  it  increases  tlie  danger  of  the 
entrance  of  blood  or  portions  of  the  growth  into  the  larynx,  which  might 
cause  asphyxia. 

The  only  instruments  required  are  a  mouth-gag,  like  that  used  for 
intubation,  and  modified  Gottstein's  curettes,  which  should  be  sharp. 
The  physician  should  have  several  sizes  with  different  curves  to  suit  the 
size  and  attachment  of  the  growth  and  the  capacity  of  the  throat.  Many 
of  the  instruments  used  for  young  children  are  too  large,  the  smaller 
ones  being  more  easily  manipulated  and  less  liable  to  do  harm. 

During  operation  it  is  an  advantage  to  have  the  patient  raised  to  a 
little  more  than  a  half-reclining  posture  and  the  head  firmly  steadied. 
Many  of  the  growths  encountered  in  ordinary  practice,  such  as  Nos.  1, 
2,  and  3  in  the  illustration,  can  be  removed  with  one  sweep  of  the  curette, 
the  mass  usually  coming  away  in  a  single  piece.  Others  may  require 
the  instrument  to  be  used  two  or  three  times.  The  forceps  (Lowen- 
berg's  and  various  modifications)  in  unskilled  hands  are  capable  of  doing 
much  harm.  One  unfamiliar  with  their  use  may  easily  tear  away  pieces 
of  the  uvula,  soft  palate,  pharyngeal  wall,  and  even  portions  of  the 
Eustachian  tubes. 

Haemorrhage  is  always  abundant,  and  seems  alarming  to  one  who  sees 
it  for  the  first  time.  In  an  average  case  it  amounts  to  one  or  two  ounces, 
but  generally  ceases  in  a  few  minutes.  A  child  should  not  pass  from 
the  physician's  observation  until  all  bleeding  has  stopped.  He  should 
be  kept  quiet,  preferably  in  bed,  for  twenty-four  hours ;  and  in  the  house 
for  five  or  six  days,  unless  the  weather  is  warm.  No  after-treatment  is 
necessary,  Eecurrences  are  occasionally  seen  even  after  a  thorough 
operation  by  an  experienced  person.  But  many  of  them  are  due  to  the 
fact  that  the  primary  operation  was  incomplete.  The  improvement  gen- 
erally begins  in  a  few  days,  sometimes  at  once,  though  the  full  benefit 
may  not  be  seen  for  a  month.  The  breathing  becomes  freer,  the  sleep 
more  quiet ;  the  mouth  may  soon  be  habitually  closed ;  voice  and  hearing 
improve,  and  the  benefit  to  the  general  health  is  soon  apparent.  The 
pallor,  listlessness,  and  inattention  disappear,  and  a  rapid  increase  in 
weight  often  follows.  The  entire  appearance  of  the  child  may  in  a  few 
months  be  transformed. 

Dangers  and  Accidents  from  Operation. — While  it  is  rare  that  any 
accidents  of  a  serious  nature  are  met  with,  it  should  not  be  forgotten 
that  they  may  occur.  Undue  laceration  of  the  parts  may  result  from  a 
bungling  operation,  particularly  with  too  large  curettes  or  with  the  for- 


294  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

ceps.  Haemorrhage  may  be  excessive  or  even  fatal.  I  have  seen  but  one 
case  of  fatal  haemorrhage,  this  in  a  bleeder,  and  but  one  other  instance  of 
serious  haemorrhage.  A  fatal  result  is  exceedingly  rare.  Hsemorrhage 
may  be  continuous  after  operation,  or  secondary,  in  which  case  it  almost 
invariably  occurs  within  twenty-four  hours.  It  is  important,  therefore, 
that  the  patient  be  kept  under  observation  for  tliat  time.  Bleeding 
is  best  controlled  by  injecting  into  the  rhino-pliarynx  through  the 
nostrils  one  or  two  drachms  of  hydrogen  peroxide,  full  strength,  or, 
this  failing,  a  solution  of  adrenalin  (1-1000)  may  be  used  in  the  same 
manner.  As  a  last  resource  plugging  of  tlie  rhino-pharynx  and  posterior 
nares  may  be  resorted  to.  In  all  cases  the  patient  should  be  kept  abso- 
lutely quiet. 

Occasionally  an  acute  attack  of  bronchitis  or  otitis  occurs  after  oper- 
ation; and  in  a  few  recorded  instances  acute  meningitis  has  followed. 
The  danger  of  asphyxia  from  the  entrance  of  blood  or  the  tumour  into 
the  larynx  has  already  been  mentioned. 

The  danger  from  chloroform  anaesthesia  is  due  not  so  much  to  the 
nature  of  the  operation  as  to  the  condition  of  the  patient.  It  is  now 
well  established  that  all  children  in  whom  the  condition  known  as  status 
lymphaticus  is  present,  bear  chloroform  very  badly. 


CHAPTER    III. 

DISEASES  OF   THE   TONSILS. 

The  tonsils  are  lymphoid  structures  closely  resembling  Peyer's 
patches,  but,  instead  of  having  a  flattened  surface,  the  lymphoid  tissue  in 
the  tonsil  is  folded  upon  itself,  forming  quite  deep  depressions — the  ton- 
sillar crypts.  These  crypts,  like  the  surface  of  the  tonsils,  are  lined  by 
epithelial  cells.  They  contain  lymphoid  cells,  desquamated  epithelium, 
particles  of  food,  and  bacteria.  Under  normal  conditions  the  tonsils 
take  no  part  in  absorption  from  the  mouth.  When,  however,  their  epi- 
thelium is  diseased  or  removed,  the  tonsils  absorb  with  very  great  facil- 
ity every  sort  of  poison  which  the  mouth  may  contain.  Such  poisons  are 
taken  up  by  the  lymphatics,  and  through  them  reach  the  general  circu- 
lation. 

Acute  inflammation  of  the  tonsils,  like  that  of  the  pharynx,  occurs 
regularly  in  diphtheria,  scarlet  fever,  and  measles,  Ipss  frequently  in  the 
other  infectious  diseases.  The  secondary  forms  will  be  considered  with 
the  diseases  with  which  they  are  associated. 

Acute  catarrhal  tonsillitis,  or  inflammation  of  the  mucous  membrane 
covering  the  tonsils,  occurs  as  part  of  the  lesion  in  acute  pharyngitis, 
but  very  rarely  is  seen  alone. 


MEMBRANOUS  TONSILLITIS.  295 

MEMBRANOUS   TONSILLITIS. 

(Pseudo-diphtheria;  Streptococcus  Angina;  Croupous  Tonsillitis.) 

This  occurs  both  as  a  primary  inflammation  and  secondary  to  the 
acute  infectious  diseases,  especially  scarlet  fever  and  measles.  The  an- 
gina of  scarlet  fever  is  essentially  a  part  of  that  disease  and  is  more 
fully  considered  in  connection  with  it. 

Etiology. — As  was  first  shown  by  Prudden  in  1888,  and  a1)undantly 
confirmed  by  others  since  that  time,  this  inflammation  is  usually  due  to 
the  streptococcus;  it  may  be  found  alone,  or  associated  with  the  staphy- 
lococcus aureus,  and  occasionally  the  staphylococcus  may  ])e  found  alone. 

The  streptococcus  is  very  frequently  found  in  the  throats  of  healthy 
children,  particularly  in  winter  and  in  cities,  and  more  often  in  those 
who  live  in  tenements  or' who  are  inmates  of  hospitals  or  other  institu- 
tions. The  local  conditions  in  the  mucous  membranes  during  an  attack 
of  measles,  scarlet  fever,  and  other  infectious  diseases,  are  especially 
favourable  for  the  development  of  these  germs,  which  at  such  times  are 
very  often  present  in  great  numbers  even  when  no  membrane  is  seen. 

Lesions. — In  the  primary  cases  the  membrane  is  generally  confined 
to  the  tonsils  or  is  chiefly  there,  only  small  deposits  appearing  elsewhere. 
In  the  secondary  cases,  the  entire  pharynx  may  be  covered  and  the  dis- 
ease may  extend  to  the  nose,  the  mouth,  the  middle  ear,  and  rarely  to  the 
larynx,  trachea,  and  bronchi. 

The  structure  of  the  membrane  resembles  that  of  true  diphtheria, 
and  it  may  be  impossible  by  a  microscopical  examination  to  separate  the 
two  diseases. 

In  the  mild  cases  the  inflammation  of  the  mucous  membrane  is  a 
superficial  one  and  the  pseudo-membrane  is  not  very  adherent.  In  the 
severe  cases,  chiefly  the  secondary  ones,  the  process  extends  much  deeper. 
Besides  the  pseudo-membrane  upon  the  surface,  there  is  intense  con- 
gestion, oedema,  and  cell-infiltration  of  all  the  lymphoid  and  cellular 
tissue  of  the  pharynx.  It  may  involve  the  tonsils,  soft  palate,  uvula,  epi- 
glottis, adenoid  tissue  of  the  vault  and  the  entire  pharyngeal  ring,  and 
also  extend  to  the  external  lymph  nodes  and  surrounding  cellular  tissue. 
The  process  both  in  the  throat  and  externally  in  the  neck  may  terminate 
in  resolution,  suppuration,  or  in  necrosis. 

The  streptococci  are  found  in  the  false  membrane,  in  the  underlying 
mucous  membrane,  in  the  lymph  spaces  and  in  the  lymph  nodes.  In  the 
most  severe  cases  there  are  present  the  lesions  of  a  general  streptococcus 
infection. 

Symptoms. — 1.  The  Primary  Cases. — The  onset  is  usually  abrupt, 
with  well-marked  symptoms :  there  are  frequently  chilly  sensations,  head- 
ache, vomiting,  general  pains,  and  in  most  cases  the  child  complains  of 
soreness  of  the  throat  and  pain  on  swallowing.     There  are  first  seen  a 


296  DISEASES  OF  THE   DIGESTI\^   SYSTEM. 

general  redness  and  swelling  of  the  tonsils,  sometimes  of  the  entire 
pharynx;  shortly  afterward  membranous  patches  appear  upon  the  ton- 
sils. These  vary  greatly  in  appearance.  In  colour  they  are  yellow  or 
gray,  often  changing  later  to  a  dirty  olive  tint.  (Plate  XVIII,  c.)  The 
membrane  seems  loosely  attached  and  can  frequently  be  wiped  off  with  a 
swab.  It  is  often  irregular  in  its  outline,  which  is  not  sharply  defined. 
The  membrane  usually  remains  but  three  or  four  days  and  disappears 
rapidly.  As  a  rule,  it  is  limited  to  the  tonsils,  and  does  not  spread  after 
it  first  forms.  Occasionally,  however,  small  patches  are  also  seen  upon 
the  fauces  or  the  pharynx.  The  constitutional  symptoms  are  generally 
severe  during  the  first  two  days,  and  the  temperature  may  be  103°  or 
104°  F.,  but  by  the  third  day  it  falls,  and  most  of  the  symptoms  subside. 
It  is  rare  for  the  disease  to  extend  either  to  the  nose  or  the  larynx.  Gen- 
erally there  are  no  complications  and  no  sequelae. 

2.  The  Secondary  Cases. — Some  of  these  are  mild,  and  do  not  differ 
from  those  just  described,  but  most  of  the  severe  cases  are  included  in 
this  group.  The  clinical  picture  of  the  latter  is  that  of  scarlatina  angi- 
nosa,  as  given  by  the  older  writers. 

In  measles  the  throat  symptoms  are  somewhat  later  than  in  scarlet 
fever;  they  may  begin  at  the  height  of  the  primary  fever,  and  increase 
while  the  eruption  fades.  The  process  is  almost  invariably  complicated 
by  broncho-pneumonia. 

Secondary  cases  as  a  class  are  characterised  by  high  temperature 
(Fig.  48),  rapid,  feeble  pulse,  great  prostration,  delirium,  apathy  or 
stupor,  and  often  albuminuria.  In  fatal  cases  death  usually  occurs 
at  the  height  of  the  disease,  from  asthenia,  broncho-pneumonia,  or 
nephritis.  If  none  of  these  complications  develop,  patients  may  with- 
stand the  toxic  symptoms  even  when  they  are  very  severe. 

There  may  be  in  connection  with  the  local  process  in  the  throat,  deep 
sloughing  of  the  tonsils  or  adjacent  structures,  suppuration  of  the  lym- 
phatic glands  or  in  the  cellular  tissue  of  the  neck,  occasionally  followed 
by  serious  haemorrhage.  However,  these  complications  are  rare,  and  if 
the  patient  survives  the  danger  of  the  acute  stage  of  the  disease,  he 
usually  recovers. 

Diagnosis. — The  clinical  features  which  distinguish  membranous  ton- 
sillitis from  diphtheria  are  considered  under  the  latter  disease.  It  is 
impossible  in  any  case  to  be  certain  of  the  diagnosis  except  by  cultures ; 
for,  although  by  clinical  symptoms  alone  one  may  in  the  great  majority 
of  cases  be  certain  that  a  given  case  is  one  of  true  diphtheria,  to  say 
that  any  membranous  inflammation  of  the  throat  is  not  diphtheria  is 
impossible.  The  bacteriologists  have  taught  us  to  be  cautious  in  pro- 
nouncing too  positively  even  upon  mild  cases,  as  it  has  been  shown 
that  some  of  them  may  be  caused  by  most  virulent  diphtheria  bacilli. 

A  membrane  which  appears  in  the  throat  early  in  the  course  of 


MEMBRANOUS  TONSILLITIS. 


297 


measles  or  scarlet  fever,  or  at  the  height  of  the  primary  disease,  is  usu- 
ally due  to  the  streptococcus;  while  one  which  develops  late  or  after  the 
primary  fever  has  subsided,  is  frequently  due  to  the  diphtheria  bacillus. 


Fig.  48. — Streptococcus  Angina,  following  Measles.  The  chart  begins  at  the  time 
of  the  full  eruption  in  a  severe  case  of  measles.  On  the  third  day  the  temperature 
fell,  with  fading  eruption,  and  child  seemed  convalescent.  With  secondary  rise  in 
temperature,  the  ton.sils,  which  before  had  been  only  red,  showed  membranous 
patches,  the  exudation  rapidly  spreading  until  the  entire  pharynx  was  covered; 
throat  symptoms  very  severe,  with  great  swelling  of  cervical  glands,  but  the  mem- 
brane did  not  extend  beyond  the  pharynx.  From  sixth  to  twelfth  day  a  most  pro- 
found septicaemia,  .so  that  life  was  despaired  of.  The  patient  was  a  vigorous  child, 
and,  escaping  both  nephritis  and  pneumonia,  made  a  good  recovery.  Convalescence 
quite  rapid;  no  sequelae.  Repeated  cultures  were  made  from  the  throat,  but  all 
showed  only  streptococci.  Patient  a  girl  four  years  old.  Case  observed  in  private 
practice. 


Prognosis. — In  a  child  previously  healthy,  primary  membranous  ton- 
sillitis is  not  a  serious  disease.  In  the  secondary  cases,  we  find  very  dif- 
ferent conditions.  From  the  best  available  statistics  it  would  appear 
that  the  usual  mortality,  when  it  is  secondary  to  scarlet  fever  and 
measles,  is  from  fifteen  to  twenty  per  cent.  However,  when  these  dis- 
eases prevail  epidemically  in  institutions,  the  mortality  is  often  higher 
than  this. 

Treatment.— Every  child  with  a  membranous  patch  on  the  tonsils 
requires  close  watching;  strict  quarantine  should  be  enforced  until  the 
diagnosis  is  positively  settled.  If  under  three  years  old,  unless  the  case 
can  be  seen  frequently,  diphtheria  antitoxin  should  be  administered, 
pending  the  result  of  a  bacteriological  examination.  The  primary  cases 
require  only  the  treatment  of  an  attack  of  tonsillitis. 

In  the  severe  secondary  cases  the  nose  and  pharynx  should  be  syringed 
with  a  warm  saline  solution  every  two  hours  by  day  and  every  four  hours 
by  night.  Where  the  swelling  and  ojdema  are  great,  benefit  may  result 
from  frequent  spraying  with  solutions  containing  adrenalin,  also  from 
inhaling  hot  vapour  impregnated  with  eucalyptol,  benzoin,  etc.     As  an 


298  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

external   application,   whenever  there   is  great   adenitis   and   cellulitis, 
nothing  is  so  beneficial  as  the  ice-bag. 

The  general  management  of  these  cases  as  to  feeding,  stimulants, 
etc.,  is  the  same  as  in  diphtheria.  Aside  from  stimulants  no  internal 
medication  should  be  attempted  with  young  children.  Those  who  are 
older  may  take  with  advantage  tr.  ferri  chlor.,  gtt.  v  to  x,  with  glycerin, 
every  three  or  four  hours. 

ULCERO-MEMBRANOUS  TONSILLITIS. 
(Vincent's  Angina.) 

This  is  an  inflammation  somewhat  resembling  croupous  tonsillitis, 
but  it  is  often  unilateral  and  associated  with  superficial  ulceration.  The 
tonsil  is  covered  with  a  dirty  yellowish  exudation,  which. may  be  mistaken 
for  diphtheria.  There  is  superficial  necrosis,  and  when  this  tissue  is 
wiped  away  with  a  swab,  bleeding  occurs.  The  disease  is  further  dis- 
tinguished by  the  swollen  lymph  nodes  at  the  angle  of  the  jaw,  and  by 
the  fact  that  the  constitutional  symptoms  which  accompany  other  forms 
of  tonsillitis  are  either  very  slight  or  absent  altogether.  The  etiology 
is  similar  to,  if  not  identical  with,  ulcerative  stomatitis,  with  which  it  is 
sometimes  associated.  At  such  times  the  breath  is  foul  and  there  is 
often  profuse  salivation. 

Ulcero-membranous  tonsillitis  was  first  described  by  Vincent,  and 
by  him  attributed  to  a  fusiform  bacillus  which  he  described,  although  a 
spirillum  was  found  associated  with  it.  Vincent's  observations  have  been 
confirmed,  and  it  has  been  shown  that  the  spirillum  is  a  degenerative 
form  of  the  bacillus.^ 

The  chief  interest  in  ulcero-membranous  tonsillitis  lies  in  the  diag- 
nosis, although  it  is  not  an  infrequent  disease.  It  is  to  be  treated,  like 
ulcerative  stomatitis,  by  the  internal  administration  of  chlorate  of  pot- 
ash, combined  with  the  local  application  of  some  antiseptic,  such  as 
peroxide  of  hydrogen  or  a  ten-per-cent  solution  of  nitrate  of  silver. 

FOLLICULAR  TONSILLITIS. 

This  is  the  most  frequent  and  most  characteristic  form  of  inflamma- 
tion of  the  tonsil.  It  is  essentially  an  inflammation  of  the  tonsillar 
crypts,  and  secondarily  of  the  whole  glandular  structure. 


'  Vincent's  bacillus  is  about  twice  as  long  as  the  Klebs-Loeffler  bacillus.  It  is  thin, 
with  pointed  ends,  and  sometimes  bent;  it  is  negative  to  Gram's  stain.  The  fusiform 
bacillus  is  occasionally  found  alone;  the  spirillum,  never  alone.  The  bacillus  is  found 
in  smears  from  the  affected  tonsil,  in  making  which  it  is  recommended  to  go  deeply 
into  the  necrotic  tissue,  since  the  superficial  parts  are  crowded  with  other  bacteria. 
It  is  grown  with  difficulty  and  only  upon  special  culture  media. 


FOLLICULAR  TONSILLITIS.  299 

Etiology. — There  is  seen  in  certain  children  a  predisposition  to  at- 
tacks of  tonsillitis,  so  that  from  very  sliglit  exciting  causes  these  occur — 
sometimes  from  exposure,  sometimes  possibly  from  derangement  of  the 
stomach,  and  sometimes  without  any  evident  reason.  Children  with  a 
rheumatic  inheritance  appear  to  be  more  susceptible  than  others.  One 
attack  predisposes  to  a  second.  Patients  suffering  from  chronic  hyper- 
trophy of  the  tonsils  are  exceedingly  prone  to  acute  tonsillitis.  It  is  not 
very  common  in  infancy,  but  after  this  period  it  is  very  frequent  through- 
out childhood.  The  disease,  in  all  probability,  begins  as  an  infectious 
inflammation  at  the  bottom  of  the  crypts,  due  to  the  presence  of  strep- 
tococci or  staphylococci,  which  readily  enter  from  the  mouth,  and  excite 
an  attack  whenever  favourable  conditions  are  present. 

Lesions. — As  a  result  of  the  inflammation,  the  tonsillar  crypts  are 
filled  with  epithelial  cells,  pus  cells,  mucus,  and  bacteria.  These  form 
masses  which  appear  at  the  mouth  of  the  crypts  as  small  yellow  dots, 
often  miscalled  ulcers.  Sometimes,  in  addition,  fibrin  is  poured  out, 
and  forms,  with  the  other  inflammatory  products,  little  plugs  which 
project  somewhat  from  the  surface  of  the  mucous  membrane,  and  which 
can  easily  be  pressed  out.  Accompanying  the  changes  in  the  mucous 
membrane  above  mentioned,  there  are  acute  congestion  and  swelling  of 
the  whole  tonsil,  with  more  or  less  proliferation  of  the  lymphoid  tissue. 
Follicular  tonsillitis  is  almost  always  bilateral.  Although  the  patholog- 
ical process  is  generally  limited  to  the  tonsils,  there  may  be  more  or 
less  pharyngitis  associated. 

Symptoms. — The  general  symptoms  usually  appear  before  the  local 
ones,  and  are  often  quite  severe.  The  onset  is  abrupt,  with  chilly  sensa- 
tions, occasionally  a  distinct  rigor.  In  infants  there  is  often  vomiting, 
and  sometimes  diarrhoea.  There  is  pain  in  the  back,  in  the  muscles  of 
the  extremities,  and  in  the  head.  Sometimes  there  is  pain  in  the  lateral 
cervical  muscles.  The  temperature  rises  rapidly  to  102°  or  103°  F. ; 
often  it  touches  104°  or  105°  F. 

The  first  local  symptoms  are  some  swelling  of  the  tonsils  and  the  ap- 
pearance upon  them  of  isolated  yellow  spots  a  little  larger  than  a  pin's 
head.  Often  these  can  be  wiped  off  with  a  swab,  or  the  little  plugs  can  be 
squeezed  out,  leaving  slight  depressions.  Later  there  is  acute  congestion 
of  the  tonsil,  with  more  swelling.  Even  when  the  disease  is  at  its  height 
the  local  pain  and  discomfort  may  be  only  moderate,  and  in  many  cases 
scarcely  noticeable.  The  swelling  and  tenderness  of  the  lymph  glands 
behind  the  angle  of  the  jaw  are  not  great,  and  may  be  absent. 

The  constitutional  symptoms,  as  a  rule,  last  three  days,  and  are  most 
severe  upon  the  first  day.  The  local  symptoms  last  somewhat  longer,  but 
usually  by  the  end  of  the  fourth  day  the  exudate  has  disappeared, 
although  enlargement  of  the  tonsil  may  persist  for  a  week  or  even  longer. 
On  account  of  the  connection  of  tonsillitis  with  rheumatism,  the  heart 


300  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

should  be  watched  during  attacks,  especially  in  those  who  are  subject 
to  thenL 

Diagnosis. — Tonsillitis  may  he  confounded  at  its  onset  with  scarlet 
fever.  The  great  frequency  of  tonsillitis  makes  inspection  of  the  throat 
imperative  in  every  case  of  acute  illness  in  children.  The  diagnosis  from 
diphtheria  is  considered  in  connection  with  that  disease. 

Treatment. — Follicular  tonsillitis  is  a  mild  disease  without  danger  to 
life,  and  one  which  runs  a  short,  self-limited  course.  The  indications 
are,  therefore,  to  make  the  patient  as  comfortable  as  possible  by  the 
relief  of  individual  symptoms.  Older  children,  particularly  those  who 
are  rheumatic,  should  be  treated  with  sodium  salicylate,  or  aspirin,  four 
or  five  grains  every  three  hours  being  given  for  the  first  twenty-four 
hours,  and  later  less  frequently.  To  infants  these  drugs  must  be  given 
in  smaller  doses  and  with  care,  lest  they  upset  the  stomach.  The  general 
muscular  pains  of  the  first  day  are  best  relieved  by  phenacetine,  two 
grains  every  four  hours  to  a  child  three  years  old.  Ijater  it  may  be 
used  in  smaller  doses,  but  enough  should  be  given  to  make  the  patient 
comfortable. 

Local  treatment  is  better  omitted  with  infants.  Older  children  may 
gargle  with  a  solution  of  boric  acid  or  may  use  a  spray  of  Dobell's  solu- 
tion. Benefit  often  follows  painting  the  tonsils  with  tincture  of  iodine 
or  a  ten-per-cent  solution  of  silver  nitrate.  In  all  doubtful  cases  the 
patient  should  be  isolated  and  the  same  general  treatment  adopted  as  in 
diphtheria. 

PHLEGMONOUS  TONSILLITIS— PERITONSILLAR  ABSCESS— QUINSY. 

This  is  an  inflammation  of  the  cellular  tissue  surrounding  the  tonsil, 
sometimes  invading  the  tonsil  itself.  It  may  terminate  in  resolution,  but 
usually  goes  on  to  the  formation  of  an  abscess.  Phlegmonous  tonsillitis 
is  much  less  common  in  children  than  in  adults,  and,  compared  with  the 
other  forms,  it  is  a  rare  disease  in  early  life.  It  is  the  only  variety  which 
is  regularly  unilateral.  In  most  cases  the  inflammatory  process  is  cir- 
cumscribed, but  in  rare  instances  there  is  seen  a  diffuse  phlegmonous 
inflammation  of  the  pharynx. 

In  certain  patients  there  exists  a  constitutional  predisposition  to  the 
disease,  which  may  be  associated  with  rheumatism.  The  exciting  cause 
may  be  exposure,  or  anything  which  may  reduce  the  patient's  general 
health,  to  which  there  is  added  local  infection.  Catarrhal  pharyngitis 
predisposes  to  this  disease. 

Symptoms. — The  onset  resembles  that  of  follicular  tonsillitis,  the 
temperature  is  often  high,  and  the  muscular  pains  and  prostration  severe. 
There  is  very  severe  pain  in  the  throat,  which  is  increased  by  deglutition, 
and  finally  may  be  so  great  that  swallowing  is  almost  impossible.  It  is 
difficult  to  open  the  mouth.    There  is  pain  in  the  lateral  muscles  of  the 


CHRONIC   HYPEllTROPHY  OF  THE  TONSH^S.  301 

neck,  and  often  tenderness.  In  the  beginning  hut  little  can  he  seen  on 
inspection,  even  though  the  patient  complains  of  a  very  sore  throat.  This 
is  always  a  suspicious  circumstance,  and  should  lead  one  to  look  out  for 
quinsy.  It  is  due  to  the  fact  that  the  inflammation  begins  in  the  deeper 
tissues,  and  that  the  mucous  membrane  is  affected  later.  After  twenty- 
four  or  forty-eight  hours  there  is  usually  quite  marked  swelling,  which 
is  rather  more  behind  the  tonsil  than  elsewhere,  pushing  it  upward  and 
forward;  sometimes  it  is  more  in  front  of  the  tonsil.  A  little  later  there 
is  intense  inflammation  of  the  mucous  membrane  covering  the  tonsil, 
fauces,  and  uvula,  and  not  infrequently  a  fibrinous  exudate ;  the  uMila  may 
be  pushed  to  one  side,  and  the  isthmus  of  the  fauces  diminished  to  less 
than  one-half  its  natural  size.  In  one  of  my  own  cases  marked  torticollis 
was  present,  and  existed  for  two  or  three  days  before  the  diagnosis  of 
quinsy  could  be  made  by  the  other  symptoms. 

In  most  cases  the  recognition  of  quinsy  is  quite  easy  by  attention  to 
the  symptoms  above  mentioned.  By  inspection  of  the  throat,  less  in- 
formation is  sometimes  obtained  than  by  palpation ;  ])y  this  means  a 
fulness,  and  later  a  point  of  fluctuation,  can  readily  be  made  out.  Acute 
phlegmonous  tonsillitis  generally  involves  no  danger  to  life.  In  very 
young  infants  serious  results  may  follow  spontaneous  rupture  during 
sleep;  and  in  older  children  occasionally  there  may  be  oedema  of  the 
glottis.  If  not  treated,  abscess  usually  forms  in  from  five  to  seven  days, 
and  opens  spontaneously. 

Treatment. — If  an  early  diagnosis  is  made  an  attack  of  quinsy  may 
possibly  Ije  aborted.  For  this  many  drugs  have  been  advocated,  but 
to  my  mind  the  best  is  salol,  which  should  be  given  in  doses  of  two 
grains  every  two  hours  to  a  child  of  five  years.  In  some  patients  larger 
doses  may  be  used.  This  may  be  combined  with  small  doses  (gr.  ^)  of 
Dover's  powder.  Eelief  may  be  afforded  by  very  hot  or  cold  applications, 
according  to  the  sensations  of  the  patient.  The  holding  of  ice  in  the 
mouth  and  the  application  of  an  ice-bag  externally,  often  give  great 
comfort.  In  other  cases,  gargling  with  veiy  hot  water  and  the  applica- 
tion of  hot  flaxseed  poultices  externally,  will  be  preferred.  As  soon  as 
fluctuation  is  detected  an  incision  should  be  made  with  a  guarded  bis- 
toury. If  made  too  early,  only  a  small  amount  of  pus  is  evacuated  and 
the  abscess  may  refill.  After  spontaneous  rupture  the  relief  to  symp- 
toms is  usually  immediate. 

CHRONIC  HYPERTROPHY  OF  THE  TONSILS.— CHRONIC  TONSILLITIS. 

The  condition  known  as  chronic  liypertrophy  is  a  permanent  enlarge- 
ment due  to  a  proliferation  of  the  lymphoid  tissue  of  the  tonsils,  and  an 
increase  in  the  connective-tissue  stroma.  If  the  increase  in  the  con- 
nective tissue  is  slight,  the  tonsil  is  soft ;  if  it  is  great,  the  tonsil  is  firm 


302  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

and  hard,  almost  like  a  fibrous  tumour.  All  degrees  are  found.  Asso- 
ciated with  hypertrophy  of  the  tonsils  there  are  usually  found  adenoid 
growths  of  the  pharynx,  both  of  these  depending  upon  similar  local  and 
constitutional  conditions.  There  is  in  nearly  all  marked  eases  a  chronic 
pharyngeal  catarrh  which  may  involve  the  Eustachian  tubes. 

Etiology. — Hypertrophy  of  the  tonsils  is  an  exceedingly  common  con- 
dition in  the  cities  of  the  seacoast  and  lake  districts  of  the  temperate 
zone.  In  a  routine  examination  of  2,000  Xew  York  school  children, 
Chappell  found  enlargement  of  the  tonsils  sufficiently  marked  in  270 
cases  to  be  considered  pathological.  The  causes  are  constitutional  and 
local.  The  condition  frequently  exists  in  certain  families  for  several 
generations.  It  is  not  connected  with  tuberculosis.  It  occurs  in  children 
who  are  in  other  respects  healthy.  Hypertrophy  of  the  tonsils  is  often  a 
congenital  condition,  increasing  slowly  during  infancy,  so  as  to  produce 
marked  symptoms  by  the  time  the  child  is  two  years  old.  The  most 
important  of  the  local  causes  are  attacks  of  aciite  or  subacute  pharyngitis. 
While  it  is  true  that  attacks  of  acute  inflammation  are  often  the  cause  of 
hypertrophy,  it  is  also  true  that  hypertrophy  is  one  of  the  most  frequent 
predisposing  causes  of  acute  attacks,  and  that  it  may  be  seen  in  children 
who  have  never  had  tonsillitis. 

Symptoms. — Hypertrophy  of  the  tonsils  is  rarely  marked  enough  to 
cause  any  decided  symptoms  before  the  end  of  the  second  year,  although 
I  once  saw  in  a  younger  child  enlargement  sufficient  to  bring  the  two 
tonsils  into  contact.  The  most  important  local  symptoms,  formerly 
ascribed  to  hypertrophied  tonsils,  are  now  known  to  depend  upon  adenoid 
growths  of  the  pharynx.  As  these  conditions  are  so  frequently  associated, 
it  is  somewhat  difficult  to  determine  which  symptoms  are  due  to  the 
tonsils  alone.  In  a  marked  case,  the  most  prominent  symptoms  are 
mouth-breathing,  disturbed  sleep  accompanied  by  snoring,  and  nasal 
voice — the  patient  in  some  cases  talking  as  though  he  had  food  in  liis 
mouth.  There  may  be  some  difficulty  in  swallowing  solid  food.  En- 
larged tonsils  may  often  be  felt  externally.  As  a  consequence  of  the 
obstruction  of  the  Eustachian  tubes  there  may  be  deafness.  Deformities 
of  the  chest,  such  as  pigeon-breast,  are  occasionally  seen,  but  probably 
depend  more  upon  obstructed  respiration  by  adenoids  than  by  the  tonsils. 

The  soft  tonsils  may  diminish  somewhat  in  size  spontaneously.  They 
sometimes  shrink  very  decidedly  after  an  attack  of  acute  tonsillitis, 
scarlet  fever,  or  diphtheria.  As  a  rule  the  tonsils  become  firmer  and 
harder  as  time  passes.  They  usually  increase  in  size  up  to  a  certain 
point,  and  then  remain  nearly  stationary  until  about  puberty,  when 
they  may  diminish  considerably.  During  intercurrent  attacks  of  inflam- 
mation, the  swelling  is  much  increased,  and  the  symptoms  are  propor- 
tionately aggravated.  In  cases  of  marked  enlargement  very  little  spon- 
taneous improvement  is  to  be  looked  for  during  childhood. 


CHRONIC  HYPERTROPHY  OF  THE  TONSILS.  303 

Treatment. — Very  large  tonsils  are  a  source  of  continued  danger  to 
the  patient,  and  in  every  case  of  marked  hypertrophy  treatment  should 
be  advised.  The  danger  may  be  from  Eustachian  catarrh  and  deafness, 
or  from  repeated  attacks  of  acute  tonsillitis.  But  quite  as  important  as 
these  is  the  fact  that  they  increase  the  liability  to  contract  diphtheria, 
and  add  to  the  dangers  both  from  diphtheria  and  scarlet  fever.  If  the 
patient  is  removed  from  the  locality  in  which  acute  tonsillitis  is  liable  to 
occur,  to  a  dry  climate,  considerable  improvement  is  likely  to  result  in 
a  young  child  in  whom  the  tonsils  are  soft,  but  not  much  is  to  be 
expected  in  older  children  with  hard,  fibrous  tonsils,  except,  perhaps,  a 
cure  of  the  accompanying  pharyngeal  catarrh. 

No  internal  remedy  offers  much  chance  of  benefit.  Astringent  ap- 
plications may  accomplish  something  in  recent,  but  practically  nothing 
in  old  cases.  In  every  marked  case,  operation  is  the  only  thing  which 
can  be  relied  upon  to  effect  a  cure.  For  convenience  of  consideration, 
the  cases  may  be  divided  into  three  groups :  ( 1 )  Those  in  which  the 
tonsils  are  nearly  or  quite  in  contact;  (2)  those  in  which  they  project 
only  slightly  beyond  the  faucial  pillars;  (3)  those  in  which  the  tonsils, 
although  large,  are  deeply  imbedded.  All  of  the  first  group  should  un- 
questionably be  operated  upon,  unless  the  patient's  general  condition  is 
such  as  to  forbid  operation  of  any  kind.  In  the  second  group  operation 
is  not  indicated  unless  there  are  repeated  acute  attacks,  or  the  tonsils  are 
the  seat  of  chronic  infection.  Whether  an  operation  is  done  in  the 
third  group  will  depend  upon  the  individual  case.  If  there  are  frequent 
attacks  of  acute  tonsillitis  or  evidence  of  involvement  of  the  ears  opera- 
tion should  be  performed. 

Various  operations  are  in  use  for  the  removal  of  hypertrophied  ton- 
sils: the  wire  snare,  amputation  with  the  guillotine,  and  enucleation. 
Each  has  its  advocates  and  each  its  advantages.  The  use  of  the  snare 
is  accompanied  with  little  risk  of  haemorrhage.  It  is  a  painful  opera- 
tion, some  preliminary  dissection  is  usually  required,  and  hence  general 
anassthesia  is  necessary.  Amputation  by  the  guillotine  is  simpler  and 
for  well-projecting  tonsils  quite  sufficient.  The  risk  of  haemorrhage  in 
children  is  slight.  An  anaesthetic  is  unnecessary  if  only  the  tonsils 
are  to  be  removed.  The  amount  of  shrinkage  from  cicatrisation  after 
operation  has  been,  in  my  experience,  generally  less  than  was  expected. 
Enlargement  of  the  tonsil  subsequent  to  amputation  is  sometimes  seen,, 
oftener  if  the  patient  operated  on  is  under  two  years  old.  I  am  not 
yet  convinced  of  the  advantages  of  complete  enucleation,  now  much  in 
vogue,  as  a  routine  operation  for  hypertrophied  tonsils,  but  in  certain 
cases  nothing  else  is  adequate.  Such  are  the  broad,  deeply  imbedded, 
adherent  tonsils.  Excessive  haemorrhage  after  any  form  of  operation 
may  be  controlled  by  digital  pressure,  or  by  the  application  of  styptic 
cotton  upon  a  swab;  in  extreme  cases,  by  transfixing  the  tonsil  stump 


304  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

with  a  harelip  pin  and  the  application  of  a  ligature.  I  have  more  than 
once  seen  physicians  greatly  alarmed  at  the  gray  wound  on  the  day  fol- 
lowing tonsillotomy,  the  appearance  being  such  as  to  lead  in  several  cases 
to  the  diagnosis  of  diphtheria.  It  is  seldom  that  any  but  good  results 
follow  the  operation  of  tonsillotomy  if  properly  performed.  When  ade- 
noids of  the  pharynx  are  also  present,  the  symptoms  may  depend  more 
upon  them  than  upon  the  enlarged  tonsils,  and  little  benefit  is  seen  un- 
less the  adenoids  also  are  removed. 


CHAPTER    IV. 
DISEASES  OF   THE  (ESOPHAGUS. 

MALFORMATIONS. 

Congenital  anomalies  of  the  oesophagus  are  often  associated  with 
those  of  the  lower  part  of  the  respiratory  tract. 

There  may  be,  (1)  Congenital  fistula  of  the  neck,  due  to  a  want  of 
closure  between  the  second  and  third  branchial  arches.  This  gives  an 
external  opening  just  above  and  to  the  outside  of  the  sterno-clavicular 
articulation,  which  communicates  with  the  upper  part  of  the  resophagus 
or  the  lower  part  of  the  pharynx.  (2)  The  oesophagus  may  be  absent, 
the  pharynx  ending  in  a  blind  pouch.  (3)  The  oesophagus  may  be  oblit- 
erated in  certain  portions,  being  represented  only  by  a  fil)rous  cord.  (4) 
There  may  be  stenosis  and  dilatation  or  diverticula.  (5)  There  may  be 
fistulous  communication  with  the  trachea,  existing  either  alone  or  asso- 
ciated with  some  of  the  other  deformities  mentioned. 

Congenital  narrowing  of  the  oesophagus  and  fistula  of  the  neck  are 
amenable  to  surgical  treatment.  The  cases  of  complete  obstruction  in 
the  oesophagus  are  almost  of  necessity  fatal,  the  patients  dying  from  in- 
anition two  or  three  days  after  birth. 

The  symptoms  of  oesophageal  obstruction  are  regurgitation  on  at- 
tempts at  swallowing  and  the  impossibility  of  passing  the  stomach  tube. 
An  X-ray  picture  after  the  administration  of  bismuth  often  gives  valu- 
able information. 

ACUTE  CESOPHAGITIS. 

It  is  quite  remarkable,  considering  the  frequency  of  pathological 
processes  in  the  pharynx,  that  these  so  rarely  extend  to  the  oesophagus. 
Thrush,  when  very  extensive  in  the  pharynx,  may  involve  the  upper  part 
of  the  oesophagus;  but  there  it  gives  rise  to  no  new  symptoms.  Diph- 
theria of  the  pharynx  may  invade  the  oesophagus,  but  this  is  seen  only 
in  rare  instances.  Diphtheria  of  the  oesophagus  produces  no  symptoms 
by  which  it  can  be  diagnosticated  during  life. 


RETRO-(ESOPHAGEAL  ABSCESS.  305 

Catarrhal  (Esophagitis. — Catarrhal  oesophagitis  is  very  rarely  met 
with.  It  may  be  caused  by  lacerations  due  to  swallowing  a  foreign  body, 
which  may  excite  a  simple  catarrhal  infiamniation,  or,  if  the  foreign 
body  is  sharp  and  angular,  lacerations  may  he  produced  which  result  in 
ulcerations  of  variable  depth.  The  chief  symptoms  of  catarrhal  oesoph- 
agitis are  soreness  and  pain  on  swallowing.  These  lacerations,  when 
slight,  are  healed  in  a  few  days,  and  are  rarely  followed  by  any  after- 
effects. 

Corrosive  (Esophagitis. — This  is  altogether  the  most  frequent  form, 
and  the  only  one  which  is  of  clinical  importance.  The  usual  causes  are 
the  same  as  of  corrosive  gastritis,  viz.,  the  swallowing  of  caustic  alkalies 
or  strong  acids.  It  is  often  in  the  oesophagus  that  the  most  extensive 
injury  is  done.  The  effects  are  superficial  or  deep,  according  to  the 
amount  of  the  irNtant  swallowed  and  its  degree  of  concentration.  There 
may  be  simply  a  destruction  of  the  epithelial  layer,  which  is  followed  by 
no  serious  consequences,  or  the  mucous  meml)rane  may  be  destroyed  and 
the  submucous  coat  invaded;  rarely,  however,  does  the  injury  extend  to 
the  muscular  layer.  If  the  patient  survives  the  dangers  incident  to  the 
irritant  poisoning  and  the  acute  inflammation  which  follows,  healing  by 
granulation  and  cicatrisation  takes  place,  the  contraction  of  the  cicatrix 
gradually  narrowing  the  lumen  of  the  oesophagus  until  stricture  is  pro- 
duced. 

The  early  symptoms  of  corrosive  oesophagitis  are  mingled  with  those 
of  inflammation  of  the  mouth,  pharynx,  and  stomach.  There  is  a  burn- 
ing pain  in  the  parts,  great  thirst,  and  spasm  of  the  oesophagus  on  at- 
tempts at  swallowing.  There  follows  a  period  of  acute  inflammation  of 
several  days'  duration,  with  great  dysphagia  and  pain,  in  which  the 
principal  danger  is  oedema  of  the  glottis.  After  this  the  patient  may 
be  comparatively  well  until  the  symptoms  of  stricture  begin,  usually  in 
from  three  to  six  months  after  the  injury. 

The  indications  for  treatment  in  the  early  stages  are,  to  neutralise  the 
caustic  in  order  to  prevent  if  possible  its  deep  action,  to  give  oils,  demul- 
cent drinks  and  ice  for  the  local  effect,  and  morphine  for  the  pain. 

The  treatment  of  oesophageal  stricture  is  purely  surgical. 

RETRO-CESOPHAGEAL  ABSCESS. 

Acute  retro-oesophageal  abscess  occurs  in  infancy,  though  very  rarely, 
the  pathology  being  the  same  as  in  acute  retro-pharyngeal  abscess,  the 
difference  being  merely  one  of  location.  A  striking  case  of  this  kind 
occurred  in  the  New  York  Foundling  Hospital.  An  infant  six  months 
old  was  admitted  with  high  fever  (104°  F.),  severe  dyspnoea,  but  with  no 
loss  of  voice,  which  were  the  prominent  symptoms  until  death  occurred 
four  days  later.  There  was  a  leucocytosis  of  100,000.  At  autopsy  an 
21 


306  DISEASES   OF  THE   DIGESTIVE  SYSTEM. 

abscess  was  found  containing  about  three  ounces  of  pus  between  the 
asophagus  and  the  spine,  extending  from  the  larynx  to  below  the  bifur- 
cation of  the  trachea.  Shortly  afterward  I  saw  a  very  similar  case  at  tlie 
Babies'  Hospital,  following  a  retro-pharyngcal  abscess  wliich  had  been 
opened  two  weeks  before.  Similar  abscesses  have  also  been  observed  after 
acute  pharyngitis  with  the  acute  infectious  diseases. 

Retro-oesophageal  adenitis,  or  enlargement  of  the  lymph  nodes  in 
this  situation  without  suppuration,  is  also  rare.  I  once  met  with  a  case 
of  this  sort  in  which  the  gland  formed  a  tumour  nearly  an  inch  in  diam- 
eter at  the  upper  part  of  the  oasophagus,  causing  pressure  symptoms 
necessitating  tracheotomy.  The  growth  was  at  first  thought  to  be  malfg- 
nant,  but  completely  disappeared  after  a  summer  in  the  country. 

Retro-oesophageal  abscess  may  result  from  the  breaking  down  of 
tuberculous  lymph  nodes  in  the  posterior  mediastinum,  and  may  give  rise 
to  symptoms  like  those  which  result  from  an  abscess  due  to  Pott's  disease. 

Perforation  of  the  oesophagus  and  a  food-fistula  connecting  the  oesoph- 
agus and  the  trachea  may  result  from  ulceration  caused  by  a  tracheal 
canula  or  by  a  foreign  body.    This  may  be  accompanied  by  abscess. 

The  most  common  variety  of  retro-oesophageal  abscess  is  that  due  to 
Pott's  disease  of  the  lower  cervical  or  upper  dorsal  region.  The  symp- 
toms are  obscure,  and  an  exact  diagnosis  is  not  often  made  during  life. 
Death  may  occur  quite  suddenly  where  the  previous  symptoms  have  been 
80  slight  as  to  be  easily  overlooked.     The  following  is  a  fair  example: 

A  girl  two  years  old  was  admitted  to  the  Babies'  Hospital  with  caries 
of  the  upper  dorsal  region  of  two  months'  duration.  The  patient  was 
kept  in  bed  and  a  plaster-of-Paris  jacket  applied.  About  a  month  later 
dyspnoea  was  first  observed;  this  was  at  times  quite  intense,  and  again 
almost  absent.  It  was  always  on  inspiration,  expiration  being  easy.  No 
explanation  for  this  was  found  in  the  lungs.  There  was  no  difficulty  in 
swallowing,  and  very  little  cough.  After  these  symptoms  had  lasted  for 
about  a  week,  the  child  while  eating  was  suddenly  seized  with  violent 
dyspnoea,  and  in  a  few  moments  became  completely  asphyxiated.  Trache- 
otomy was  immediately  done,  and  by  means  of  artificial  respiration  the 
patient  was  restored  to  comparative  comfort.  About  two  hours  later  a 
second  attack  occurred,  and  the  patient  died  in  an  hour.  At  the  autopsy 
there  was  found  an  abscess  a  little  larger  than  a  hen's  egg,  containing 
about  two  ounces  of  curdy  pus,  overlying  the  bodies  of  the  first  three 
dorsal  vertebrae  and  communicating  with  them.  These  vertebras  were 
carious.  The  right  pneumogastric  nerve,  an  inch  and  a  half  above  the 
bifurcation  of  the  trachea,  was  compressed  between  the  abscess  and  a 
large  tuberculous  lymph  node,  with  the  capsule  of  which  it  was  blended. 
In  the  lungs  were  a  few  small  tuberculous  deposits  and  the  usual  condi- 
tions found  in  death  by  asphyxia.  The  dyspnoea  seems  to  have  been  of 
nervous  and  not  of  mechanical  origin,  and  caused  by  irritation  of  the 


RETRO-CESOPHAGEAL  ABSCESS.  307 

pneumogastric.  The  fatal  issue  was  apparently  from  an  increase  of  the 
pressure  upon  the  nerve. 

I  have  seen  but  one  other  case,  and  this  closely  resembled  the  one 
reported.  In  the  thirteen  cases  collected  by  Griffith  the  symptoms  in  all 
were  much  alike.  '  DA'spncea,  usually  of  a  spasmodic  character,  was 
prominent  in  nearly  all,  and  generally  it  was  the  most  marked  symp- 
tom. It  was  more  marked  on  inspiration,  and  often  accompanied  by  a 
spasmodic  cough,  suggesting  laryngeal  stenosis.  The  voice  was  affected 
in  but  two  cases,  in  one  complete  aphonia  being  present.  It  is  striking 
that  in  no  case  was  there  any  difficulty  in  swallowing,  in  marked  con- 
trast to  retro-pharyngeal  abscess.  Swelling  in  the  neck  was  noted  in  but 
three  cases.  Spinal  caries  was  stated  to  be  present  in  seven  cases  and 
absent  in  two.  The  final  attack  of  asphyxia  sometimes  came  without 
warning,  sometimes  was  preceded  for  several  days  or  longer  by  milder 
attacks. 

The  diagnosis  of  this  condition  is  very  difficult,  and  a  positive  diag- 
nosis almost  impossible.  It  may  be  suspected  in  cases  of  Pott's  disease 
of  the  lower  cervical  or  upper  dorsal  regions,  when  there  is  spasmodic 
inspiratory  dyspnoea,  especially  if  accompanied  by  irritative  cough.  It 
should,  however,  be  remembered  that  precisely  similar  symptoms  may 
depend  upon  the  irritation  of  a  tuberculous  node,  and  that  the  sudden 
asphyxia  is  exactly  like  that  caused  by  the  ulceration  of  such  a  node 
into  the  trachea  or  a  large  bronchus.  The  latter,  however,  may  occur 
without  the  presence  of  Pott's  disease.  If  the  abscess  is  higher  up,  there 
may  be  a  lateral  swelling  on  either  side  of  the  neck,  just  above  the  clav- 
icle. In  most  of  the  cases  there  are  no  external  signs  of  disease.  Such 
abscesses  are  too  low  to  be  reached  by  digital  examination  of  the  pharynx. 
The  attack  of  asphyxia  may  also  be  confounded  with  that  due  to  the 
presence  of  a  foreign  body  in  the  larynx. 

The  prognosis  in  cases  of  retro-oesophageal  abscess  is  exceedingly  bad. 
Death  usually  results  from  pressure  upon  the  pneumogastric,  as  in  the 
cases  reported.  The  abscess  may  rupture  into  the  oesophagus  and  recov- 
ery follow.  This  termination  is  very  rare,  but  such  a  case  has  been  re- 
ported by  Knight.  A  fatal  one  is  reported  by  Loschner  and  Lambl.  The 
abscess  may  burrow  along  the  oesophagus  into  the  abdominal  cavity  and 
excite  peritonitis;  finally,  it  may  open  externally. 

But  little  is  to  be  said  under  the  head  of  Treatment.  The  symptoms 
are  rarely  definite  enough  to  justify  a  radical  surgical  operation.  Trache- 
otomy gives  but  temporary  relief  to  the  asphyxia.  This  operation  should 
be  performed,  however,  in  every  case,  because  of  the  impossibility  of 
making  a  diagnosis  of  retro-oesophageal  abscess  from  other  conditions 
in  which  the  operation  might  be  curative. 


308  DISEASES  OV  THE   DIGESTIVE   SYSTEM. 

CHAPTER    V. 

DISEASES  OF   THE  STOMACH. 

It  is  difficult  wholly  to  separate  diseases  of  the  stomach  from  those 
of  the  intestine.  Although  in  older  children  they  are  often  quite  dis- 
tinct, in  infancy  they  are  more  frequently  associated ;  but  at  one  time 
the  gastric  symptoms  may  be  prominent,  and  at  another  the  intestinal 
symptoms.  Functional  disorders  particularly  are  likely  to  involve  the 
whole  tract.  Serious  organic  lesions  are  more  frequently  limited  in 
their  extent  either  to  the  stomach  or  to  the  intestine.  The  former  are 
rare,  while  the  latter  are  very  common.  The  diseases  in  which  the  stom- 
ach is  alone  or  chietiy  involved  will  be  considered  by  themselves.  Those 
in  which  both  the  stomach  and  intestine  are  involved  are  classed  with 
the  intestinal  diseases,  as  the  intestinal  symptoms  usually  predominate. 

DIGESTION   IN   INFANCY. 

The  first  step  in  the  process  of  digestion  in  the  newly-born  infant  is 
sucking.  During  this  act  the  nipple  is  grasped  between  the  lower  lip  and 
tongue  below,  and  the  upper  lip  and  jaw  above.  The  back  of  the  mouth 
is  closed  by  the  palate.  A  strong  downward  movement  of  the  lower  jaw 
causes  a  partial  vacuum  in  the  mouth,  and  produces  the  suction  force 
which  causes  the  milk  to  flow.  Sucking  can  be  carried  on  only  when  the 
nose  is  free  for  respiration  and  the  palate  and  upper  jaw  intact.  Chil- 
dren with  deformities  of  the  mouth,  like  cleft  palate  and  harelip,  suck 
only  with  the  greatest  difficulty,  and  complete  nasal  obstruction  prevents 
nursing. 

The  Saliva. — This  is  present  at  birth  only  in  very  small  amount,  and 
the  part  which  it  plays  in  digestion  in  early  infancy  is  an  insignifi- 
cant one.  During  the  third  and  fourth  months  it  increases  markedly  in 
quantity,  and  at  this  time  it  possesses  quite  actively  the  power  of  trans- 
forming starch  into  sugar.  This  property  is  present  only  to  a  very  slight 
degree  during  the  early  weeks. 

The  Stomach. — The  position  of  the  stomach  in  the  foetus  is  nearly 
vertical.  In  the  newly-born  child  it  lies  somewhat  obliquely  in  the  abdo- 
men, and  at  the  end  of  infancy  has  almost  reached  the  transverse  posi- 
tion. The  stomach  at  birth  is  nearly  cylindrical,  but  the  fundus  increases 
in  size  rapidly  during  the  first  year,  although  it  does  not  reach  its  full 
development  until  quite  late  in  childhood.  In  Plate  VII  are  shown  the 
actual  size  and  shape  of  the  stomach  at  various  periods.  In  the  follow- 
ing table  are  given  the  results  of  post-mortem  measurements  of  the 
stomach,  which  I  have  personally  made  in  ninety-one  infants  under 
fourteen  months  of  age: 


PLATE    VII. 


DIGESTION   IN   INFANCY. 


309 


The  Capacity  of  the  Stomach. 


Number 

Average 

Number 

Average 

of  cases. 

capacity. 

of  cases. 

capacity. 

Birth 

5 

1.20  oz. 

12  weeks 

6 

4.50  OZ. 

2  weeks 

7 

1.50   " 

14  to  18  weeks  .  . 

12 

5.00   " 

4      "      

4 

2.00   " 

5  to  6  months  .  . 

14 

5.75   " 

6      "      

11 

2.27    " 

7  to  8        "       ... 

9 

6.88   " 

8      "      

4 

3.37   " 

10  to  11    "       ..  . 

7 

8.14   " 

10      "     

2 

4.25   " 

12  to  14   "       ... 

10 

8.90  " 

In  brief,  tlie  average  capacity  was,  at  l)irt]i,  one  and  one-fifth  ounces ; 
at  three  months,  four  and  a  half  ounces;  at  six  months,  six  ounces;  at 
twelve  months,  nine  ounces. 

Gastric  Digestion. — The  part  taken  by  the  stomach  in  digestion  is 
not  so  important  in  infants  as  in  adults.  The  function  of  the  stomach 
is  largely  that  of  a  reservoir,  into  which  the  milk  is  received  and  from 
which  it  is  allowed  to  pass  gradually  into  the  intestine;  the  gastric  pro- 
cess is  only  a  preliminary  and  partial  one,  even  in  the  digestion  of  pro- 
tein, this  being  completed  in  the  intestine. 

The  gastric  juice  acts  chiefly  upon  the  protein  of  the  food;  the 
digestive  agents  being  pepsin  and  hydrochloric  acid.  It  is  pretty  well 
established  that  protein  digestion  in  the  stomach  does  not  go  beyond  the 
stage  of  peptone  formation.  The  amount  of  gastric  Juice  secreted  is 
very  large.  In  experiments  upon  animals  it  has  been  found  to  be  nearly 
as  great  as  the  volume  of  milk  taken. 

Pepsin  is  found  in  the  stomach  at  birth,  and  even  in  the  foetus  as 
early  as  the  fourth  month.  In  fifteen  minutes  after  feeding  the  reaction 
of  the  stomach  contents  is  always  acid.  Free  hydrochloric  acid  can  not 
usually  be  demonstrated  until  about  an  hour  after  feeding,  then  only  in 
small  quantities,  and  in  very  many  cases  not  at  all.  The  reason  for  this 
is,  that  the  acid  combines  with  the  casein  and  the  salts  of  milk,  those  of 
cow's  milk  in  particular  having  a  great  power  of  combining  with  hydro- 
chloric acid. 

The  coagulation  of  milk  in  the  stomach  is  accomplished  through  the 
agency  of  the  rennet  ferment.  Many  good  authorities  consider  that  this 
is  not  a  separate  substance,  but  that  coagulation  is  one  of  the  properties 
of  pepsin.  Coagulation  is  the  first  change  which  the  milk  undergoes  in 
the  stomach.  Woman's  milk  coagulates  in  loose  flocculi  and  quite  im- 
perfectly. Cow's  milk,  unless  diluted,  coagulates  in  firmer,  rather  com- 
pact masses.  Under  the  influence  of  pepsin  and  hydrochloric  acid,  solu- 
tion of  this  coagulum  now  begins ;  but  this  is  only  partially  accomplished 
in  the  stomach.  It  goes  forward  much  more  rapidly  in  the  case  of  wom- 
an's milk,  because  the  amount  of  casein  is  less  and  because  of  the  smaller 
curds.  The  fluid  portion  of  the  milk  begins  to  leave  the  stomach  very 
soon  after  the  meal,  and  even  during  the  first  half  hour  a  considerable 


310  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

part  passes  into  the  intestine.  At  the  end  of  an  hour  the  stomach  in  a 
young  infant  is  often  empty.  If  the  food  is  cow's  milk,  not  only  are  the 
coagula  firmer,  but  the  amount  of  casein  present  is  much  larger,  and 
hence  the  milk  is  retained  in  the  stomach  a  considerably  longer  time; 
even  then  some  of  it  passes  but  little  changed  into  the  intestine.  The 
existence  of  a  fat-splitting  ferment  in  the  stomach  of  infants  is  now 
generally  admitted,  though  it  plays  but  a  small  role  in  digestion. 

The  duration  of  gastric  digestion  varies  with  the  age  of  the  infant 
and  with  the  food.  During  the  first  month  the  stomach  of  healthy 
nursing  infants  is  usually  found  empty  in  an  hour  and  a  half  after  feed- 
ing, often  in  one  hour.  In  tliose  taking  cow's  milk  the  average  is  at 
least  one  hour  longer.  In  infants  from  two  to  eight  months  old  the 
average  is  two  hours  for  those  receiving  breast-milk,  and  two  and  a  half 
to  three  hours  for  those  fed  upon  cow's  milk.  The  time  is  influenced  by 
the  size  of  the  meal  taken  and  by  the  composition  of  the  food.  The 
water  and  milk  sugar  first  pass  into  the  intestine,  then  the  protein  in 
various  stages  of  digestion,  and,  lastly,  the  fat.  The  higher  the  propor- 
tion of  fat  in  the  meal  the  longer  the  food  is  retained  in  the  stomach, 
and  also  the  smaller  the  amount  of  gastric  juice  secreted.  Very  little 
absorption  takes  place  from  the  stomach.  There  is  here  absorbed  a  cer- 
tain proportion  of  the  sugar  and  salts,  and  a  small  amount  of  the  nitrog- 
enous material,  but  practically  no  water  or  fat. 

The  bacteria  of  the  stomach  are  very  few  as  compared  with  those  of 
the  intestine,  and  no  varieties  are  constantly  present. 

The  Intestines. — The  length  of  the  small  intestine  at  birth  is  about 
nine  feet;  that  of  the  large  intestine  about  eighteen  inches.  The  great 
length  of  the  sigmoid  flexure  is  the  most  striking  peculiarity,  this  being 
nearly  one-half  the  length  of  the  large  intestine. 

Intestinal  Digestion. — All  the  important  elements  of  food — protein, 
carbohydrates,  and  fat — are  acted  upon  by  the  pancreatic  juice.  The 
protein  is  converted  into  peptones  by  trypsin.  How  much  of  the  protein 
of  the  milk  is  left  for  intestinal  digestion,  depends  upon  how  well  the 
stomach  has  done  its  part.  In  every  case  something  is  left;  in  most 
cases  a  large  part  of  the  protein  passes  but  little  changed  into  the  in- 
testine. The  digestion  of  protein  is  completed  by  the  erepsin  of  the 
intestinal  juice,  which  converts  peptones  and  albumoses  into  amino  acids. 
In  this  form  the  nitrogenous  portion  of  the  food  is  finally  absorbed. 

The  amylolytic  ferment  of  the  pancreas  has  the  power  of  converting 
starch  into  maltose.  This  action  is  feeble  during  the  first  five  or  six 
months,  but  is  present  even  in  early  infancy.  Milk  sugar  is  changed  into 
galactose  and  glucose;  and  cane  sugar  and  maltose  into  glucose  through 
the  agency  of  the  intestinal  and  pancreatic  juices.  Fats  are  partly  emul- 
sified and.  partly  saponified  by  the  pancreatic  juice  in  connection  with 
the  bile. 


DIGESTION    IN   INFANCY.  311 

Absorption. — From  the  small  intestine  absorption  takes  place  very 
rapidly.  The  protein  is  absorbed  in  the  form  of  peptids  and  amino  acids. 
Sugars  of  all  varieties  are  changed  to  glucose  during  absorption.  Fat  is 
absorbed  in  the  form  of  fatty  acids  and  soaps;  but  in  their  passage 
through  the  wall  of  the  intestine  the  fatty  acids  are  converted  into 
neutral  fats.  Absorption  from  the  large  intestine,  except  of  water,  is 
quite  imperfect.  Fat  absorption  is  very  sligiit.  Sugar,  salts,  and  pep- 
tones, however,  may  be  absorbed  with  moderate  facility. 

Intestinal  Bacteria. — For  the  fundamental  work  upon  this  subject  we 
are  indebted  to  the  researches  of  Escherich.  Bacteria  are  absent  from 
the  entire  gastro-enteric  tract  at  birth.  They  quickly  enter  by  the  mouth 
and  rectum,  and  by  the  end  of  twenty-four  hours  they  are  usually  found 
in  all  parts  of  the  intestinal  tract.  The  meconium-l)acteria  are  derived 
from  the  inspired  air,  and  hence  vary  somewhat  with  surroundings.  As 
soon  as  the  ingestion  of  milk  begins  these  varieties  are  displaced,  and 
throughout  the  period  in  which  the  infant  has  this  food  exclusively,  there 
have  been  found  in  healthy  conditions  but  few  varieties  which  are  con- 
stantly present.  These  are  the  h.  lactis  aerogenes,  the  b.  coli  communis, 
and  the  b.  bifidus.  The  number  of  bacteria  vary  in  different  parts  of  the 
intestine.  They  are  found  in  greatest  numbers  in  the  caecum  and  colon, 
and  are  relatively  few  in  the  small  intestine.  The  b.  lactis  aerogenes 
•  is  found  most  abundantly  in  the  upper  part  of  the  small  intestine,  in 
small  numbers  only  in  the  colon,  and  usually  there  are  none  in  the 
fseces. 

The  b.  coli  communis  is  found  in  but  small  numbers  in  the  upper 
small  intestine,  becoming  more  abundant  lower  down.  In  the  colon  and 
in  the  faeces  it  is  present  in  considerable  numbers.  The  most  abundant 
organism  in  the  large  intestine,  however,  is  the  b.  bifidus.  A  change 
from  a  milk  diet  to  a  mixed  diet  of  meat  and  farinaceous  food  produces 
a  marked  change  in  the  character  of  the  intestinal  bacteria. 

Fseces. — The  first  discharges  after  birth  are  called  meconium ;  this  is 
of  a  dark  brownish-green  colour,  semi-solid,  and  usually  passed  from 
four  to  six  times  daily  during  the  first  two  or  three  days.  On  the  third 
day  the  stools  begin  to  change  in  character,  and  by  the  fourth  or  fifth 
day  they  have  usually  assumed  the  appearance  of  healthy  milk-faeces. 
Under  many  abnormal  conditions  the  stools  may  continue  to  have  the 
character  of  meconium  for  a  week  or  mere.  Meconium  is  composed 
of  intestinal  mucus,  bile,  the  vernix  caseosa,  epithelial  cells  from  the 
epidermis,  hairs,  fat-globules,  and  cholesterin  crystals.  For  its  forma- 
tion there  are  necessary  the  secretions  of  the  intestine  and  the  liver  and 
the  swallowing  of  a  considerable  amount  of  amniotic  fluid. 

Milk-fceces. — The  normal  amount  of  faeces  discharged  daily  by  a 
healthy  nursing  infant  is  from  two  to  three  ounces.  Such  stools  have  the 
colour  of  the  yolk  of  egg.    They  are  smooth,  homogeneous,  of  a  soft,  but- 


312  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

ter-like  consistency,  with  an  acid  reaction,  and  a  slightly  acid  but  not 
unpleasant  odour.  The  reaction  is  due  to  the  presence  of  fatty  acids 
or  lactic  acid.  The  colour  depends  upon  bilirubin.  The  stools  of  an 
infant  fed  upon  cow's  milk  may,  in  conditions  of  perfect  digestion,  differ 
in  no  respect  from  those  just  described ;  usually,  however,  they  are  firmer, 
of  a  paler  yellow  colour,  and  may  be  neutral  or  even  alkaline  in  reaction. 
The  normal  stool  contains  about  85  per  cent  of  water  and  15  per  cent  of 
solids,  of  which  the  most  imjx)rtant  ingredient  is  fat. 

The  only  gases  present  are  hydrogen  and  carbon  dioxide.  Sulphur- 
etted hydrogen  and  marsh  gas,  to  which  the  odour  of  adult  stools  ia 
largely  due,  are  not  present. 

The  protein  of  both  woman's  and  cow's  milk  is  almost  entirely  ab- 
sorbed. The  nitrogenous  content  of  the  normal  stool  is  derived  chiefly 
from  the  intestinal  secretions  and  the  bodies  of  the  bacteria. 

Fat  is  always  present,  and  forms  from  ten  to  thirty  per  cent  of  the 
dry  residue  of  milk-faeces.  It  is  present  as  neutral  fat,  fatty  acids,  and 
soaps.  Sugar  is  not  found,  but  its  derivative,  lactic  acid,  may  be  present 
in  a  small  amount.  Inorganic  salts  form  about  ten  per  cent  of  the  dry 
residue.  They  are  chiefly  the  salts  of  calcium.  Of  the  biliary  elements 
there  are  h3'drobilirubin,  unchanged  bilirubin,  and  eholesterin  in  con- 
siderable amount.  The  presence  of  biliary  acids  is  doubtful.  Mucus  is 
always  present  in  considerable  quantity. 

Microscopically  there  are  seen  epithelial  cells,  chiefly  of  the  columnar 
variety,  a  few  round  cells,  mucous  corpuscles,  fat  globules  and  crystals  of 
fatty  acids,  eholesterin,  mucin,  crystalline  inorganic  salts,  sometimes 
bilirubin  in  crystals,  yeast  fungi,  and  bacteria  in  immense  numbers. 

If  the  infant  is  taking  a  food  containing  starch,  this  may  appear  to 
a  greater  or  less  extent  in  the  stools,  a  larger  amount  in  the  case  of  very 
young  infants. 

The  number  of  stools  during  the  first  two  weeks  is  from  three  to  six 
daily.  After  the  first  month  two  stools  a  day  are  the  average;  many 
infants  have  three,  many  others  but  one. 

As  soon  as  an  infant  is  put  upon  a  mixed  diet,  the  peculiar  charac- 
ters of  the  stools  disappear,  and  they  come  to  resemble  more  closely  those 
of  the  adult,  though  remaining  softer  throughout  infancy.  They  be- 
come darker  in  colour  and  assume  the  adult  odour,  while  retaining  their 
acid  reaction.  The  bacteria,  while  still  in  great  numbers,  are  more 
varied  than  are  met  with  in  milk-faeces. 


MALPOSITIONS  AND   MALFORMATIONS  OF  THE   STOMACH. 

The  stomach  is  sometimes  in  the  thoracic  cavity  in  cases  of  diaphrag- 
matic hernia.  It  may  be  found  in  a  vertical  (foetal)  position,  variously 
adherent  to  the  colon  and  small  intestine.    Malformations  are  much  less 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS.  313 

frequent  than  those  of  other  parts  of  the  alimentary  tract.  There  may 
be  atresia  or  stenosis  at  either  orifice,  and  very  rarely  a  constriction  is 
found  near  the  middle  of  the  organ,  dividing  it  into  compartments.  The 
symptoms  of  atresia  at  either  orifice  are  persistent  regurgitation  or 
vomiting,  and  death  in  a  few  days  from  inanition. 

HYPERTROPHIC   STENOSIS  OF  THE   PYLORUS. 

This  condition  known  also  as  pijlorospasin  and  as  congenital  steno- 
sis of  the  pylorus,  or  simply  as  pyloric  stenosis  of  infancy,  is  not  an 
uncommon  one.  It  is  met  with  in  early  infancy  and  is  characterised 
by  persistent  vomiting,  constipation,  wasting,  marked  visible  gastric 
peristalsis,  and  often  a  palpable  tumour.  It  is  a  serious  condition,  nearly 
one-half  of  the  cases  ending  fatally.  Little  is  known  of  its  etiology. 
Fully  four-fifths  of  the  cases  occur  in  males.  It  has  no  relation  to  the 
method  of  feeding;  a  large  proportion  of  the  recorded  cases  have  been 
in  nursing  infants.  The  variety  of  names  reflects  the  different  theories 
which  have  been  advanced  to  explain  its  occurrence.  By  some  the  con- 
dition is  considered  a  primary  hypertrophy  with  a  secondary  spasmodic 
element  added;  by  others,  as  a  purely  spasmodic  condition  from  gastric 
or  duodenal  irritation,  possibly  due  to  increased  acidity;  by  still  others 
the  spasmodic  condition  is  regarded  as  primary,  with  hypertrophy  devel- 
oping secondarily.  Pylorospasm  has  its  analogue  in  other  spasmodic 
conditions  of  the  circular  muscle  fibres  in  early  infancy.  As  examples 
may  be  mentioned :  constipation  due  to  a  spastic  condition  of  the  sphinc- 
ter ani,  intussusception  due  to  irregular  or  intermittent  muscular  spasm 
of  the  intestines,  and  various  spasmodic  affections  of  the  larynx  and 
bronchi. 

The  post-mortem  findings  are  remarkably  uniform.  The  pylorus 
appears  as  a  hard,  whitish  tumour  about  the  size  of  a  peanut,  of  almost 
cartilaginous  consistency.  Its  lumen  may  be  so  narrowed  as  barely  to 
admit  a  fine  probe,  while  the  normal  pylorus  will  usually  admit  a  No.  21 
sound,  French  scale.  Frequently  water  can  not  be  forced  through  the 
stenosis  owing  probably  to  the  fact  that  the  mucous  membrane  is  thrown 
into  folds.  The  walls  of  the  stomach  are  often  hypertrophied,  especially 
toward  the  pyloric  end.  The  stomach  is  usually  much  dilated ;  its  lower 
border  may  be  below  the  navel.  There  may  even  be  some  dilatation  of 
the  oesophagus.  On  section  the  thickening  of  the  pylorus  is  seen  to  be 
chiefly  of  the  circular  muscle  fibres.  This  coat  appears  to  be  two  or 
three  times  the  normal  thickness.  The  other  coats — submucous,  mucous 
and  longitudinal  muscular — are  thickened  but  to  a  much  less  degree. 

Symptoms. — The  general  clinical  picture  is  a  striking  one.  An  in- 
fant who  for  the  first  two  or  three  weeks  has  shown  no  signs  of  gastric 
disorder,  and  often  has  been  nursing  and  gaining  regularly  in  weight,  be- 


314  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

gins  to  vomit ;  at  first  occasionally,  but  soon  habitually.  The  change  from 
the  usual  type  of  vomiting  to  the  forcible  and  constant  vomiting  is  often 
abrupt  and  without  evident  cause.  The  vomiting  is  not  the  ordinary 
gastric  regurgitation  of  indigestion  but  is  forcible  and  projectile.  Changes 
in  diet  have  but  a  temporary  effect  upon  it,  or  none  at  all.  The  bowels 
are  constipated.  The  infant  wastes  steadily,  the  scales  often  showing 
a  loss  of  one  or  two  ounces  a  day.  There  is  no  fever  and  little  or  no 
evidence  of  pain.  There  is  progressive  failure  in  nutrition  and  death 
may  occur  from  exhaustion  in  from  four  to  six  weeks  from  the  beginning 
of  marked  symptoms. 

l^ime  of  Beginning  of  Symptoms. — Exceptionally  this  is  in  the  first 
week  or  even  in  the  first  days  of  life.  The  average  time,  however,  is 
after  the  first  week  and  during  the  first  month,  very  rarely  as  late  as 
the  sixth  or  seventh  week. 

Vomiting. — The  manner  of  vomiting  is  characteristic.  It  is  more 
forcible  than  that  seen  under  "any  other  condition.  I  have  often  seen 
an  infant  fairly  shoot  out  the  contents  of  the  stomacli  to  a  distance  of 
four  or  five  feet;  Food  frequently  comes  through  the  nose.  The  vomit- 
ing has  usually  a  relation  to  the  taking  of  food.  It  most  frequently 
comes  directly  after  the  meal,  often  while  the  child  is  still  at  the  breast. 
After  an  attack  of  vomiting,  nursing  is  sometimes  resumed  with  avidity, 
showing  a  distinct  absence  of  the  usual  symptoms  of  gastric  indigestion. 
All  the  food  is  generally  expelled  at  one  time.  The  frequent  regurgita- 
tion of  small  amounts  is  seldom  seen.  Generally  vomiting  does  not 
occur  at  night  unless  the  child  is  nursed  at  that  time.  The  vomited 
matters  at  first  consist  only  of  food,  often  but  little  changed.  After  a 
time  there  is  mucus,  sometimes  in  large  quantities.  The  amount  vomited 
at  one  time  is  often  considerably  greater  than  the  meal  just  taken, 
indicating  a  considerable  retention  of  food  in  the  stomach.  Some  of 
these  children  vomit  regularly  after  every  feeding;  others  retain  two 
or  three  feedings  and  then  expel  the  whole  amount.  The  frequency  of 
vomiting  varies  from  once  or  twice  to  six  or  eight  times  a  day.  Owing 
to  the  loss  of  fluid  by  vomiting  the  urine  is  usually  very  scanty.  There 
is  no  uniform  change  in  the  gastric  secretions,  but  there  is  frequently 
hyperacidity  present. 

Bowels. — Obstinate  constipation  is  the  rule.  If  the  pyloric  obstruc- 
tion is  complete  the  stools  resemble  meconium.  Exceptionally  diarrhcea 
is  present.  I  have  seen  it  in  but  a  single  case  and  here  the  obstruction 
was  not  complete. 

Wasting. — Progressive  wasting  is  one  of  the  striking  symptoms,  and  a 
close  observation  of  the  weight  one  of  our  best  guides  to  the  progress  of 
the  case.  If  the  loss  is  only  two  or  three  ounces  a  week  the  outlook  is 
hopeful ;  while  if  this  amounts  to  two  or  three  ounces  a  day  the  condition 
should  be  considered  most  critical.     The  rate  of  the  loss  depends  natur- 


HYPERTROPHIC  STENOSIS  OF  THE   PYLORUS.  315 

ally  upon  the  completeness  of  the  obstruction  and  it  is  proportionate  to 
the  amount  of  vomiting  and  the  degree  of  constipation. 

General  Appearance. — At  first  nothing  abnormal  is  seen,  but  soon 
all  the  evidences  of  rapid  malnutrition  are  present,  without,  however,  the 
other  usual  symptoms  of  indigestion,  such  as  might  be  expected  with  the 
vomiting.  The  tongue  is  usually  clean;  the  appetite  often  voracious; 
there  are  no  eructations  of  gas;  the  breath  is  sweet. 

Peristalsis. — On  examination  of  the  abdomen  the  epigastrium  is 
usually  full  and  the  lower  half  of  the  abdomen  sunken.     If  the  skin  is 


Fig.  49. — Gastric  Peristalsis  in  Pyloric  Stenosis.     (Thomson). 
Patient  eight  weeks  old. 

bared  and  the  patient  placed  in  a  good  light  the  characteristic  peristaltic 
waves  are  seen  which  are  the  most  diagnostic  feature  of  the  disease. 
One  should  not  expect  to  see  them  if  the  stomach  is  empty;  they  are 
best  seen  immediately  after  taking  food  or  water.  When  not  appearing 
spontaneously  they  may  often  be  excited  by  slight  friction  or  tapping  of 
the  epigastrium.  There  is  seen  a  slowly  moving  wave  from  left  to  right. 
First  a  ball-like  tumour  appears  just  below  the  ribs  on  the  left  side  (see 
Fig.  49).  It  is  usually  about  one  and  a  half  to  two  inches  in  diameter 
and  slowly  moves  toward  the  right  and  slightly  upward.  It  disappears 
just  beyond  the  median  line.  It  is  repeated  every  minute  or  two.  Some- 
times one  wave  is  quickly  followed  by  another.  These  gastric  contrac- 
tions can  hardly  be  mistaken  for  anything  else.  They  may  be  accom- 
panied by  slight  evidences  of  pain. 

Tumour. — The  hardened  pylorus  can  with  careful  attention  to  details 
be  felt  in  most  cases.  It  may  be  obscured  by  distention  of  the  stomach 
or  the  colon  or  by  enlargement  of  the  liver.  The  pylorus  may  be  dis- 
placed. The  position  of  the  tumour  is  therefore  of  less  importance  in 
diagnosis  than  its  character.  It  is  usually  felt  about  one  and  a  half 
to  two  inches  below  the  free  border  of  the  ribs,  just  inside  of  the  right 


316  DISEASES  OF  THE  DIGESTI^^  SYSTEM. 

mammary  line.  It  is  felt  only  during  contraction  of  the  stomach,  i.  e., 
best  during  active  peristalsis.  It  appears  somewhat  smaller  than  the 
little  finger  and  about  three-fourths  of  an  incli  long,  somewhat  like  a 
small  spool. 

Course  of  the  Disease. — Two  types  of  cases  are  seen:  (1)  the  acute, 
the  usual  type  which,  unless  relieved  by  medical  or  surgical  treatment, 
generally  proves  fatal  in  one  or  two  months;  less  frequently,  and  when 
the  symptoms  are  of  a  milder  type,  after  persisting  for  several  weeks  or 
months,  the  vomiting  gradually  subsides  and  the  patient  recovers;  (2) 
the  subacute  or  chronic  form,  which  is  very  rare,  but  which  may  give 
symptoms  at  irregular  intervals  during  infancy  and  early  childhood. 
The  acute  cases  differ  much  in  severity  but  little  in  other  respects.  The 
chronic  cases  may  show  periods  of  exacerbation  for  years.  These  exacer- 
bations are  sometimes  apparently  excited  by  attacks  of  indigestion.  In 
this  type  correct  diagnosis  is  seldom  made  unless  operation  is  done  or 
the  case  comes  to  autopsy. 

Diagnosis. — The  diagnosis  of  pyloric  stenosis  of  infancy  is  usually 
easy  after  two  or  three  days  of  observation,  but  may  be  impossible  at  the 
first  examination,  owing  to  the  difficulty  of  obtaining  the  most  distinctive 
signs — the  peristaltic  waves  and  the  tumour.  The  time  of  onset  and 
nature  of  the  vomiting  are  very  suggestive,  but  not  quite  conclusive.  It 
has  been  mistaken  for  cerebral  disease  on  account  of  the  projectile  vomit- 
ing and  obstinate  constipation.  In  the  rare  cases  seen  in  older  children 
it  might  be  confounded  with  cyclic  vomiting.  However,  the  query  arises 
whether  some  of  the  cases  diagnosticated  cyclic  vomiting  may  not  be  of 
this  kind.  I  have  myself  seen  one  such.  Usually,  however,  the  only 
difficulty  is  to  distinguish  between  the  vomiting  of  gastric  indigestion 
and  that  of  pyloric  stenosis.  The  occurrence  of  vomiting  in  nursing 
infants  wlio  have  previously  thriven  on  the  same  food,  the  abruptness  of 
the  development  of  the  vomiting  without  assignable  cause,  and  its  per- 
sistence in  spite  of  all  treatment,  should  set  one  right.  Cases  in  which 
there  is  atresia  of  the  duodenum  or  other  part  of  the  small  intestine 
may  be  mistaken  for  pyloric  stenosis  in  which  the  symptoms  begin 
soon  after  birth.  However,  in  atresia  all  the  symptoms  are  altogether 
more  severe  and  the  condition  is  usually  fatal  in  a  few  days.  I  have  seen 
one  case  of  partial  obstruction  of  the  duodenum  due  to  pressure  by  a 
band  in  which  persistent  and  projectile  vomiting  and  gastric  peristalsis 
were  present.  The  vomited  matters,  however,  were  green  from  the  pres- 
ence of  bile.     This  does  not  occur  in  pyloric  stenosis. 

Prognosis. — The  condition  is  always  serious,  and  even  with  the  most 
approved  methods  of  treatment  the  mortality  is  large.  I  believe  that 
fully  fifty  per  cent  of  the  cases  prove  fatal.  Much,  of  course,  depends 
upon  early  diagnosis  and  proper  treatment.  Sbme  writers  who  include 
in  the  group  of  pyloric  stenosis  many  cases  regarded  by  them  as  milder 


HYPERTROPHIC   STENOSIS  OF  THE   PYLORUS.  317 

types  of  the  disease,  give,  of  course,  a  much  lower  mortality.  The 
tighter  the  obstruction — as  indicated  l)y  persistence  of  vomiting  in  spite 
of  stomach  washing,  stools  of  a  meconium  character,  and  rapid  wasting — 
the  worse  the  prognosis. 

Treatment. — Some  surgeons  argue  tliat,  given  a  correct  diagnosis,  the 
only  rational  treatment  is  operation,  all  other  measures  being  only  a 
waste  of  time  and  lessening  the  chances  of  surgical  success  because  of 
the  weakened  condition  of  the  patient.  On  the  other  hand,  so  high  is 
the  mortality  after  surgical  operation  and  so  great  are  the  difficulties  of 
after-treatment,  even  when  the  immediate  result  of  the  operation  is 
favourable,  and  so  many  are  the  undoubted  cases  which  have  recovered 
without  operation,  that  most  physicians  favour  a  faithful  and  patient 
trial  of  other  measures  before  referring  the  case  to  the  surgeon,  and 
recommend  operation  only  as  a  last  resort.  One's  view  of  treatment  will 
naturally  be  modified  according  to  the  etiological  factor  he  holds  to  be 
most  important.  If  the  obstruction  is  chiefly  from  tonic  spasm,  there  is 
no  reason  why  this  may  not  relax  and  complete  recovery  take  place.  If 
the  obstruction  is  chiefly  due  to  congenital  hypertrophy  with  only  a  mod- 
erate amount  of  spasm,  and  this  secondary,  little  that  is  permanent  is 
to  be  expected  by  medical  means  alone.  It  is  my  own  belief  that  both 
of  these  types  of  cases  are  seen:  the  one  in  which  the  obstruction  is 
nearly  all  due  to  spasm,  and  the  other  in  which  the  hypertrophy  is  the 
more  important  factor.  It  is  certain  that  many  cases  have  recovered 
completely  and  permanently  without  surgical  aid.  A  considerable  num- 
ber have  come  under  my  own  observation.  We  should,  therefore,  I 
think,  approach  these  cases  with  the  knowledge  that  the  condition  is 
a  serious  one,  that  the  chances  of  the  patient's  recovery  are  only  about 
even  under  any  method  of  treatment,  that  there  is  a  fair  prospect  of  cure 
by  medical  measures  alone,  but,  finally,  that  some  cases  can  be  saved  only 
by  operation. 

Medical  Treatment. — This  consists  in  diet  and  stomach  washing.  If 
a  child  is  nursing  and  the  milk  is  normal,  weaning  is  not  generally  ad- 
visable. Small  meals,  not  too  near  together,  are  essential.  The  breast 
should  be  given  at  three-hour  intervals,  and  the  nursing  period  varied 
from  three  to  eight  minutes,  according  to  the  amount  obtained.  It  is 
often  advantageous  to  pump  the  breasts  and  give  a  definitely  measured 
amount  of  breast-milk.  Usually  for  a  child  a  month  old  not  more  than 
two  ounces  should  be  allowed  at  one  feeding.  On  no  account  should  an 
infant  be  weaned  immediately  because  of  the  development  of  the  symp- 
toms of  pyloric  stenosis.  For  some  infants  who  have  been  artificially 
fed  nothing  succeeds  as  well  as  a  wet-nurse.  The  chief  objection  to  tlie 
breast-milk  is  its  high  fat  which  sometimes  increases  the  vomiting. 

For  infants  who  are  artificially  fed  a  few  general  principles  are 
pretty  well  established.     In  all  milk  formulas  the  fat  should  be  low. 


318  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

usually  less  than  that  in  whole  milk.  The  formulas  from  .skimmed  milk 
have  usually,  in  my  experience,  succeeded  best.  The  addition  of  fat 
in  the  form  of  olive  oil  can  often  be  made  when  the  fat  of  milk  is  not 
tolerated.  Other  things  besides  milk  which  are  sometimes  useful  are, 
egg  albumin  and  beef  juice.  Feeding  should  be  regular  and  not  oftener 
than  every  three  hours,  and  the  amount  at  one  time  from  one  and  a  half 
to  three  ounces. 

No  one  thing  is  better  attested  than  the  beneficial  effects  of  stomach 
washing.  It  empties  the  organ  of  food  and  mucus,  and  it  certainly  aids 
in  allaying  spasm.  I  prefer  the  use  of  water  at  108°  to  110°  F.,  ren- 
dered alkaline  by  the  addition  of  one  per  cent  of  bicarbonate  of  soda. 
It  is  desirable  to  see  how  much  food  there  has  been  retained  in  the 
stomach;  a  measured  amount  of  water  should  therefore  be  introduced 
and  then  removed.  The  washing  should  be  done  about  two  and  a  half 
hours  after  feeding,  and  repeated  twice  in  twenty-four  hours.  It  should 
be  continued  for  a  considerable  period.  In  cases  which  recover  it  has 
often  been  found  necessary  for  six  to  eight  weeks  twice  daily,  and  for 
three  or  four  months  once  daily.  Hot  applications  over  the  epigastrium 
may  possibly  aid  in  relaxing  spasm,  but  are  of  much  less  value  than 
stomach  washing.  The  administration  of  drugs,  especially  preparations 
of  opium  and  belladonna,  for  the  same  purpose,  is  advocated  by  many, 
but  in  my  experience  they  have  been  entirely  without  value.  The  usual 
effect  of  stomach  washing  and  changes  in  diet  are  a  cessation  of,  or  at 
least  a  great  diminution  in,  the  vomiting.  But  it  should  not  be  discon- 
tinued because  of  this  improvement.  The  loss  of  weight  is  less  rapid, 
then  ceases,  and  afterward  a  slow  gain  occurs;  but  the  condition  of  the 
patient  continues  critical  for  some  months. 

Indications  for  Operative  Interference-. — In  other  cases  no  improve- 
ment whatever  results  from  medical  treatment;  the  vomiting  is  as 
frequent  and  as  severe  as  ever;  the  daily  loss  in  weight  may  be  as 
much  as  two  ounces;  and  the  stools  indicate  that  nothing  passes  the 
pylorus.  If  such  conditions  have  been  observed  to  exist  for  several  days, 
to  postpone  surgical  interference  is  useless.  The  surgical  aspects  of 
these  cases  are  fully  treated  in  works  on  surgery.  The  operations  chiefly 
done  are  gastro-enterostomy  and  divulsion  (Loreta's  operation).  Each 
has  its  advocates.  The  weight  of  opinion  seems  now  in  favour  of  the 
former  operation.  The  immediate  dangers  are  considerable.  Shock  is 
generally  marked  in  these  little  patients,  but  in  my  own  experience  less 
than  was  expected.  Some  of  these  wasted  infants  of  sevCn  or  eight 
pounds  have  gone  through  an  operation  which  consumed  thirty-five  min- 
utes in  a  manner  most  surprising.  Haemorrhages  and  peritonitis  are 
also  risks  to  be  reckoned  with.  The  after-treatment  is  most  important, 
and  even  after  a  successful  operation  the  dangers  are  by  no  means  passed, 
the  child's  life  often  hangs  by  a  thread  for  two  weeks  or  more.    Exhaus- 


VOMITING.  319 

tion  from  shock  and  feeble  assimilation,  inanition  from  a  continuance 
of  the  vomiting  or  the  development  of  diarrhoea,  both  common  symp- 
toms, may  carry  off  the  patient.  The  post-operative  treatment  should 
be  in  the  hands  of  the  physician  rather  than  the  surgeon.  To  supply  fluid 
immediately  after  operation,  nothing  is  better  than  the  continuous  intro- 
duction of  water  into  the  bowel  by  the  "  Murphy,"  or  "  drop  method." 
After  operation  vomiting  may  sometimes  be  allayed  by  placing  the  child 
in  a  semi-erect  position.  Feeding  should  be  begun  after  twenty-four 
hours  with  breast-milk  if  possible,  at  first  in  teaspoonful  doses,  the 
amount  being  gradually  increased  according  to  the  child's  symptoms. 
The  nutrition  for  the  first  weeks  is  nearly  always  a  matter  of  much  diffi- 
culty and  taxes  the  resources  of  the  physician  to  the  utmost.  If  breast- 
milk  can  not  be  obtained,  cow's  milk  should  be  given,  modified  accord- 
ing to  the  child's  symptoms,  preferably  with  a  rather  low  fat  percentage. 
To  keep  the  child  perfectly  quiet  after  feeding  is  very  necessary  for  a 
long  time.  Eelapses  occur  in  a  very  small  proportion  of  the  cases  treated 
by  forcible  stretching,  and  I  have  seen  a  relapse  in  a  case  treated  by 
stomach  Avashing  and  diet,  but  it  is  not  a  cojnmon  occurrence. 

VOMITING. 

Vomiting  is  one  of  the  most  frequent  symptoms  of  disease  in  in- 
fants and  young  children,  and  occurs  from  a  wide  variety  of  causes. 
The  physician  must  have  in  mind  both  its  common  and  its  uncommon 
causes.  Vomiting  takes  place  with  great  facility  in  young  infants  even 
from  slight  causes,  owing  to  the  position  and  shape  of  the  stomach. 

1.  Vomiting  from  Overfilling  of  the  Stomach. — This  is  often  seen  in 
nursing  infants,  and  there  may  be  no  other  symptom  of  disease.  It 
comes  within  a  few  minutes  after  nursing,  is  easy  and  without  effort, 
and  the  food  is  but  little  changed.  It  may  be  excited  by  moving  the 
child  or  making  undue  pressure  upon  the  stomach.  It  often  comes  with 
eructations  of  gas  or  air  which  has  been  swallowed. 

Vomiting  from  overdistention  may  be  regarded  as  a  safety-valve, 
and  requires  no  treatment  except  to  diminish  the  quantity  of  food. 

2.  Vomiting  is  almost  invariably  present  in  cases  of  acute  gastric  in- 
digestion and  acute  gastritis.  With  the  former  it  does  not  usually  come 
immediately  after  feeding,  and  it  may  be  delayed  for  several  hours; 
with  the  latter  it  is  usually  persistent.  The  vomited  matter  consists  of 
the  contents  of  the  stomach,  but  often  mucus,  and,  in  severe  cases,  bile 
and  traces  of  blood  may  be  vomited  for  some  time  afterward. 

3.  In  the  hypertrophic  stenosis  of  the  pylorus  of  early  infancy,  un- 
controllable vomiting  without  fever  is  the  principal  symptom.  (See 
previous  Chapter.) 

4.  In  acute  intestinal  obstruction  vomiting  is  rarely  absent,  and  in 


320  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

most  cases  it  is  persistent.  In  the  newly  born,  persistent  vomiting  is 
almost  invariably  dependent  upon  congenital  obstruction  of  the  intes- 
tine, which  is  most  frequently  in  the  duodenum.  In  malformations  of 
the  colon  and  rectum  it  is  less  constant  and  appears  later.  In  intussus- 
ception, vomiting  is  forcible,  immediately  excited  by  the  taking  of  food, 
and  is  at  first  bilious,  but  later  may  become  faecal. 

5.  Vomiting  is  a  frequent  and  almost  a  constant  symptom  of  acute 
peritonitis,  whether  localised  or  general,  of  which  appendicitis  is  the 
usual  cause.  It  is  then  associated  with  abdominal  distention,  tenderness, 
and  fever. 

6.  In  certain  nervous  diseases,  especially  tumour  of  the  brain  and 
acute  meningitis,  whether  cerebro-spinal  or  tuberculous,  vomiting  is  very 
common.  Cerebral  vomiting  is  usually  forcible  or  projectile.  It  may 
have  no  relation  to  meals.  Headache,  dulness,  slight  fever,  constipation, 
and  irregular  pulse  and  respiration  are  usually  present  sooner  or  later. 

7.  In  infants,  and  less  frequently  in  older  children,  vomiting  is  one 
of  the  most  frequent  symptoms  to  mark  the  onset  of  acute  febrile  dis- 
eases, especially  the  beginning  of  scarlet  fever,  pneumonia,  and  malaria. 

8.  An  accumulation  in  the  blood  of  various  toxic  materials  may  pro- 
voke vomiting;  the  best  known  example  is  uraemia.  In  cyclic  vomit- 
ing it  is'  quite  probable  that  the  cause  is  the  accumulation  of  some  toxic 
substance  in  the  blood.  The  absorption  of  poisons  taken  in  v/ith  milk 
or  other  food,  or  developing  in  the  gastro-enteric  tract,  may  excite  vom- 
iting. In  some  of  these  conditions  it  is  possible  that  the  vomiting  may 
be  eliminative.  The  cases  dependent  upon  renal  disease  are  discovered 
by  examination  of  the  urine.  The  other  forms  are  often  exceedingly 
obscure,  and  recognised  only  by  the  exclusion  of  all  other  causes  of 
vomiting. 

9.  Vomiting  may  be  reflex  from  irritation  in  the  pharynx.  This  is 
frequent  in  young  infants,  who  may  induce  vomiting  by  stuffing  the 
fingers  into  the  mouth.  In  certain  cases  the  irritation  from  worms  in 
the  intestinal  tract  may  cause  vomiting,  and  it  is  possible  that  even  den- 
tition may  produce  it. 

10.  Habit  is  a  frequent  cause,  in  cases  of  chronic  vomiting.  I  have 
seen  many  children  who  had  the  power  of  vomiting  at  will  anything  in 
the  nature  of  food  which  they  did  not  like,  yet  who  would  retain  other 
food  with  no  difficulty.  One  such  child  would  tolerate  large  doses  of 
quinine,  to  which  he  had  no  aversion,  without  the  slightest  disturbance. 
In  young  infants  a  habit  of  regurgitating  the  food  may  be  acquired, 
so  that  this  takes  place  more  or  less  during  the  process  of  digestion  after 
every  meal.  This  is  sometimes  preceded  by  a  movement  of  the  mouth 
and  fauces  resembling  swallowing,  until  finally  the  milk  appears  in  the 
mouth.  Habit  is  a  potent  cause  in  continuing  vomiting  where  it  has 
occurred  frequently.     In  children  who  have  this  habit  the  most  trivial 


CYCLIC  VOMITING.  321 

cause  will  provoke  it.  It  may  be  present  without  any  other  sign  of  gas- 
tric disease,  and  appears  simply  to  depend  upon  exaggerated  reflex 
irritability  of  the  organ.  I  have  seen  a  number  of  children  who  up  to 
the  third  or  fourth  year  objected  so  strenuously  to  taking  solid  food 
that  they  would  immediately  vomit  it,  no  matter  of  what  variety  or  in 
how  small  a  quantity,  although  fluids  were  taken  and  easily  digested. 

11.  Chronic  vomiting  may  depend  upon  habit,  as  just  described,  or 
upon  chronic  indigestion;  or  it  may  be  associated  with  chronic  pulmo- 
nary disease — vomiting  here  being  excited  by  the  attacks  of  cough,  at 
first  only  when  the  paroxysms  are  severe,  and  later  even  when  they  are 
slight. 

The  diagnosis  of  a  case  in  which  vomiting  is  the  chief  symptom 
may  be  difficult.  The  first  important  distinction  to  be  made  is  be- 
tween cases  in  which  the  vomiting  is  of  gastric  origin,  and  those  in 
which  it  depends  upon  other  -causes.  It  is  only  by  a  careful  consideration 
of  the  associated  symptoms  that  an  accurate  diagnosis  can  be  reached. 

The  treatment  of  vomiting  is  the  treatment  of  the  cause  upon  which 
it  depends. 

CYCLIC  VOMITING. 

This  is  quite  a  frequent  condition;  it  has,  however,  attracted  but 
little  attention  except  in  this  country.  Although  the  clinical  picture 
is  a  very  clear  and  definite  one,  its  exact  pathology  is  undetermined. 
It  has  also  been  described  under  the  names  periodical  vomiting  and 
recurrent  vomiting.  It  is  characterised  by  periodical  attacks  of  vomit- 
ing, which  recur  at  regular  or  irregular  intervals  of  weeks  or  months, 
apparently  without  any  adequate  exciting  cause.  The  usual  duration 
of  the  attacks  is  two  or  three  days,  during  which  all  attempts  to  control 
the  vomiting  are  usually  without  avail,  but  at  the  end  of  this  time  it 
generally  ceases  spontaneously. 

Etiology. — The  first  attacks  are  usually  seen  between  the  ages  of 
two  and  four  years,  but  they  may  date  back  to  infancy.  The  two  sexes 
seem  to  be  almost  equally  liable.  A  few  of  the  patients  are  strong  chil- 
dren, but  the  great  majority  are  rather  delicate  and  of  a  highly  nervous 
temperament.  The  cases  are  seen  chiefly  in  private  practice,  often  oc- 
curring among  those  who  have  the  best  surroundings.  In  most  cases  the 
antecedents  of  patients  are  of  a  neurotic  type.  The  attacks  are  not 
usually  traceable  to  distinct  or  flagrant  errors  in  diet,  and  yet  the  habit- 
ual diet  seems  to  bear  some  relation  to  the  disease.  The  exciting  cause 
is  often  a  nervous  one — great  fatigue  or  unusual  excitement,  sometimes 
a  railroad  journey  or  a  child's  party;  in  many  instances  it  seems  to  be 
induced  by  some  minor  illness  having  no  relation  to  the  digestive  tract, 
such  as  an  attack  of  tonsillitis  or  bronchitis.  In  children  subject  to  this 
condition  serious  diseases,  such  as  scarlet  fever  or  measles,  may  be  ushered 
22 


322  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

in  by  prolonged  and  repeated  vomiting,  which  usually  ceases  before  the 
end  of  the  febrile  period.  General  anaesthesia,  especially  by  ether,  is  very 
likely  to  precipitate  an  attack. 

Symptoms. — The  clinical  picture  presented  by  these  cases  is  very 
characteristic,  and  is  well  illustrated  by  the  history  of  the  following 
case: 

The  patient  was  a  well-nourished  boy  of  six  years  when  he  first  came 
under  treatment.  He  belonged  to  a  neurotic  family,  and  the  attacks 
dated  back  to  infancy.  From  this  time  they  had  recurred  usually  at  in- 
tervals of  a  few  months ;  occasionally  five  or  six  months  would  pass  with- 
out one.  The  symptoms  in  all  the  attacks  were  similar  in  kind,  differ- 
ing only  in  degree.  They  were  preceded  by  a  prodromal  period  lasting 
from  twelve  to  twenty-four  hours,  marked  by  languor,  dulness,  dark 
rings  under  the  eyes,  loss  of  appetite,  and  a  general  sense  of  discomfort 
in  the  epigastrium.  At  this  time  the  temperature  was  generally  slightly 
elevated.  The  vomiting  then  began  suddenly.  It  was  attended  with 
great  retching  and  distress;  it  was  often  repeated  every  half-hour  or 
hour  for  two  days.  On  one  occasion  it  occurred  seventeen  times  in  a 
single  night.  Vomiting  was  immediately  excited  by  the  taking  of  any 
food  or  drink,  but  it  occurred  when  nothing  was  taken.  The  vomited 
matters  consisted  of  frothy  mucus  and  serum,  frequently  streaked  with 
blood,  apparently  from  the  violence  of  the  emesis,  and  often  containing 
bile.  The  temperature  usually  fell  to  about  100°  F.  when  the  vomiting 
began,  and  continued  at  or  below  this  point  throughout  the  attack.  By 
the  end  of  the  second  day  the  exhaustion  was  very  marked — so  severe,  in 
fact,  as  apparently  to  threaten  life. 

The  child  lay  in  a  semi-stupor,  with  eyes  half  open,  lips  and  tongue 
dry,  rousing  at  times  to  beg  for  water.  The  pulse  was  rapid  and  weak, 
and  sometimes  slightly  irregular.  There  was  no  distention  of  the  abdo- 
men; it  was  usually  flattened.  By  the  third  day  the  vomiting  became 
less  frequent  and  then  ceased  entirely.  Convalescence  was  rapid,  and 
by  the  end  of  the  week  the  boy  was  almost  as  well  as  usual.  The  attacks 
continued  to  recur  at  gradually  lengthening  intervals  until  they  finally 
ceased  altogether  at  about  the  twelfth  year. 

A  great  number  of  these  cases  have  come  under  my  observation,  and 
in  many  patients  I  have  had  an  opportunity  to  witness  several  attacks. 
The  usual  duration  is  one  to  three  days.  In  one  child  they  lasted  regu- 
larly for  five  days.  Occasionally  a  severe  attack  will  last  a  week.  The 
average  number  of  attacks  is  three  or  four  a  year. 

Prodromal  symptoms  are  present  in  most  of  them — headache,  gen- 
eral languor,  coated  tongue,  and  anorexia  are  the  most  frequent;  in 
some  there  is  marked  constipation,  with  a  history  of  very  white  stools 
for  some  time.  But  it  is  not  uncommon  for  an  attack  to  occur  in  the 
midst  of  apparently  perfect  health.    The  tongue  is  usually  coated  at  the 


CYCLIC  VOMITING.  323 

beginning  of  an  attack,  and  at  its  height  it  is  often  dry  and  brown.  The 
abdomen  seems  empty  and  its  walls  sunken;  pain  and  tenderness  are 
both  rare.  The  bowels  are  usually  constipated  and  move  only  with  diffi- 
culty by  artificial  means.  Very  exceptionally  there  may  be  diarrhoea 
with  foul  stools. 

There  is,  as  a  rule,  no  desire  for  food,  but  the  continual  cry  is 
for  water  to  quench  the  constant,  burning  thirst.  The  pulse  after  the 
second  day  becomes  rapid,  soft,  and  often  somewhat  irregular.  The 
respiration  is  shallow,  and  at  times  this  also  may  be  irregular.  The 
temperature  is  usually  under  100.5°  F.,  rarely  it  may  be  102°  or  103°  F. 
The  usual  low  temperature  is  a  point  of  much  diagnostic  value.  The 
patients  are  dull,  apathetic,  and  usually  wish  to  be  left  alone.  Head- 
ache is  very  common. 

The  disposition  to  vomit  is  sometimes  so  great  that  patients  are 
afraid  to  move  or  even  to  talk  lest  it  may  be  provoked.  The  vomited 
matter  is  often  large  in  amount,  considering  that  the  patient  is  fasting. 
It  is  essentially  gastric  juice,  containing  free  HCl,  mucus,  serum,  many 
epithelial  cells,  and  often  traces  of  blood.  Less  frequently  vomiting  may 
occur  only  two  or  three  times  a  day.  The  urine  is  concentrated,  and 
frequently  contains  at  the  height  of  the  attack  a  trace  of  albumin,  a  few 
hyaline  casts,  and  some  blood  cells.  An  increase  in  the  renal  secretion 
may  be  the  first  sign  of  improvement.  There  is  usually  an  excess  of 
indican  both  during  and  between  attacks.  A  condition  practically  con- 
stant, and  first  pointed  out  by  Edsall,  is  the  presence  in  the  urine  of 
acetone,  diacetic  and  oxybutyric  acids.  These  substances  appear  in  the 
urine  so  early  in  the  attack  that  they  can  not  be  ascribed  to  starvation, 
and'  are  therefore  of  much  diagnostic  value. 

The  Nature  of  the  Attacks. — These  cases  have  little  in  common  with 
the  ordinary  attacks  of  indigestion.  With  our  present  knowledge  they 
are  to  be  regarded  as  explosions  due  to  faulty  metabolism,  and  there 
are  many  reasons  for  the  opinion  that  the  vomiting  is  an  effort  at 
elimination.  It  is  probable  that  not  all  the  cases  depend  upon  the 
same  condition. 

Prognosis. — Although  these  patients  very  often  seem  to  be  most 
alarmingly  ill,  the  danger  to  life  is  slight.  I  have  seen  but  one  fatal 
ease,  and  in  this  the  diagnosis  is  open  to  question,  as  no  autopsy  could 
be  obtained.  Griffith  reports  two  fatal  cases,  the  autopsy  in  one  showing 
nothing  characteristic.  The  probabilities  are  always  in  favour  of  a  recur- 
rence of  the  attacks.  In  most  of  the  patients  who  have  been  observed 
they  have  extended  over  a  series  of  several  years,  although  by  a  careful 
regime  much  may  be  done  to  reduce  their  frequency  and  diminish  their 
severity.  In  a  small  proportion  of  cases  they  may  be  stopped  altogether. 
Toward  puberty  there  appears  to  be  a  strong  tendency  to  spontaneous 
recovery. 


324  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

Diagnosis. — Organic  disease  of  the  brain  and  kidneys  must  first  be 
excluded.  The  first  attacks  witnessed  may  strongly  suggest  the  onset  of 
tuberculous  meningitis;  and  only  the  course  of  the  symptoms  may  show 
that  this  is  not  present.  Usually  a  history  of  many  previous  attacks 
may  be  obtained.  From  acute  indigestion,  cyclic  vomiting  is  differen- 
tiated by  the  fact  that  the  attacks  are  not  brought  on  by  indigestible 
food,  and  also  by  the  persistence  of  the  vomiting,  and  the  early  presence 
in  the  urine  of  the  acetone  bodies.  It  is  distinguished  from  gastritis  by 
its  severity,  the  shorter  duration  of  its  symptoms,  and  its  self-limited 
course. 

Appendicitis  is  excluded  by  the  absence  of  pain,  tenderness,  and  mus- 
cular rigidity;  intussusception  by  the  fact  that  the  symptoms  are  less 
severe,  by  the  absence  of  blood  and  mucus  from  the  stools,  and  by  the 
fact  that  intussusception  is  usually  seen  in  infancy. 

Treatment. — When  the  premonitory  symptoms  appear,  starvation 
and  free  purgation  offer  the  best  prospect  of  aborting  an  attack.  If 
the  vomiting  has  once  begun,  nothing  seems  to  have  the  slightest  influ- 
ence in  controlling  it.  It  is  usually  increased  by  the  taking  of  food  or 
drink  or  by  any  medication  by  the  mouth,  and  all  should  be  withheld. 
The  patient  should  be  kept  absolutely  quiet  and  water  given,  per  rectum, 
at  regular  intervals,  usually  six  to  eight  ounces,  four  or  five  times  a  day. 
This  keeps  up  the  urinary  secretion,  allays  thirst  and  often  restlessness, 
and  when  it  is  retained  usually  adds  much  to  the  patient's  comfort. 
When  the  vomiting  has  ceased  for  several  hours  it  is  not  likely  to  recur 
if  food  is  very  judiciously  administered,  at  first  in  small  quantities. 
Broth,  barley  water,  kumyss,  or  small  quantities  of  iced  milk  and  lime- 
water  in  equal  proportions  may  then  be  given. 

The  alkaline  treatment  has  been  strongly  advocated;  it  consists 
in  giving  between  the  attacks  bicarbonate  of  soda  in  doses  of  fifteen 
to  thirty  grains  three  times  daily,  and,  when  the  prodromal  signs  of 
an  attack  appear,  to  administer  very  large  doses,  as  much  as  thirty 
grains  every  hour.  I  have  used  this  plan  of  treatment  with  some  appar- 
ent success  and  think  it  deserves  a  trial.  In  the  interval  the  treatment 
should  be  chiefly  dietetic.  All  sugar  and  sweets  should  be  carefully  ex- 
cluded. The  diet  should  consist  principally  of  meat,  green  vegetables, 
milk,  cereals  in  moderate  amount,  and  stale  bread.  In  addition  to  care- 
ful regulation  of  the  diet  the  general  nutrition  should  be  considered, 
and  the  patient's  life  so  regulated  that  extreme  fatigue  and  exhaustion 
are  prevented.  In  most  cases  close  attention  to  these  matters  has  re- 
sulted in  a  very  great  diminution  in  the  frequency  of  the  attacks. 

GASTRALGIA. 

This  term  is  applied  to  sudden,  severe  attacks  of  abdominal  pain. 
Gastralgia  occurs  as  a  symptom  in  most  of  the  severe  attacks  of  acute 


ACUTE  GASTRIC  INDIGESTION.  325 

gastric  indigestion;  in  such  cases  it  is  more  marked  in  older  children 
than  in  infancy.  The  pain  of  diaphragmatic  pleurisy  is  often  referred 
to  the  epigastrium,  and  may  be  so  severe  as  to  lead  one  to  think  that 
the  stomach  is  the  seat  of  disease.  Another  cause  may  be  appendicitis. 
In  vertebral  caries  of  the  dorsal  region  epigastric  pain  is  a  very  frequent, 
early  symptom.  It  is  also  common  in  children  who  suffer  from  malaria 
at  the  onset  of  acute  attacks,  and  it  may  be  severe  when  the  febrile  symp- 
toms are  not  well  marked.  In  other  cases  pain  in  the  stomach  is  of  the 
nature  of  a  true  neuralgia,  which  may  be  excited  by  exposure  to  cold, 
by  wetting  the  feet,  by  drinking  ice-water,  and  by  many  other  causes. 

In  mild  cases  there  is  an  intermittent  pain,  and  usually  no  other 
symptoms.  In  severe  cases  the  pain  may  be  so  great  as  to  cause  pallor, 
faintness,  cold  perspiration,  and  very  marked  prostration.  The  epigas- 
trium may  be  hard  and  sometimes  retracted,  the  stomach  appearing  to 
be  in  a  state  of  spasm. 

The  principal  interest  attaches  to  diagnosis.  If  the  pain  is  acute,  one 
should  carefully  exclude  appendicitis,  renal  and  hepatic  colic,  ulcer  with 
perforation,  and  all  acute  inflammatory  conditions  in  the  abdomen;  if 
more  chronic.  Pott's  disease  should  not  be  forgotten. 

During  the  attacks  the  patient  should  be  put  to  bed,  and  counter- 
irritation  used  over  the  stomach,  best  by  means  of  a  turpentine  stupe  or 
a  mustard  paste.  Internally  there  should  be  given  hot  water  containing 
a  few  drops  of  brandy  or  gin  and  five  drops  of  spirits  of  chloroform ;  all 
food  should  be  withheld.  Hot  bottles  should  be  applied  to  the  feet  if 
they  are  cold.  In  the  interval  between  the  attacks  the  treatment  should 
be  directed  to  the  patient's  general  condition ;  especially  should  the  cause 
be  discovered,  and  if  possible  removed.  In  cases  of  recurring  pain  of  a 
neuralgic  character  arsenic  in  the  form  of  Fowler's  solution,  one  or  two 
drops  three  times  a  day,  may  prove  of  benefit.  In  all  cases  attention 
should  be  directed  to  the  diet.  j 

ACUTE  GASTRIC  INDIGESTION. 

This  occurs  whenever  the  stomach  is  unequal  to  the  task  imposed 
upon  it.  It  may  be  either  because  the  task  is  too  great  or  because  the 
capacity  of  the  stomach  for  work  is  diminished.  Under  these  two  heads 
we  may  group  the  principal  causes  of  acute  indigestion. 

Under  the  first  head  the  most  important  thing  is  the  giving  of  im- 
proper food.  In  infants  this  is  sometimes  improper  breast-milk;  but 
more  often  cow's  milk  containing  too  high  fat.  Other  common  causes 
are  sudden  weaning  or  any  other  abrupt  change  in  diet,  the  too  early 
use  of  solid  food,  and  overloading  the  stomach.  In  older  children  the 
usual  causes  are  indigestible  articles  of  food,  such  as  unripe  fruits, 
pastry,  imperfectly  cooked  cereals,  etc.,  overloading  the  stomach,  and 


326  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

swallowing  food  without  sufficiently  masticating  it.  Conditions  whith 
may  diminish  for  the  time  the  capacity  of  the  stomach  for  work  are 
fatigue,  depression  induced  by  atmospheric  heat,  chilling  of  the  surface, 
especially  the  extremities,  dentition,  and  the  nervous  impression  caused 
by  the  onset  of  any  acute  disease.  The  effect  is  seen  both  on  the 
glandular  and  muscular  apparatus  of  the  stomach.  The  secretions  are 
diminished  or  altered  in  character,  and  the  motility  of  the  organ  is 
arrested. 

Symptoms. — One  of  the  first  consequences  of  arrested  gastric  diges- 
tion is  that  the  food  remains  long  in  the  stomach.  Instead  of  the  stom- 
ach's being  empty  in  about  three  hours  after  feeding,  as  is  normal  in  in- 
fancy, the  food  may  remain  in  it  five  or  six  hours,  or  even  longer.  The 
irritation  from  this  undigested  and  fermenting  mass  excites  vomiting, 
which  usually  ceases  after  the  stomach  has  been  emptied.  The  vomiting 
may  be  preceded  by  nausea,  pain,  and  constitutional  depression  which 
varies  with  the  age  and  susceptibility  of  the  child ;  in  infants  it  may  be 
very  alarming. 

The  nervous  symptoms  are  sometimes  of  a  striking  character.  There 
may  be  dulness,  stupor,  and  sometimes  contracted  pupils,  so  as  to  sug- 
gest opium  narcosis,  or  there  may  be  restlessness,  and  even  convulsions. 
There  is  also  marked  prostration  and  fever.  The  temperature  in  most 
cases  of  acute  indigestion  is  from  101°  to  103°  F. ;  not  infrequently  it 
rises  to  104°  or  105°  F.  The  tongue  is  coated  and  the  appetite  entirely 
lost.  In  infants  these  symptoms  are  usually  associated  with  or  followed 
by  more  or  less  intestinal  disturbance — generally  diarrhoea,  with  un- 
digested food  in  the  stools.  Epigastric  distention  may  be  present. 
Usually  the  vomiting  ceases  in  from  six  to  twelve  hours  and  after  the 
stomach  has  been  thoroughly  emptied  the  temperature  falls.  Provided 
rest  to  the  organ  can  be  secured,  and  the  exciting  cause  is  one  that  can 
be  removed,  the  patimt  may  be  quite  well  in  two  or  three  days.  Relapses 
are,  however,  easily  excited ;  and  in  a  susceptible  patient  it  is  surprising 
to  see  how  trivial  a  cause  may  excite  one. 

The  diagnosis  between  a  simple  attack  of  acute  indigestion  and  one  of 
gastritis  can  not  be  made  at  the  outset.  The  former  is  much  more  fre- 
quent, and  may  be  quite  as  severe,  but  is  of  shorter  duration.  The 
prognosis  in  these  cases  is  good,  except  in  very  young  or  very  delicate 
infants. 

Treatment. — The  indications  are,  to  empty  the  stomach  as  com- 
pletely as  possible  and  then  to  secure  for  it  absolute  rest.  If  proper 
treatment  is  employed  at  the  outset,  the  majority  of  such  attacks  can 
be  cut  short.  Xothing  is  so  efficient  in  infants  as  stomach-washing.  A 
single  washing  usually  suffices.  If  for  any  reason  this  can  not  be  em- 
ployed, the  child  may  take  from  its  bottle  a  large  amount  of  lukewarm 
water.    The  free  vomiting  which  this  usually  provokes  may  be  sufficient 


ACUTE  GASTRITIS.  327 

to  cleanse  the  stomach  fairly  well,  but  by  no  means  so  thoroughly  as 
stomach-washing.  Persistent  vomiting  is  sometimes  arrested  by  giving 
small  quantities  of  hot  water. 

The  subsequent  treatment  is  chiefly  dietetic.  Everything  should  be 
withiield  for  six  to  eiglit  hours,  when  thin  barley  water  or  albumin 
water  may  be  given  in  small  quantities,  e.  g.,  half  an  ounce  to  one 
ounce  every  hour.  After  twenty-four  hours  beef  juice  or  broth  may  be 
added,  but  no  milk  should  be  given  for  two  or  three  days.  When  begun, 
it  should  be  skimmed  and  diluted  with  five  or  six  parts  of  water.  In  a 
nursing  child,  the  breast  should  be  withheld  altogether  for  twenty-four 
hours,  and  then  nursing  allowed  for  two  minutes  every  three  hours, 
the  time  of  nursing  being  gradually  increased  to  three,  five,  and  ten 
minutes  as  improvement  occurs.  The  great  mistake  made  in  these  cases 
is  to  begin  food  too  soon  and  to  give  too  much,  especially  of  cow's 
milk. 

Drugs  are  relatively  of  little  value.  If  the  measures  mentioned  have 
been  used  promptly  they  will  not  often  be  required.  In  many  cases  inju- 
dicious medication  aggravates  the  symptoms  and  prolongs  the  attack. 
Unless  the  bowels  have  acted  freely,  calomel  (gr.  |  every  hour)  may  be 
given  until  this  effect  is  obtained.  Where  there  is  continuous  vomiting 
of  very  acid  mucus  and  serum,  alkalies  are  indicated — lime-water,  chalk 
mixture,  or  the  subcarbonate  of  bismuth.  It  is  important  to  keep  the 
child  as  quiet  as  possible.  Local  applications  to  the  epigastrium  are  very 
often  useful.  Either  dry  heat  may  be  applied  by  means  of  a  hot-water 
bag  or  hot  flannels,  or  more  active  counter-irritation  by  mustard.  In 
older  children  the  stomach  should  be  kept  entirely  at  rest  for  half  a  day, 
only  carbonated  waters  or  barley  water  being  allowed  in  small  quantities 
to  allay  thirst.  Later,  broth  or  beef  juice  may  be  given,  afterward 
skimmed  milk  diluted  with  lime-water.  The  patient  should  be  kept 
upon  a  very  low  diet  for  four  or  five  days. 

ACUTE  GASTRITIS. 

In  comparison  with  the  frequency  of  inflammatory  diseases  of  the 
intestine,  those  of  the  stomach  are  rare,  particularly  so  in  infancy. 
Owing  largely  to  the  character  of  its  secretion  and  its  contents,  the  stom- 
ach is  much  more  resistant  to  infection  than  are  the  intestines.  Gastritis 
seldom  exists  alone,  but  is  usually  associated  with  enteritis  or  colitis. 

Etiology. — The  causes  of  gastritis  are,  in  the  main,  those  of  acute 
gastric  indigestion — improper  food  or  feeding — to  which  possibly  is 
added  infection.  Gastritis  may  also  be  caused  by  the  introduction  of 
irritants,  which  may  either  be  swallowed  accidentally  or  given  as  drugs. 

Lesions. — The  mucous  membrane  of  the  stomach  may  be  the  seat  of 
acute  catarrhal,  ulcerative,  or  membranous  inflammation,  all  forms  ex- 


328  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

cept  the  catarrhal  being  rare.  Tliere  is  also  seen  a  mixed  form,  which 
from  its  cause  is  usually  termed  "  corrosive  gastritis." 

Catarrhal  Gastritis. — This  is  characterised  by  byperaemia  of  the  mu- 
cous membrane,  exudation  of  cells  into  the  mucosa,  a  great  increase 
in  the  secretion  of  the  mucous  glands,  and  changes  in  the  epithelium. 
About  the  only  change  which  can  be  recognised  by  the  naked  eye  is 
congestion  and  swelling  of  the  mucous  membrane.  These  are  usually 
more  marked  toward  the  pyloric  end  and  along  the  greater  curvature. 
There  may  be  small  extravasations  of  blood  into  the  mucosa.  The  stom- 
ach contains  undigested  food  and  mucus,  which  may  be  thick  and  tena- 
cious, adhering  very  closely  to  the  mucous  membrane.  The  mucus  may 
be  stained  brown  from  the  capillary  haemorrhages.  The  stomach  may  be 
either  distended  or  contracted.  Under  the  microscope  the  changes  are 
seen  to  be  almost  entirely  in  the  mucosa.  In  some  places  there  is  loss  of 
the  superficial  epithelium,  in  others  only  degenerative  cbanges  in  it  are 
seen.  The  mucosa  is  infiltrated  with  round  cells,  this  process  being 
rarely  diffuse,  but  generally  occurring  in  patches.  The  blood-vessels  are 
distended  and  many  small  extravasations  are  seen.  Sometimes  there  is 
a  moderate  infiltration  of  the  submucosa.  Acute  catarrhal  gastritis 
alone  is  rarely  severe  enough  to  cause  death.  It  is  usually  seen  in  cases 
which  prove  fatal  from  other  causes,  particularly  diseases  of  the  intestine. 

Gastric  softening  (gastromalacia)  is  a  condition  dependent  upon 
post-mortem  changes — probably  self-digestion  of  the  stomach.  It  is 
found  both  where  gastric  symptoms  were  present  and  where  they  were 
absent.  It  is  situated  nearly  always  in  the  posterior  wall,  and  usually 
covers  a  considerable  area,  about  one-third  or  one-fourth  of  this  wall.  It 
is  recognised  by  the  gelatinous,  translucent  appearance  of  the  walls  of 
the  stomach,  which  are  so  softened  that  the  finger  may  be  pushed  through 
them  without  force,  or  that  sometimes  the  stomach  ruptures  while  it  is 
being  removed.  This  condition  is  rarely  seen  when  the  stomach  is  empty. 
It  can  scarcely  be  mistaken  for  a  pathological  condition,  if  its  occurrence 
is  borne  in  mind. 

Ulcerative  Gastritis. — This  was  met  with  six  times,  not  including 
tuberculous  cases,  in  390  consecutive  autopsies  upon  infants  in  the 
Babies'  Hospital.  Three  of  the  patients  were  less  than  four  months  old, 
and  all  were  females.  The  ulcers  varied  from  one  twenty-fifth  to  one 
quarter  of  an  inch  in  diameter,  and  usually  from  ten  to  fifty  were  pres- 
ent. They  seldom  extended  to  the  muscular,  and  never  to  the  peritoneal 
coat.  The  lesion  was  most  marked  in  the  posterior  wall,  toward  the 
pyloric  end  and  along  the  greater  curvature.  Evidences  of  catarrhal  in- 
flammation were  present  in  most  of  the  cases,  and  in  four,  of  mem- 
branous inflammation.  Lesions  in  some  other  part  of  the  digestive  tract 
were  present  in  all  but  one  case,  in  two  there  was  thrush  in  the  oesopha- 
gus ;  in  three  there  was  ulceration  somewhere  in  the  intestines. 


ACUTE   GASTRITIS.  329 

Membranous  Gastritis. — This  is  even  more  rare  than  the  varieties 
previously  mentioned.  I  have  met  with  it  but  four  times  in  infants. 
One  case  was  associated  with  a  membranous  colitis;  a  second  case  with 
a  streptococcus  inflammation  of  the  fauces  and  larynx  in  an  infant  but  six 
weeks  old.  The  oesophagus  was  not  involved  in  this  case;  and  indeed  it 
often  escapes.  No  Klebs-Loeffler  bacilli  could  be  found  either  in  cover- 
slip  preparations  or  by  culture. 

To  the  naked  eye  the  membrane  appears  of  a  grayish-green  colour; 
it  is  adherent,  but  can  be  detached  in  quite  large  patches.  Only  a  por- 
tion of  the  stomach  was  covered  in  any  of  the  cases ;  in  two  the  principal 
disease  was  about  the  pylorus;  in  another  along  the  greater  curvature. 
The  microscopical  appearances  resemble  those  of  membranous  colitis. 
There  is  a  pseudo-membrane  composed  of  fibrin,  granular  matter,  epi- 
thelial cells,  and  bacteria.  The  mucosa  shows  a  moderately  dense  infil- 
tration with  round  cells,  and  in  places  superficial  ulceration.  There  is 
also  infiltration  of  the  submucosa,  and  in  some  places  even  the  muscular 
coat  is  involved. 

Membranous  gastritis  occurring  in  patients  dying  of  diphtheria  is 
not  common.  Councilman,  Mallory,  and  Pearce  noted  its  presence  in 
only  five  of  one  hundred  and  twenty-seven  autopsies. 

Corrosive  Gastritis  (toxic  gastritis). — This  form  of  inflammation  is 
excited  by  various  irritating  and  caustic  substances,  which  are  usually 
taken  by  accident,  sometimes  for  the  purpose  of  producing  emesis.  The 
most  frequent  substances  are  carbolic  acid  and  caustic  alkalies. 

The  lesions  in  the  stomach  depend  upon  the  amount  of  the  substance 
swallowed,  the  degree  of  concentration,  and  whether  the  stomach  was 
full  or  empty  at  the  time.  Strong  caustics,  whether  acids  or  alkalies, 
usually  act  more  deeply  and  extensively  in  the  pharynx  and  oesophagus, 
for,  owing  to  the  spasmodic  contraction  of  the  muscles  of  these  parts, 
often  but  a  small  amount  of  the  substance  reaches  the  stomach.  Concen- 
trated irritant  poisons  produce  in  the  stomach,  especially  along  the 
greater  curvature,  irregular  ulcers,  which  may  be  so  deep  as  to  cause  per- 
foration, or  they  may  affect  the  mucous  membrane  only.  In  severe  cases 
death  takes  place  early,  often  in  a  few  hours.  Dark,  ragged  ulcers  are 
found  in  the  stomach,  the  surrounding  mucous  membrane  is  the  seat  of 
intense  congestion,  and  in  places  there  are  extravasations  of  blood.  If 
death  is  delayed  there  are  evidences  of  intense  inflammation,  sometimes 
with  the  production  of  a  pseudo-membrane.  If  the  amount  of  poison  is 
not  sufficient  to  cause  death,  and  if  the  patient  recovers  from  the  result- 
ing gastritis,  a  cicatricial  condition  of  the  stomach  results,  which  later 
may  lead  to  stenosis  of  the  pylorus  or  other  deformity  of  the  organ. 

Symptoms. — Catarrhal  gastritis  can  not  be  distinguished  at  its  begin- 
ning from  an  attack  of  acute  indigestion.  There  are  fever,  pain,  vomit- 
ing, thirst,  loss  of  appetite,  coated  tongue,  and  prostration.     The  pres- 


330  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

ence  of  inflammatory  changes  is  indicated  by  the  continuance  of  these 
symptoms,  particularly  the  pain,  vomiting,  fever,  and  thirst.  With  the 
pain  there  may  be  epigastric  tenderness.  All  food  and  liciuids  are  im- 
mediately rejected,  and  even  when  nothing  is  taken  the  retching  and 
vomiting  may  continue,  nothing  but  frothy  mucus  or  serum  being 
brought  up,  sometimes  streaked  with  blood.  The  vomited  matters  are 
usually  very  sour;  they  may  be  bilious.  The  temperature  is  rarely  high 
except  at  the  outset.  After  the  first  or  second  day  it  usually  ranges 
between  100°  and  101.5°  F.  Thirst  is  intense,  and  all  liquids  are  taken 
with  avidity,  especially  if  cold,  even  though  they  are  immediately 
vomited.  The  tongue  is  thickly  coated  with  a  white  fur,  and  the  breath 
may  be  foul.  The  constitutional  symptoms  are  generally  most  severe  at 
the  outset.  The  usual  duration  of  sucli  attacks  is  from  four  to  seven 
days,  but  with  improper  management,  especially  injudicious  feeding, 
the  disease  may  be  much  prolonged.  One  attack  may  follow  another 
until  a  chronic  condition  is  established.  In  most  of  the  cases  there  is 
some  disturbance  of  the  intestines,  usually  a  sharp  attack  of  diarrhoea. 
Sometimes  the  gastric  symptoms  subside  after  a  few  days  and  those  of 
the  intestines  become  the  predominant  ones.  The  symptoms  above  given 
are  those  in  infancy.  In  older  children  there  is  less  fever,  prostration, 
and  diarrhoea,  but  pain  and  vomiting  are  prominent.  The  attacks  are 
usually  shorter  and  altogether  less  severe. 

The  rare  cases  of  ulcerative  gastritis  have  nothing  by  which  they 
can  be  distinguished  from  the  form  described,  except  a  more  prolonged 
course  and  a  greater  liability  to  haemorrhage. 

Membranous  gastritis  also  presents  no  peculiar  symptoms.  In  fact, 
in  the  cases  I  have  personally  seen,  the  gastric  symptoms  were  insig- 
nificant, and  the  condition  not  suspected  during  life. 

In  corrosive  gastritis  the  effects  of  the  caustic  may  be  seen  in  the 
mouth  and  pharynx,  the  mucous  membrane  being  usually  of  a  gray  or 
whitish  colour.  Pain  and  a  sense  of  constriction  are  felt  in  the  oesophagus 
and  stomach,  and  thirst  is  great.  Vomiting  follows  almost  immediately, 
and  the  matters  vomited  are  usually  bloody.  The  subsequent  course  in 
most  of  the  cases  is  the  rapid  development  of  collapse,  and  death  in  a 
few  hours  from  shock.  The  younger  the  child  the  sooner  does  the  case 
terminate.  In  irritant  poisoning  not  severe  enough  to  produce  death, 
the  symptoms  of  acute  gastritis  follow,  usually  accompanied  by  more  or 
less  enteritis  owing  to  the  passage  of  the  irritant  into  the  intestine. 
There  is  seen  a  continuance  of  the  vomiting,  pain  and  epigastric  disten- 
tion, and  diarrhoea,  and  from  these  symptoms  death  may  result  in  two 
or  three  days.  It  is  extremely  rare  in  infancy  for  the  patient  to  survive 
both  the  stage  of  shock  and  that  of  acute  inflammation,  so  that  the 
deformities  of  the  stomach  and  the  chronic  conditions  mentioned  are 
practically  never  met  with  excepting  in  older  children. 


CHRONIC  GASTRIC   INDIGESTION.  331 

Treatment. — Cases  of  acute  catarrhal  gastritis  are  to  be  managed 
very  much  like  those  of  acute  gastric  indigestion.  Thirst  may  be  re- 
lieved by  swallowing  bits  of  ice.  Where  there  is  continuous  vomiting  of 
acid  mucus,  relief  is  sometimes  afforded  by  repeating  the  stomach-wash- 
ing once  in  twelve  hours  with  a  one-per-cent  solution  of  bicarbonate  of 
soda,  at  110°  F.  In  older  children,  beneficial  results  sometimes  follow 
the  use  of  bismuth  subcarbonate  (gr.  x  every  two  hours)  ;  but  in  infants 
I  have  seen  but  little  effect  from  any  form  of  medication,  the  reliance 
being  upon  rest,  careful  feeding,  and  stomach- washing. 

Cases  of  corrosive  gastritis  require  special  treatment.  The  first  indi- 
cation is  to  administer  the  proper  chemical  antidote  to  the  substance 
swallowed,  and  the  next  to  use  bland  mucilaginous  or  oily  fluids,  such 
as  milk,  albumin  water,  oils  in  large  quantities,  etc.  Especially  should 
stomach-washing  be  avoided.  Opium  is  always  required,  on  account  of 
pain,  and  should  be  given  hypodermically.  The  general  symptoms  are 
to  be  treated  according  to  the  indications  of  the  individual  case. 

CHRONIC   GASTRIC    INDIGESTION— CHRONIC    GASTRITIS— GASTRIC 

CATARRH. 

Although  from  a  pathological  point  of  view  these  conditions  may  not 
be  identical,  from  a  clinical  standpoint  there  is  no  advantage  in  attempt- 
ing to  separate  them.  Nothing  distinguishes  chronic  indigestion  from 
chronic  gastritis  except  that  in  the  latter,  in  addition  to  continued  de- 
rangement of  function,  there  is  a  greater  increase  in  the  production  of 
gastric  mucus.  Chronic  indigestion  does  not  long  exist  without  the 
production  of  a  certain  amount  of  catarrhal  inflammation.  This  con- 
dition in  the  stomach  seldom,  if  ever,  exists  without  more  or  less  involve- 
ment of  the  intestine,  and  in  the  majority  of  cases  the  intestinal  condi- 
tion is  the  more  important.  In  some,  however,  the  gastric  symptoms 
predominate,  and  it  is  only  those  which  are  here  considered. 

Etiology. — Chronic  gastric  indigestion  may  follow  acute  attacks,  or 
it  may  be  chronic  from  the  outset.  If  the  latter,  it  depends  in  infancy 
upon  the  continued  use  of  improper  food  or  bad  methods  of  feeding. 
The  improper  food  is  very  often  a  modified  cow's  milk  of  improper  pro- 
portions. The  most  frequent  mistake  is  the  use  of  too  high  a  percentage 
of  fat.  Less  frequently  the  cause  is  the  sugar,  especially  the  use  of  foods 
containing  much  cane  sugar  or  maltose.  Other  factors  of  importance 
are  overfeeding,  too  large  meals,  unsuitable  food,  especially  solid  food 
for  infants.  The  condition  generally  accompanies  dilatation  of  the 
stomach.  As  a  consequence  of  imperfect  digestion,  fermentation  in  the 
residuum  takes  place,  and  the  irritating  products  of  this  fermentation 
soon  cause  a  catarrhal  inflammation  with  a  production  of  mucus.  Chronic 
gastric  indigestion  also  complicates  most  of  the  constitutional  diseases 
of  infancy,  especially  rickets,  syphilis,  tuberculosis,  malnutrition,  and 


332  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

marasmus.  It  may  follow  any  of  the  acute  infectious  diseases.  In  older 
children  it  is  due  chiefly  to  the  use  of  improper  food,  sometimes  to  the 
habit  of  rapid  eating  and  insufficient  mastication,  the  cause  of  which  is 
very  often  carious  teeth.  It  is  associated  with  constitutional  diseases  as 
in  infancy,  and  may  complicate  valvular  disease  of  the  heart. 

Lesions. — The  changes  found  in  chronic  gastritis  are  usually  confined 
to  the  mucosa.  In  the  mild  form  there  are  degenerative  changes  of  the 
epithelium  of  the  tubules,  with  an  increased  production  of  mucus;  there 
may  be  a  slight  infiltration  of  the  mucosa  with  round  cells.  The  more 
severe  form,  with  marked  cell  infiltration  and  the  production  of  new 
connective  tissue,  is  extremely  rare.  The  submucous  coat  may  be  thick- 
ened and  the  muscular  coat  attenuated.  The  lesion  can  not  be  recognised 
by  the  naked  eye.  The  stomach  is  apt  to  be  more  or  less  dilated,  and  its 
surface  is  coated  with  thick  and  very  adherent  mucus.  This  lesion  rarely 
exists  alone,  practically  never  in  infancy,  but  is  associated  with  similar 
lesions  in  the  intestines,  the  latter  often  being  more  severe. 

Symptoms. — In  Infants. — For  our  knowledge  of  the  conditions  ex- 
isting in  the  stomach  in  chronic  indigestion  we  are  indebted  to  the  work 
chiefly  of  Cassel,  Leo,  Troitzky,  Wohlmann,  and  Clarke.  The  results 
obtained  in  the  examination  of  stomach  contents  have  not  been  uniform, 
and  in  practice  one  should  not  lay  much  stress  upon  the  absence  of  the 
normal  secretions.  The  presence  of  mucus  in  the  vomited  matters  or 
in  the  washings  from  the  stomach  is  a  constant  feature.  This  greatly 
interferes  with  digestion,  even  though  secretions  are  normal.  The  re- 
action of  the  stomach  is  almost  invariably  acid,  but  the  acidity  may  be 
due  more  to  the  products  of  fermentation  than  to  hydrochloric  acid.  The 
latter  is  almost  invariably  diminished  in  quantity  and  is  sometimes  ab- 
sent. Free  hydrochloric  acid  is  very  seldom  present.  The  rennet  fer- 
ment and  pepsin  are  usually  present  in  normal  amount.  Fermentation 
takes  place  in  the  fats  and  the  carbohydrates.  The  results  of  fermenta- 
tion are  the  production  of  lactic,  acetic,  butyric,  and  other  volatile  fatty 
acids,  which  are  especially  irritating  to  the  mucous  membrane.  There 
is  an  increased  production  of  gas.  Food  remains  long  in  the  stomach 
because  of  motor  inactivity,  which  is  partly  the  cause  and  partly  the 
result  of  the  disease.  It  often  continues  after  all  other  symptoms  have 
disappeared. 

The  most  important  local  symptom  is  vomiting.  It  may  occur  soon 
or  long  after  feeding.  It  is  often  accompanied  by  frequent  regurgitation 
of  small  amounts  of  food,  which  may  begin  soon  after  one  feeding  and 
continue  quite  to  the  time  for  the  next.  In  nearly  all  protracted  cases 
the  vomited  matters  contain  mucus,  and  sometimes  this  is  a  conspicuous 
feature.  The  regurgitation  of  a  sour  irritating  fluid  occurs  even  when 
but  little  food  is  rejected,  and  usually  accompanies  the  belching  of  gas. 
In  infants  some  of  the  most  striking  symptoms  are  due  to  the  gas.    The 


CHRONIC   GASTRIC   INDIGESTION.  333 

stomach  may  be  distended  and  hard  most  of  the  time,  and  often  so  much 
gas  is  present  that  infants  find  difficulty  in  taking  food.  Though 
evidently  hungry,  they  can  take  so  little  at  a  time  that  an  hour  or  more 
may  be  required  to  take  four  or  five  ounces.  That  the  food  remains 
long  in  the  stomach  is  best  demonstrated  by  stomach-washing.  Instead 
of  the  stomach's  l)eing  empty  in  two  and  a  half  or  three  hours,  as  it  should 
be,  food  may  be  found  four  or  five  hours,  and  in  some  cases  six  or  eight 
hours,  after  feeding.  There  may  be  dilatation  of  the  stomach,  especially 
in  rachitic  children. 

The  appetite  may  be  abnormally  great,  or  it  may  be  poor.  As  a 
rule,  children  take  less  food  than  in  health.  The  tongue  is  usually 
coated.  The  general  symptoms  are  those  of  malnutrition;  there  is  con- 
stant fretfulness  and  sleep  is  irregular  or  disturbed;  the  weight  is  sta- 
tionary, or  there  is  steady  loss;  there  is  also  anaemia,  and  the  child's 
development  is  arrested.  There  is  nearly  always  some  derangement  of 
the  bowels,  more  often  constipation  than  diarrhoea. 

There  is  little  tendency  to  spontaneous  improvement  or  recovery,  the 
prognosis  depending  almost  entirely  upon  the  treatment  employed.  Un- 
less relieved  the  condition  is  apt  to  continue,  until  some  serious  acute 
disease  develops  which  may  be  fatal.  In  young  infants,  chronic  gastric 
indigestion  should  not  be  confounded  with  hypertrophic  stenosis  of  the 
pylorus. 

In  Older  Children. — The  disease  is  not  so  common  as  in  infants.  In 
all  cases  the  most  constant  symptom  is  vomiting,  which  may  occur  reg- 
ularly after  meals,  or  only  in  the  morning  before  breakfast.  If  the  latter, 
the  vomited  matters  consist  chiefly  of  mucus.  In  addition  to  these  reg- 
ular attacks  there  may  be  the  frequent  regurgitation  of  small  quantities 
of  food.  There  are  gastric  flatulence  and  pain,  due  to  hyperacidity  or 
to  acid  fermentation.  The  appetite  is  variable — sometimes  inordinate, 
sometimes  entirely  lost;  it  may  be  capricious,  there  being  usually  a 
craving  for  highly  seasoned  food.  The  tongue  is  constantly  furred,  and 
the  breath  usually  disagreeable.  These  symptoms  are  seen  in  all  degrees 
of  severity.  Intestinal  disturbances  are  not  so  frequent  as  in  infancy. 
Constipation  is  more  common  than  diarrhoea.  The  general  symptoms  are 
those  of  malnutrition.  There  are  anaemia,  wasting,  constant  fretfulness, 
disturbed  sleep,  and  various  other  nervous  disorders. 

Prognosis. — The  prognosis  depends  upon  the  age  of  the  patient,  the 
duration  of  the  disease,  the  surroundings,  and  upon  how  well  treatment 
can  be  carried  out.  In  infants  under  three  months  the  prognosis  as  to 
life  is  doubtful.  If  children  live  to  the  age  of  four  or  five  months,  they 
usually  recover  with  proper  treatment.  These  patients  do  much  better 
in  private  practice  than  in  institutions.  The  principal  danger  from  this 
condition  consists  in  the  predisposition  it  gives  to  acute  diarrhoeal  dis- 
eases in  summer. 


334  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

In  older  children,  as  in  the  case  of  infants,  these  s3Tnptoms  may  con- 
tinue indefinitely;  there  is  little  tendency  to  spontaneous  recovery,  but 
under  favourable  circumstances,  with  constant  care,  much  may  be  done 
for  all  these  patients  and  many  of  them  may  be  completely  cured. 

Treatment. — Infants. — The  general  treatment  is  too  apt  to  be  ig- 
nored, but  it  is  just  as  important  as  measures  directed  more  specifically 
to  the  stomach.  A  large,  roomy  nursery,  and  plenty  of  fresh  air  by  night 
and  by  day,  are  very  important ;  equally  necessary  are  quiet  surroundings 
and  freedom  from  disturbing  conditions  which  sometimes  obtain  in  the 
nursery;  sometimes  under  the  influence  of  these  alone  improvement 
begins.  General  friction  of  the  body  is  useful  in  delicate  children  with 
poor  circulation.  Infants  must  be  properly  covered,  and  it  is  of  the 
utmost  importance  that  the  feet  be  kept  warm.  Of  the  measures  directed 
to  the  stomach,  two  are  chiefly  to  be  depended  upon — stomach-washing 
and  proper  feeding. 

Stomach-washing  is  useful,  flrst,  in  removing  the  mucus  which  is 
abundant  in  most  of  these  cases;  secondly,  in  cleansing  the  organ  thor- 
oughly at  least  once  a  day,  this  of  itself  being  most  important ;  thirdly, 
as  a  stimulant  to  the  gastric  secretions,  especially  hydrochloric  acid. 
Plain  boiled  water,  or  a  weak  alkaline  solution — sodium  bicarbonate,  one 
drachm  to  the  pint — may  be  employed.  In  the  early  part  of  the  treat- 
ment the  washing  should  be  done  daily ;  later,  every  second  or  third  day. 
The  time  selected  is  not  very  important,  but  it  is  better  to  make  this 
about  three  hours  after  feeding. 

The  question  of  diet  has  been  quite  fully  discussed  in  the  chapter 
on  Infant-Feeding,  particularly  in  the  pages  in  which  the  feeding  in 
difficult  cases  is  considered.  If  milk  is  being  given,  one  should  first 
endeavour  to  determine  which  of  the  elements  is  the  chief  cause  of  the 
trouble.    This  is  most  frequently  the  fat,  and  next  the  sugar. 

The  quantity  of  food  and  the  frequency  of  feeding  are  both  matters 
of  importance.  With  a  serious  amount  of  chronic  gastric  disturbance 
in  infants  over  three  months  old  the  interval  between  feedings  should 
not  be  less  than  three  hours;  many  do  better  when  the  interval  is  four 
hours.  Small  meals  of  a  somewhat  concentrated  food  are  usually  better 
than  large  feedings  of  a  very  dilute  food.  Careful  study  of  the  indi- 
vidual child  is  indispensable  to  success. 

Drugs  have  a  very  limited  application  in  the  treatment  of  this  condi- 
tion in  infants.  Generally  they  are  too  much  used,  and  too  little  attention 
is  given  to  the  details  of  feeding,  by  which  means  alone  permanent  im- 
provement is  reached.  The  continued  use  of  pepsin  and  other  digestive 
ferments  is  irrational  and  without  benefit.  Hydrochloric  acid,  however, 
may  at  times  prove  of  considerable  value,  but  it  must  be  given  in  rather 
large  doses,  i.  e.,  five  to  fifteen  drops  of  the  dilute  acid  after  each  feed- 
ing.    But  for  the  relief  of  one  condition  drugs  may  be  of  considerable 


DILATATION  OF  THE  STOMACH.  335 

advantage:  wherever  the  production  of  gas  and  constant  eructations  are 
prominent  symptoms,  the  benzoate  of  soda  is  sometimes  useful.  It  may 
be  given  with  the  feedings  in  doses  of  two  or  three  grains. 

Older  Children. — The  management  of  these  cases  in  older  children 
must  be  conducted  along  the  lines  laid  down  for  infants.  With  them, 
stomach-washing  can  not  be  easily  employed,  and  other  means  must  be 
used  to  clear  the  stomach  of  mucus.  The  best  is  undoubtedly  the  use 
of  large  draughts  of  water,  as  hot  as  can  be  borne,  an  hour  before  eat- 
ing. From  six  to  eight  ounces  should  be  taken,  preferably  slowly  by 
sipping.  To  this  may  be  advantageously  added,  in  many  cases,  fifteen  or 
twenty  grains  of  bicarbonate  of  soda. 

The  diet  should  consist  of  skimmed  milk  diluted  at  least  once,  kumyss 
or  matzoon,  beef  juice,  rare  meat,  and  a  moderate  amount  of  starchy 
food,  preferably  dried  bread  or  zwieback.  All  fruits  should  be  avoided. 
All  pastry,  sweets,  nuts,  and  candies  should  be  absolutely  prohibited. 
With  improvement  in  the  symptoms  green  vegetables  may  be  added  to 
the  diet,  and  the  amount  of  starchy  food  increased.  The  amount  of 
water  taken  at  meal-time  should  be  carefully  restricted.  Beneficial  re- 
sults are  often  obtained  in  these  cases  by  the  use  of  nux  vomica  or  sim- 
ple bitters  before  meals,  and  the  regular  administration  of  hydrochloric 
acid  (gtt.  V  to  viij  of  the  dilute  acid)  shortly  after  meals.  The  general 
treatment  must  not  be  neglected.  The  patient  should  lead  an  out-of- 
door  life  as  much  as  possible,  and  should  take  regular  but  very  moderate 
exercise.  Great  caution  is  necessary  against  overfatigue.  Iron  may  be 
given  in  most  cases  during  convalescence;  but  cod-liver  oil  should  be 
carefully  avoided  until  the  gastric  symptoms  have  quite  disappeared. 
Relapses  are  easily  excited,  and  the  most  constant  care  regarding  the  food 
must  be  maintained  for  months,  or  even  years. 

DILATATION   OF  THE  STOMACH. 

Moderate  dilatation  of  the  stomach  is  quite  a  frequent  condition, 
although  it  is  not  so  large^  a  factor  in  the  disorders  of  digestion  in 
infancy  and  childhood  as  many  who  have  written  upon  the  subject 
would  lead  us  to  believe.  A  very  marked  degree  of  dilatation  is  rare, 
but  in  these  cases  its  recognition  is  important  and  its  treatment  difficult. 

Dilatation  is  almost  invariably  regular  or  cylindrical;  it  is  usually 
most  marked  at  the  cardiac  extremity.  Cases  of  irregular  or  saccular 
dilatation,  except  when  associated  with  cicatricial  conditions,  are  of 
somewhat  doubtful  occurrence.  The  irregular  shapes  of  the  stomach 
found  at  autopsy  dependent  upon  the  contraction  of  the  muscular  coats, 
may  be  easily  mistaken  for  hour-glass  contraction  or  saccular  dilatation. 

Dilatation  may  also  result  from  congenital  stenosis  of  the  pylorus. 
The  most  important  predisposing  cause,  however,  is  the  muscular  atony 
which  accompanies  rickets.    It  is  found  to  a  slight  degree  in  almost  all 


336  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

severe  cases  of  rickets.  The  principal  exciting  causes  are  continued 
distention  from  overfeeding  and  chronic  indigestion. 

In  most  cases  the  only  symptoms  are  those  of  the  chronic  indigestion 
which  almost  invariably  accompanies  dilatation.  The  vomiting  seen 
with  dilatation  is  peculiar  in  that  it  is  infrequent,  possibly  only  once  a 
day;  but  then  the  quantity  vomited  is  larger  than  the  last  meal  taken. 
In  young  infants  the  pressure  symptoms  resulting  from  acute  dilatation 
may  be  very  serious.  This  is  particularly  true  of  those  with  acute  bron- 
chitis or  broncho-pneumonia,  or  atelectasis.  In  such  patients  I  have  seen 
very  grave  symptoms  accompany  the  rapid  distention  of  a  dilated  stom- 
ach, and  in  one  very  delicate  infant  of  three  months  this  was  appar- 
ently the  cause  of  death.  A  positive  diagnosis  of  dilatation  is  only 
made  by  the  physical  signs.  There  is  epigastric  fulness  and  distention, 
and  in  some  thin  patients  the  outline  of  the  stomach  can  be  distinctly 
seen.  Dilatation  of  the  transverse  colon,  however,  may  be  mistaken  for 
dilatation  of  the  stomach.  In  the  latter,  the  lower  outline  is  convex, 
while  in  the  former  it  is  usually  slightly  concave.  The  most  satisfactory 
means  of  diagnosis  is  by  percussion.  The  examination  should  be  made 
three  or  four  hours  after  feeding,  at  which  time  the  whole  abdomen  is 
apt  to  be  tympanitic.  The  stomach  should  then  be  filled  with  water; 
the  lower  limit  of  the  area  of  flatness  will  be  the  lower  border  of  the 
stomach.  This  is  much  more  satisfactory  than  determining  the  outline 
after  the  generation  of  gas  in  the  stomach.  If  the  lower  border  comes 
below  the  umbilicus,  it  is  dilated. 

In  moderate  dilatation  of  the  stomach  the  prognosis  is  good  unless 
due  to  pyloric  stenosis.  If  the  infant  has  any  acute  or  chronic  pulmo- 
nary disease,  dilatation  of  the  stomach  may  add  to  the  discomfort  and 
even  to  the  danger  from  that  condition.  The  distention  of  a  dilated 
stomach  occurring  in  the  course  of  any  acute  pulmonary  disease  should 
be  relieved  by  the  use  of  the  stomach  tube. 

In  the  management  of  these  cases  the  first  point  is  to  restrict  the 
use  of  fluids,  reduce  the  size  of  the  meals,  and  regulate  the  diet  in 
accordance  with  the  general  plan  outlined  in  the  chapter  on  Chronic 
Indigestion.  If  the  dilatation  is  marked,  the  stomach  should  be  washed 
once  a  day.  The  general  condition  of  the  patient  usually  requires  tonics. 
Rickets,  if  present,  should  receive  its  appropriate  constitutional  treat- 
ment. 

ULCER  OF  THE  STOMACH. 

Ulceration  of  the  stomach  may  be  found  in  connection  with  several 
pathological  processes  which  are  quite  distinct  from  one  another: 

1.  Ulcers  in  the  Newly  Born. — These  have  already  been  referred  to  in 
the  chapter  on  Haemorrhages  of  the  Newly  Born.  The  only  character- 
istic symptom  is  haemorrhage. 


TUMOURS  OF  THE  STOMACH.  337 

2.  Ulcers  Resulting  from  Acute  Gastritis. — Tliese  also  are  not  fre- 
quent. As  a  rule  they  give  no  symptoms  except  those  of  gastritis, 
although  in  several  cases  I  have  known  severe  haemorrhage  to  result 
from  them.     This  symptom  will  be  considered  later. 

3.  Tuberculous  Ulcers. — These  are  quite  rare.  I  met  with  gastric 
ulcers  five  times  in  one  hundred  and  nineteen  autopsies  on  tubercu- 
lous cases;  however,  the  evidence  was  not  conclusive  in  all  of  them 
that  the  ulcers  were  tuberculous;  but  in  three  the  tubercle  bacilli  were 
found.  Usually  there  were  several  small  ulcers;  in  one  case  but  two 
were  present,  the  larger  one  being  nearly  three-fourths  of  an  inch  in 
diameter,  and  situated  on  the  posterior  wall  near  the  middle  of  the 
greater  curvature.  All  but  one  of  these  cases  were  in  infants,  one  child 
being  only  ten  months  old.  The  ulcers  gave  no  symptoms  during  life, 
and  death  took  place  from  general  tuberculosis.  This  is  the  history  of 
nearly  all  the  few  cases  on  record.  In  one,  however,  reported  by  Casin, 
a  tuberculous  ulcer  perforated  the  stomach  and  caused  death  from  peri- 
tonitis. 

4.  Simple  Perforating  Ulcers. — These  are  of  great  rarity  and  uncer- 
tain pathology.  I  have  found  but  five  recorded  cases  in  young  children 
in  non-tuberculous  patients,  two  of  these  being  young  infants.  Eotch's 
patient  was  but  seven  weeks  old,  and  Cade's  but  two  months.  Two  other 
cases  were  under  four  years  old. 

The  symptoms  of  ulcer  before  perforation  are  gastric  pain  and  ten- 
derness, vomiting  of  blood,  and  often  bloody  stools.  In  most  of  these 
cases  in  children  there  were  no  symptoms  until  perforation,  then  fol- 
lowed collapse,  sometimes  high  temperature,  the  rapid  development  of 
tympanites,  and  death  from  shock  or  from  peritonitis. 

The  prognosis  is  bad  in  all  forms  of  ulcer  of  the  stomach,  except  the 
small  follicular  variety.  In  this,  however,  the  diagnosis  can  not  posi- 
tively be  made  except  by  gastric  haemorrhage,  and  it  is  only  this  which 
makes  these  cases  serious. 

Treatment. — The  treatment  is  absolute  rest,  ice  by  mouth,  small 
doses  of  opium,  and  rectal  feeding;  later,  bismutli,  arsenic,  or  nitrate  of 
silver.  If  symptoms  of  perforation  occur  the  abdomen  should  be  opened 
without  delay,  .as  offering  the  only  chance  of  recovery. 

TUMOURS  OF  THE  STOMACH. 

Although  exceedingly  rare,  tumours  of  the  stomach  occur  in  child- 
hood, and  are  seen  even  in  infancy.  A  case  of  sarcoma  of  the  stomach  in 
a  child  of  three  and  a  half  years  has  been  reported  by  Finlayson.  It  was 
apparently  primary.  The  microscopical  examination  showed  it  to  be  of 
the  spindle-celled  variety.  This  writer  could  find  no  other  recorded 
case  under  the  age  of  fifteen. 
23 


338  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

Lymphadenoma  of  the  stomach  in  a  rachitic  infant  of  eighteen 
months'  has  been  recorded  by  RoUeston  and  Lathan.  There  were  mul- 
tiple tumours  arising  from  the  mucous  membrane  in  the  pyloric  region. 
The  case  in  many  features  resembled  leukaemia. 

Six  cases  of  cancer  of  the  stomach  in  children  under  ten  years  are 
collected  in  an  article  by  Osier  and  McCrae.  Four  of  these  were  in 
young  infants  and  probably  congenital.  One  case,  in  a  child  of  eight, 
presented  the  usual  symptoms  and  lesions  of  the  adult  disease. 

HEMORRHAGE   FROM   THE  STOMACH   {Haematemesis). 

The  most  frequent  variety  of  hfemorrhage  from  the  stomach,  that 
is  seen  in  the  newly  born,  has  already  been  considered. 

I  have  met  with  three  fatal  cases  in  young  infants,  the  eldest  being 
fifteen  months  old.  In  the  first  case  there  were  symptoms  of  ordinary 
gastro-enteritis.  On  the  seventh  day  the  vomiting  of  blood  began,  and 
was  repeated  about  ten  or  twelve  times  during  the  next  twenty-four 
hours,  when  death  took  place.  The  blood  was  quite  abundant,  as  much 
as  a  drachm  of  red  blood  being  discharged  at  once.  At  autopsy  there 
were  found  in  the  stomach  about  two  ounces  of  dark-brown  fluid,  but  no 
gross  lesion  was  discovered,  and  no  explanation  of  the  bleeding.  This 
haemorrhage  was  apparently  capillary.  In  the  second  case  there  were 
symptoms  of  acute  gastro-enteritis  of  thirty-six  hours'  duration.  After 
this  time  there  was  marked  abdominal  distention  with  symptoms  of  col- 
lapse; then  a  profuse  haemorrhage  from  the  stomach,  the  child  dying 
while  vomiting  blood.  At  least  half  a  pint  was  discharged.  The  stom- 
ach contained  at  autopsy  two  ounces  of  dark  fluid  blood,  and  the  mucous 
membrane  was  filled  with  minute  ulcers  extending  quite  through  the 
mucosa.  In  the  third  case  there  was  no  vomiting  of  blood,  but  the 
patient  died  with  symptoms  of  internal  haemorrhage.  There  was  blood 
in  the  upper  part  of  the  intestine,  and  the  stomach  was  filled  with  blood ; 
it  contained  many  small  follicular  ulcers  resembling  those  found  in  the 
previous  case. 

Haemorrhage  irom  the  stomach  may  occur  in  purpura,  haemophilia, 
scurvy,  and  rarely  in  malaria.  In  young  girls  about  puberty  it  may  be  a 
form  of  vicarious  menstruation.  Occasionally  blood  may  be  vomited  in 
cases  of  haemorrhagic  measles.  Two  cases  are  reported  in  which  fatal 
haemorrhage  followed  the  swallowing  of  a  foreign  body.  In  both,  vomit- 
ing of  blood  occurred  long  after  the  original  accident.  In  one  case  two 
and  a  half  years  had  elapsed.  The  autopsy  in  this  case  showed  impac- 
tion of  the  foreign  body  and  ulceration  into  the  arch  of  the  aorta.  Spu- 
rious haemorrhages  may  occur  where  blood  has  been  swallowed  and  then 
vomited.  The  source  of  this  is  most  frequently  the  nose  or  pharynx. 
It  may  happen  in  infants  at  the  breast,  where  the  blood  is  drawn  from 


THE  SWALLOWING  OF  FOREIGN   BODIES.  339 

a  fissure  or  ulcer  in  the  nipple.  The  amount  of  blood  vomited  under 
these  circumstances  may  be  large  enough  to  be  quite  alarming.  It  may 
be  recognised  by  the  child's  general  condition  being  normal,  and  by  the 
presence  of  fissures  or  ulcers  upon  the  nipple!  It  may  sometimes  be 
noticed  that  the  vomiting  of  blood  follows  nursing  from  one  breast  and 
not  from  the  other. 

Symptoms. — There  may  be  no  symptoms  except  those  of  internal 
haemorrhage,  but  this  is  rare.  Usually  there  is  vomiting  of  blood,  and 
blood  appears  in  the  stools.  If  the  haemorrhage  is  rapid  and  vomiting 
speedily  occurs,  the  blood  may  be  of  a  bright-red  colour.  If  it  has  been 
long  in  the  stomach  it  is  of  a  dark-brown  or  black  colour  resembling 
coffee-grounds.  The  stools  containing  blood  from  the  stomach  are 
black  and  tarry  in  appearance.  The  general  symptoms  will  depend  upon 
the  amount  of  blood  lost. 

In  a  case  where  blood  is  vomited,  the  first  point  is  to  distinguish  spu- 
rious from  tl-ue  gastric  haemorrhage.  The  nose  and  pharynx,  especially 
its  posterior  wall,  should  be  carefully  examined.  If  the  child  is  at  the 
breast,  the  nipples  should  be  examined.  In  older  children  it  is  important 
to  distinguish  vomiting  of  blood  from  haemoptysis.  This  distinction  is 
to  be  made  in  accordance  with  the  rules  laid  down  in  text-books  on  gen- 
eral medicine.  The  prognosis  is  bad  if  the  haemorrhage  is  due  to  ulcer, 
if  it  is  very  profuse,  or  if  it  occurs  in  young  infants.  When  it  occurs  in 
connection  with  constitutional  diseases  the  prognosis  depends  upon  the 
original  disease. 

Treatment. — Altogether  the  most  efficient  remedy  is  the  suprarenal 
extract.  It  may  be  given  very  freely,  at  least  two  grains  every  half  hour 
to  a  child  of  one  year.  The  patient  should  be  kept  quiet,  preferably  upon 
the  back;  if  there  are  signs  of  collapse,  stimulants  may  be  given  hypo- 
dermically  or  by  the  rectum.  No  food  or  water  should  be  given  by  the 
stomach  for  at  least  twenty-four  hours  after  the  haemorrhage  has  ceased. 

THE  SWALLOWING  OF  FOREIGN   BODIES. 

Between  the  ages  of  one  and  four  years  the  habit  of  swallowing  for- 
eign substances  is  a  very  common  one.  The  variety  of  objects  swallowed 
includes  all  those  articles  which  the  young  child  can  reach  and  put  into 
his  mouth.  The  most  common  are  detached  parts  of  toys,  marbles,  peb- 
bles, buttons,  and  coins.  Not  only  are  such  smooth  articles  swallowed, 
but  also  with  equal  readiness,  sharp  ones,  such  as  pins  of  every  variety, 
bits  of  glass,  fragments  of  bone,  nails,  and  small  toy  knives  and  forks, 
etc.  At  the  time  of  swallowing,  choking  attacks,  severe  pharyngeal  pain, 
and  sometimes  slight  haemorrhage  may  occur.  Symptoms  referable  to 
the  oesophagus  are  very  few.  Nor  in  the  stomach  are  symptoms  often 
excited.    While  passing  through  the  intestine  there  may  be  colicky  pains. 


340  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

but  in  the  majority  of  instances  there  are  no  symptoms  whatever  even 
with  sharp  or  angular  bodies.  Impaction  and  perforation,  while  pos- 
sible, are  extremely  rare.  The  usual  time  required  for  a  foreign  body  to 
traverse  the  intestinal  tract  is  from  four  to  ten  days,  but  it  may  be  con- 
siderably longer.  If  the  body  swallowed  is  a  smooth  one,  it  passes  the 
sphincter  ani  without  difficulty.  But  with  sharp  bodies  there  may  be 
severe  pain  and  sometimes  haemorrhage. 

The  diagnosis  is  often  a  matter  of  much  difficulty,  and  without  an 
X-ray  examination  a  positive  diagnosis  is  impossible.  Very  often  when 
the  physician  is  called  because  this  condition  is  suspected  by  parents  the 
alarm  turns  out  to  be  a  false  one. 

It  is  most  surprising  to  see  the  size,  variety,  and  dangerous  character 
of  the  foreign  bodies  which  pass  through  the  intestinal  tract  without 
causing  any  symptoms  whatever.  The  expectant  treatment  is  therefore 
by  all  means  to  be  recommended.  No  emetics  or  cathartics  should  be 
administered.  The  diet  should  be  abundant  and  composed  of  articles  of 
food  which  leave  much  residue,  e.  g.,  coarse  cereals,  bread,  and  vegetables. 
Most  of  all  operation  should  not  be  performed  or  even  considered  unless 
there  are  definite  local  symptoms. 

Quite  distinct  from  such  accidental  swallowing  of  foreign  substances 
as  has  just  been  described,  is  the  practice  of  pulling  off  and  swallowing 
fur  from  rugs,  wool  from  toys  or  blankets,  shreds  from  clothing,  and  a 
great  variety  of  other  substances.  This  habit  is  usually  seen  in  nervous 
children,  and  often  in  those  where  some  gastric  irritation  seems  to  excite 
an  abnormal  craving.  In  infants  the  quantity  of  the  substance  is  gen- 
erally small  and  usually  it  provokes  vomiting  or  the  material  is  speedily 
passed  by  the  bowel.  Very  recently  in  the  Babies'  Hospital  a  coloured 
child  of  about  eighteen  months  passed  in  one  day  a  large  mass  of  hair 
which  she  had  pulled  from  her  own  head.  Another  child  in  the  same  ward 
pulled  into  shreds  and  swallowed  a  large  portion  of  the  foot  of  a  cotton 
stocking,  and  passed  the  same  by  the  bowel  the  following  day.  Such  oc- 
currences are  not  very  common.  It  occasionally  happens  that  the  sub- 
stance swallowed  does  not  pass  the  bowel  but  forms  an  intestinal  tumour 
which  may  give  rise  to  obscure  and  sometimes  to  severe  symptoms  of 
long  duration.  But  more  often  the  tumour  forms  in  the  stomach.  These 
gastric  tumours  are  usually  composed  of  hair  from  the  patient's  own  head. 
They  are  more  frequently  seen  in  older  children  than  in  infants,  and 
usually  in  girls  on  account  of  the  long  hair.  Many  of  these  patients  are 
of  the  nervous  type.  The  habit  may  continue  until  a  tumour  of  consider- 
able size  may  form,  sometimes  attaining  two  or  three  pounds  in  weight. 

The  symptoms  are  vague  until  the  tumour  is  discovered.  There  are 
usually  gastric  disturbances  of  a  rather  indefinite  character.  Epigastric 
pain  is  common,  but  vomiting  is  not  especially  marked.  The  general 
health  may  suffer  but  little  for  a  long  time.    The  tumour  may  be  mis- 


MALFORMATIONS  AND  MALPOSITIONS  OF  INTESTINES.      341 

taken  for  cancer,  a  displaced  spleen  or  kidney,  faocal  impaction,  or  a  tu- 
mour of  the  omentum.  A  correct  diagnosis  is  seldom  made  until  opera- 
tion is  done.  In  a  few  instances  the  tumour  has  disappeared  after 
catharsis.    If  operation  is  done  the  outcome  is  almost  always  favourable. 


CHAPTER    VI. 
DISEASES  OF   THE  INTESTINES. 

MALFORMATIONS  AND   MALPOSITIONS. 

Malformations  are  not  very  frequent,  but  are  of  great  variety. 
With  the  exception  of  those  situated  at  the  lower  end  of  the  intestine 
they  are  not  of  much  practical  importance,  for  the  condition  is  such 
ordinarily  as  to  be  incompatible  with  life.  Malformations  may  be  met 
with  at  any  point  in  the  canal,  but  most  frequently  in  the  rectum  and 
anus.  Aside  from  these,  malformations  of  the  large  intestine  are  much 
less  common  than  those  of  the  small  intestine. 

Malformations  of  the  Rectum. — In  Fig.  50  are  shown  the  usual  vari- 
eties of  malformation  of  the  rectum.  The  most  frequent  is  atresia  of 
the  anus  (1).  In  this  the 
cutaneous  septum  has  not 
been  absorbed,  but  the  intes- 
tine is  normal  to  its  lower 
extremity.  This  form  is  read- 
ily curable  by  a  surgical  op- 
eration. In  the  next  variety 
(2)  the  cutaneous  orifice  and 
the  lower  part  of  the  rectum 
are  normal,  but  a  membrane 
separates  this  portion  from 
the  upper  part  of  the  gut;  this  is  usually  situated  within  two  or  three 
inches  of  the  anus.  The  bulging  of  the  lower  part  of  the  distended  in- 
testine can  usually  be  felt  by  the  finger  in  the  rectum,  and  a  simple 
division  of  the  membrane  by  a  guarded  bistoury  may  relieve  the  condi- 
tion. The  third  form  (3)  is  more  serious.  Here  the  rectum  terminates 
in  a  blind  pouch  at  a  variable  distance  from  the  anus,  and  is  represented 
below  by  an  impervious  fibrous  cord.  The  diagnosis  of  this  condition 
can  not  positively  be  made  without  opening  the  abdominal  cavity.  The 
bulging  of  the  intestine  appreciable  by  the  finger  in  the  rectum,  is  the 
only  point  which  differentiates  the  preceding  variety  from  this  one.  In- 
stead of  atresia  of  the  rectum  there  may  be  stenosis  of  varying  degrees, 
which  may  give  rise  to  the  usual  symptoms  of  stricture.  This  is  often 
curable  by  dilatation. 


-Malformations  of  the  Rectum. 
A,  anus;  R,  rectum. 


342  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

Malformations  of  the  Small  Intestine. — There  may  be  stenosis  or 
atresia  at  any  point,  often  at  many  points.  Obstruction  is  much  more 
frequent  in  the  upper  than  in  the  lower  part  of  the  small  intestine,  the 
most  common  seat  being  the  duodenum.  Atresia  is  more  often  seen  than 
stenosis.  There  may  be  a  single  point  of  obstruction,  or  the  lumen  of 
the  intestine  may  be  obliterated  for  a  considerable  distance,  the  intestine 
being  represented  only  by  a  fibrous  cord  which  connects  the  two  open  por- 
tions, or  there  may  be  no  connection  between  them.  In  all  cases  the  in- 
testine above  is  found  very  greatly  distended,  while  that  below  is  empty 
and  usually  atrophied.  The  causes  of  these  multiple  deformities  are 
mainly  two — foetal  peritonitis  and  volvulus.  In  foetal  peritonitis  there 
are  usually  found  bands  of  adhesions  between  the  intestinal  coils,  and  be- 
tween the  intestine  and  the  solid  viscera.  Syphilis  has  been  assigned  as 
a  cause  in  many  cases.  Volvulus,  or  a  twisting  of  the  intestine  during 
its  development,  is  a  more  satisfactory  explanation  for  the  majority  of 
the  cases,  especially  where  there  are  multiple  points  of  atresia.  All 
these  conditions  are  beyond  the  reach  of  surgical  treatment.  The  symp- 
toms appear  soon  after  birth  and  are  those  of  intestinal  obstruction. 
The  higher  the  point  of  obstruction  the  shorter  the  duration  of  life;  it 
is  rarely  more  than  a  week  in  any  case  of  atresia;  in  stenosis  it  may 
be  two  or  three  months. 

Meckel's  Diverticulum. — This  is  the  remains  of  the  omphalo-mesen- 
teric  duct,  which  in  foetal  life  forms  a  communication  between  the  intes- 
tine and  the  umbilical  vesicle.  It  is  given  off  from  the  ileum,  usually 
about  a  foot  above  the  ileo-caecal  valve.  Most  frequently  it  exists  as  a 
blind  pouch  from  one-half  to  two  or  three  inches  long,  communicating 
with  the  intestine.  At  the  extremity  of  this  there  may  be  a  fibrous  cord, 
which  is  free  in  the  abdominal  cavity  or  attached  to  the  umbilicus.  In 
other  cases  the  duct  may  remain  pervious  quite  to  the  umbilicus,  so  that 
there  is  a  faecal  fistula.  Prolapse  of  the  mucous  membrane  of  the  duct 
may  lead  to  an  umbilical  tumour,  described  elsewhere.  Meckel's  diver- 
ticulum, especially  when  present  as  a  cord  connecting  the  ileum  with  the 
umbilicus,  may  compress  a  coil  of  intestine,  leading  to  obstruction  or  even 
strangulation.     This  may  occur  in  infancy  or  later  in  life. 

Malpositions. — The  ascending  colon  may  be  found  upon  the  left  side. 
There  may  be  a  complete  transposition  of  the  abdominal  viscera.  In 
cases  of  congenital  umbilical  hernia  a  large  part  of  the  intestines  may  be 
found  in  the  tumour,  and  in  diaphragmatic  hernia  they  may  be  in  the 
thoracic  cavity. 

DIARRHCEA. 

The  term  diarrhcea  is  used  to  include  all  conditions  attended  by  fre- 
quent loose  evacuations  of  the  bowels.  These  depend  upon  an  increase 
in  peristalsis  and  in  the  intestinal  secretions. 


D1ARRH(1.A.  343 

The  importance  of  diarrhoeal  diseases  in  children  can  best  be  appre- 
ciated by  reference  to  the  following  table,  showing  the  mortality  of  diar- 
rhoeal disease  in  children  under  two  years,  as  compared  with  that  from 
certain  infectious  diseases  for  all  ages. 

Deaths  in  New  York  City  for  Five  Years. 


Measles,  all  ages 

Scarlet  fever,  all  ages 

Pertussis,  "     "     

Typhoid,  "     "     

Diphtheria,       "     "     

Total  deaths  from  five  diseases 

Diarrhoeal  disease  under  two  years  .  . 


3,378 
4,152 
2,000 
3,523 
10,277 

23,330 

26,563 


There  are  several  important  underlying  factors  upon  which  diarrhceal 
diseases  depend.  Their  greatest  frequency  belongs  to  the  first  year  of 
life;  and  after  the  second  year  a  notable  diminution  both  in  frequency 
and  severity  is  seen,  and  a  fatal  outcome  is  relatively  rare.  The  extreme 
susceptibility  in  infancy  is  due  to  several  causes.  The  digestive  organs 
are  severely  taxed  to  provide  for  the  needs  of  the  growing  body.  The 
mucous  membrane  of  the  gastro-enteric  tract  of  all  infants  is  very  deli- 
cate in  structure,  and  even  in  those  with  good  health  is  exceedingly 
vulnerable.  This  vulnerability  is  enormously  increased  in  the  very 
young,  and  in  those  who  are  feeble,  delicate,  or  suffering  from  any  form 
of  digestive  disorder.  The  mucous  membrane  of  the  digestive  tract  is 
furthermore  constantly  exposed  to  injury,  either  mechanical  or  chemical, 
and  to  infection. 

The  next  most  striking  fact  about  diarrhoeal  diseases  is  their  preva- 
lence during  the  summer  season.  This  is  graphically  shown  in  Fig.  51, 
where  are  given  by  months  the  mortality  records  for  New  York  City 
for  ten  years. 

Diarrhoeal  diseases  are  especially  frequent  in  cities  and  among  the 
poor,  for  here  are  found  united  the  three  great  causes — unfavourable 
hygienic  surroundings,  want  of  proper  care,  and  improper  food  and  feed- 
ing. Severe  and  even  fatal  cases  are,  however,  met  with  among  all 
classes  and  in  all  places.  Their  frequency  and  severity  are  both  increased 
by  want  of  cleanliness  and  bad  hygiene. 

But  intelligent  care  with  proper  feeding,  even  in  very  poor  surround- 
ings, may  enable  children  to  escape  serious  diarrhoea  in  summer. 

Everything  which  lowers  the  general  vitality  increases  the  liability  to 
diarrhoeal  diseases.  Chronic  disorders  of  digestion,  marasmus,  malnutri- 
tion, and  rickets  are  especially  important  factors. 

Occasionally  diarrhoea  and  dentition  are  closely  associated,  the  bowels 


344 


DISEASES  OF  THE   DIGESTIVE   SYSTEM. 


quickly  becoming  normal  when  the  teeth  have  pierced  the  gum.     These 
cases,  although  rare,  do  occasionally  occur. 

The  form  of  feeding  is  an  etiological  factor  of  the  first  importance. 
Of  1,943  fatal  cases  which  I  have  collected,  only  three  per  cent  had  the 
breast  exclusively.  Fatal  cases  of  diarrhceal  disease  in  nursing  infants 
are  rare.  It  is  not,  however,  artificial  feeding  per  se  that  is  to  be  blamed, 
but  ignorant  feeding  and  improper  food.  This  is  shown  by  the  relatively 
small  number  of  deaths  from  diarrhoeal  diseases  seen  among  the  intel- 
ligent well-to-do.  Breast-feeding  requires  but  little  experience,  and  may 
be  very  successfully  done  even  by  those  with  a  very  low  grade  of  intel- 
ligence and  among  the  poor;  but  artificial  feeding  is  not  successful 


F. 

C 

Jan. 

Feb. 

Mar. 

Apr. 

May. 

June. 

July. 

Aug. 

Sept. 

Oct. 

Not. 

Dec. 

11" 

25° 
20° 
15° 
10° 
5° 
0° 

1 

•8° 

\ 

, 

v* 

— 

— 

« 

* 

m° 

./ 

'•j 

1 

1   i> 

■■ 

^ 

# 

1 

* 

f 

V 

'- 

CO' 

* 

\ 

' 

' 

\ 

' 

1 

s 

1 

J 

\ 

* 

/ 

> 

k 

\ 

v 

r 

s 

. 

/ 

s. 

« 

> 

1 

»». 

■ 

^ 

u- 

^ 

^" 

■ 

< 

82° 

_ 

. 

__ 

_ 

^_ 

__ 

__ 

L. 

315   289   359   403   660  1103  12,168  6205  3611   1723  518   321 

FiQ.  51. — Mortality  from  Diarrhceal  Di.seases  in  New  York  for  Ten  Years  in 
Children  Under  Five;  Compared  with  the  Mean  Temperature  for  the  Same 
Period.     ,  mortality; ,  mean  temperature.     (Seibert.) 


unless  carried  on  with  much  intelligence  and  experience,  and  at  the  same 
time  with  a  certain  amount  of  money  to  secure  reliable  materials,  espe- 
cially pure  milk. 

That  impure  milk  can  cause  diarrhoea  in  infants  is  a  fact  that 
seems  established  beyond  question.  I  have  myself  seen  every  one  of 
twenty-three  healthy  children,  all  over  two  years  old,  occupying  one 
dormitory  cottage,  attacked  in  a  single  day  with  diarrhoea,  which  was 
traced  to  this  cause.  The  important  question  is  whether  impure  milk, 
especially  the  bacterial  contamination  of  milk,  is  the  chief  cause  of  the 
great  increase  of  diarrhoeal  diseases  in  summer,  or  whether  this  is  only 
one  of  the  factors,  others,  especially  atmospheric  heat,  being  really  more 
important.  Since  about  the  year  1890,  wlien  the  enormous  bacterial 
contamination  of  milk  began  to  be  appreciated,  the  opinion  has  pre- 
vailed that  in  this  was  to  be  found  the  real  cause  of  the  prevalence  and 
fatality  of  diarrhoeal  diseases  in  summer.  This  belief  carried  with  it 
the  expectation  that  by  furnishing  to  every  artificially  fed  infant  a  clean, 
fresh  milk,  or  milk  which  had  been  pasteurised  or  sterilised,  this  great 
cause  of  infant  mortality  could  largely  be  removed.     It  is  true  that  a 


DIARRHCEA. 


345 


great  reduction  in  infant  mortality  from  summer  diarrhceal  diseases  has 
been  effected  during  the  last  two  decades;  but  it  is  also  true  that  there 
has  been  quite  as  great  a  reduction  in  infant  mortality  in  other  seasons, 
and,  in  summer,  from  other  causes  than  diarrhceal  diseases.  (See  Fig. 
52.)     This  leads  us  to  raise  the  question,  whether  the  assumption  that 


189 

92 

93 

94 

95 

96 

97 

98 

99 

1900 

01 

02 

03 

04 

OS 

06 

07 

08 

09 

10 

1 

130 

L) 

e£ 

tHs 

unc 

er 

1 

y 

ec 

J 

per 

n 

JUL 

orPbi: 

u  at 

ion 

\ 

1 

120 

\ 

und 

er 

1 

Y 

e£ 

r, 

Ne 

w 

Ylor 

k 

Cty 

. 

\ 

110 

> 

\ 

100 

\ 

— 

>x 

90 

s 

'V 

\ 

80 

\ 

4 

t 

ur 

Tir 

ner 

M|0^ 

W 

IS 

All 

Ca^ 

ses 

\ 

70 

> 

^ 

"-J 

\ 

60 

s 

/ 

' 

^ 

N 

^ 

-" 

s 

\ 

/ 

\ 

/ 

60 

\ 

^ 

V 

ert^ 

ntai 

?e 

c 

t 

5U 

m 

rr 

er 

L 

e 

at 

1S  + 

ro 

m 

Uia 

•rho 

eal 

Us^ 

Use 

s. 

'n 

/" 

y 

— ^= 

'^►r 

"1 

\" 

- 

"" 

■x^ 

^,- 

'- 

-. 

J 

^ 

■' 

•^ 

. 

.-• 

s 

40 

f 

— 

-1 

N, 

, 

'' 

-- 

-" 

"" 

N 

.<' 

\, 

V 

r-. 

^ 

^ 

30 

"" 

^ 

^ 

s 

20 

4 

S 

ur 

in 

le 

■ 

vl 

pn 

tl- 

s. 

L 

larr 

loe^ 

J  U 

S( 

;a 

le 

s. 

S 

--' 

10 

n 

J 

130 


120 


no 


Fig.  52. — Deaths  Under  One  Year  per  1,000  of  Population  Under  One  Year, 
New  York  City.  A  comparison  of  summer  deaths  from  all  causes  with  summer 
deaths  from  diarrhceal  diseases  for  a  period  of  twenty  years. 

the  bacterial  contamination  of  milk  is  the  great  cause  is  correct,  and  also 
whether  the  lowered  mortality  in  summer  has  not  been  brought  about 
quite  as  much  by  other  conditions,  such  as  better  hygiene  and  care  and 
a  better  understanding  of  infant-feeding,  as  by  the  exclusion  of  germs 
from  milk  or  their  destruction  by  heat. 

In  the  years  1901  to  1903  an  investigation  ^  was  undertaken  by  The 
Eockefeller  Institute  in  co-operation  with  the  Health  Department  of 
New  York  to  secure  data  regarding  the  following  points:  (1)  The  re- 
sults in  infant-feeding  obtained  with  milk  of  different  degrees  of  purity 
both  in  winter  and  in  summer,  as  shown  by  the  gain  or  loss  in  weight, 
the  amount  of  gastro-intestinal  disturbance,  and  the  death  rate;  (2) 
the  relation,  if  any,  existing  between  the  number  of  bacteria  present  in 
the  milk  and  the  frequency  of  diarrhceal  disease;  (3)  whether  any 
organisms  with  pathogenic  properties  could  be  found  in  milk  to  which 
diarrhceal  disease  could  be  ascribed  as  a  cause;  (4)  whether  the  practice 
of  heating  milk — pasteurisation  or  sterilisation — affected  the  results  ob- 

*  The  full  report  of  this  investigation  was  published  by  Prof.  William  H.  Park  an<J 
the  author  in  the  Medical  News,  December  5,  1903, 


346  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

tained  with  any  given  milk;  (5)  to  what  degree  older  children  as  well 
as  infants  were  affected  by  bacterial  contamination  of  milk. 

Observations  were  made  upon  592  bottle-fed  infants  living  in  tene- 
ments of  New  York;  202  were  observed  in  winter  and  390  in  summer. 
The  infants  were  well  when  the  observations  were  begun,  and  were 
watched  for  a  period  of  about  three  months,  being  visited  regularly  by 
physicians,  who  gave  advice  when  needed.  For  some  of  the  children 
no  change  was  made  in  the  milk  which  they  were  already  taking;  for 
others  special  milk  was  provided.  Samples  of  milk  as  fed  to  the  chil- 
dren were  frequently  examined  as  to  the  number  and  character  of  the 
bacteria  present.  Observations  were  possible  upon  infants  taking  (1) 
condensed  milk,  (2)  the  cheapest  grade  of  store  milk,  such  as  is  usually 
purchased  by  the  poor,  (3)  a  better  grade  of  milk  delivered  in  bottles, 
(4)  the  best  bottled  milk  sold  in  the  city,  all  of  the  above  being  pre- 
pared at  home,  (5)  milk  modified  at  milk  depots  and  furnished  to  pa- 
tients in  separate  feeding-bottles. 

During  the  winter  period  of  observation,  the  mortality  was  but  2.5 
per  cent,  and  in  but  one  instance  was  death  due  to  disease  of  the  digestive 
tract.  The  health  of  the  infants  observed  was  not  appreciably  affected 
by  the  kind  of  milk  nor  by  the  number  of  bacteria  which  it  contained. 
The  different  grades  of  milk  varied  much  less  in  the  amount  of  bacterial 
contamination  in  winter  than  in  summer,  the  cheap  store  milk  averaging 
only  about  750,000  per  c.c. 

During  the  summer  period,  the  mortality  was  10.5  per  cent,  four- 
fifths  of  the  deaths  being  due  to  diarrhceal  disease.  The  worst  results 
were  seen  in  those  whose  food  was  either  the  cheap  grade  of  store  milk 
or  condensed  milk,  and  in  those  who  received  the  poorest  care.  The  best 
results  were  seen  in  those  whose  food  was  the  best  grade  of  bottled  milk, 
or  modified  milk  furnished  from  milk  depots,  and  in  those  who  received 
the  best  care. 

The  number  of  bacteria  which  milk  may  contain  before  it  becomes 
noticeably  harmful  to  the  average  infant  in  summer  is  not  at  all  uniform. 
Of  the  usual  varieties  present,  no  strikingly  deleterious  results  were  seen 
until  the  number  approached  the  one  million  mark.  But  much  above 
this  point  injurious  effects  were  usually  manifest.  Below  it  other  factors 
rather  than  the  number  of  bacteria  seemed  of  greater  importance  in 
producing  diarrhoea.  Thus  in  condensed  milk,  prepared  as  it  usu- 
ally was  with  hot  water,  the  bacterial  contamination  was  relatively  small, 
yet  the  results  were  almost  as  bad  as  with  the  most  highly  contaminated 
milk. 

No  relationship  could  be  discovered  between  any  special  forms  of 
bacteria  present  in  the  milk  and  the  health  of  children.  The  patiiogenic 
properties  of  139  varieties  of  bacteria  isolated  from  milk  were  tested 
upon  animals  in  various  ways,  chiefly  by  feeding  pure  cultures  to  young 


DIARRHOEA. 


347 


kittens.  The  results  were  negative.  Nor  could  a  relationship  be  estab- 
lished in  any  other  way  between  any  special  form  of  bacteria  in  milk 
and  the  summer  diarrhoeas  of  infancy. 

To  test  the  effect  of  heating  milk,  observations  were  made  during 
two  summers  upon  92  infants  who  were  taking  the  modified  milk  pre- 
pared at  a  milk  depot.  The  milk  used  was  from  a  good  farm,  and  had 
been  kept  properly  cooled.  The  infants  were  divided  into  two  groups  as 
nearly  alike  as  possible.  To  one  group  the  milk  was  given  pasteurised 
(lf)5°  ¥.  for  thirty  minutes),  to  the  otlier  group  the  same  kind  of  milk 
was  given  raw.  All  the  infants  were  well  at  the  beginning  of  the  j)eriod 
of  observation.    The  results  are  shown  in  the  following  table: 


Total 

Remained 

Had 

Average 

Food. 

number  of 

well  entire 

severe 

days 

Deaths. 

infants. 

summer. 

diarrhcea. 

diarrhoea. 

Pasteurised  milk  containing  1,000 

to  50,000  bacteria  per  c.c.  at  the 

time  of  use. 

41 

31 

10 

4 

1 

Raw  milk  containing  1,200,000  to 

20,000,000  bacteria  per  c.c.  at 

the  time  of  use 

51 

17 

34 

lli 

2 

Thirteen  of  the  fifty-one  infants  on  raw  milk  were  changed  before 
the  end  of  the  season  to  pasteurised  milk  because  of  serious  diarrhoea; 
but  for  this  the  results  with  raw  milk  would  have  been  even  more  un- 
favourable. A  similar  experiment  was  made  a  third  season  with  almost 
identical  results.  Although  the  number  of  cases  is  not  large,  the  results, 
which  were  practically  uniform  for  three  successive  seasons,  show  un- 
mistakably that  in  hot  weather  raw  milk,  although  from  a  good  source, 
but  at  the  time  of  feeding  highly  contaminated  with  bacteria,  causes  ill- 
ness in  a  much  larger  number  of  cases  than  when  it  has  been  previously 
heated. 

After  the  first  two  years,  children  are  much  less  affected  by  bacteria 
in  milk.  The  observations  seemed  to  show  that  milk  from  healthy  cows, 
produced  under  cleanly  conditions  and  kept  at  a  temperature  below 
60°  F.,  although  containing  large  numbers  of  bacteria,  sometimes 
amounting  to  many  millions  per  c.c,  might  be  taken  in  considerable 
quantities  and  for  long  periods  by  children  over  three  years  old,  without 
any  appreciably  harmful  effects  resulting  either  from  the  living  bacteria 
or  their  toxins.  A  single  example  is  typical  of  a  number  of  observations 
made.  An  orphan  asylum,  containing  650  children  from  three  to  four- 
teen years  old,  used  during  an  entire  summer  milk  in  which  the  bacteria 
ranged  from  2,000,000  to  20,000,000  per  c.c. ;  yet  during  this  period  there 
occ)irred  no  case  of  diarrhoea  of  sufficient  severity  to  call  a  physician. 
The  milk  was  kept  cold  (below  60°  F.)  until  used;  but  was  given  with- 
out sterilisation. 


348  DISEASES  OF  THE  DIGESTH'E  SYSTEM. 

Mere  numbers  of  bacteria  certainly  appear  to  count  for  much  less 
than  was  once  supposed.  But  the  fact  should  not  be  overlooked  that 
milk  abounding  in  bacteria  because  of  careless  handling  is  also  always 
liable  to  contain  pathogenic  organisms  derived  from  human  or  animal 
sources.  These  observations,  continued  for  three  seasons  and  giving 
each  summer  nearly  identical  results,  indicate  that  we  are  to  seek  else- 
where than  in  a  moderate  bacterial  contamination  of  milk  the  great 
cause  of  summer  diarrhoeas.  Though  it  is  clear  that  excessive  contam- 
ination is  highly  detrimental  to  infants,  we  must  certainly  look  to  the 
other  factors  for  the  explanation  of  a  very  large,  possibly  the  largest, 
proportion  of  the  cases.  Of  the  other  factoi-s,  atmospheric  heat  is  clearly 
first  in  importance.  This  may  act  by  so  interfering  with  normal  diges- 
tion and  metabolism  as  to  lead  to  the  formation  within  the  body  of  in- 
jurious substances  which  excite  diarrhoea ;  or  it  may  favour  the  excessive 
growth  of  bacteria  ordinarily  present  in  the  digestive  tract.  In  this 
group  of  cases  the  role  of  the  bacteria  seems  to  be  secondary,  though 
perhaps  a  very  important  one.  According  to  this  hypothesis,  the  cause 
of  the  diarrhoeas  under  consideration  is  not  something  introduced  from 
without,  but  something  produced  within  the  body  itself. 

Another  group  of  diarrhoeal  diseases  exists  which  may  be  due  to  in- 
fection introduced  from  without,  through  water,  milk,  or  other  food; 
to  these  the  term  dysentery  is  more  often  applied.  These  cases  have 
been  found  to  be  associated  with  definite  bacteria  or  amoebae.  It  is  likely 
that  intestinal  disease  of  this  type  may  supervene  upon  the  preceding  one. 

ACUTE  INTESTINAL  INDIGESTION  AND  INTOXICATION. 

The  eases  included  in  this  chapter  comprise  many  types  which,  how- 
ever, are  closely  allied  and  shade  into  one  another.  Though  the  extremes 
of  the  series  differ  as  widely  as  possible,  yet  intermediate  types  of  almost 
every  grade  are  met  with.  They  are  discussed  under  a  single  heading, 
since  they  have  no  essential  anatomical  differences,  nor,  so  far  as  yet 
determined,  do  they  differ  etiologically.  Some  of  the  attacks  are  so 
mild  in  character  that  in  children  with  normal  resistance,  and  receiving 
prompt  treatment,  they  may  last  but  a  few  hours.  On  the  other  hand, 
they  may  be  so  rapid  in  development  and  so  severe  as  to  result  in  death 
in  a  few  hours ;  or,  beginning  with  less  intensity,  they  may  be  the  start- 
ing point  of  prolonged  functional  disorders  or  may  prepare  the  way  for 
the  development  of  infectious  processes. 

Etiology. — The  most  important  causes  have  been  mentioned  in  the 
foregoing  discussion  on  the  General  Etiology  of  Diarrhoeal  Diseases.  A 
predisposition  to  attacks  is  furnished  by  summer  weather,  a  delicate  con- 
stitution, and  any  previous  derangement  of  digestion.  The  exciting  cause 
of  an  attack  may  be  the  use  of  improper  food,  overfeeding  or  some  sudden 


ACUTE  INTESTINAL  INDIGESTION   AND   INTOXICATION.    349 

change  in  food  as  in  weaning;  but,  the  food  remaining  unchanged, 
it  is  often  otlier  influences  affecting  the  cliild,  such  as  summer  heat. 
The  most  striking  thing  about  these  cases  is  their  prevalence  during 
liot  weather.  Year  after  year  are  repeated  in  New  York  the  conditions 
which  are  graphically  represented  in  Fig.  51,  viz.,  an  epidemic  which, 
beginning  in  June,  rapidly  increases  in  severity,  reaching  its  height  usu- 
ally in  July,  from  which  time  it  diminishes  steadily,  regularly  coming 
to  an  end  in  September.  What  is  true  of  New  York  is  true  also  of  Phil- 
adelphia, Chicago,  and  other  large  cities  of  the  temperate  zone.  The 
severity  of  the  epidemic  bears  a  fairly  close  relation  to  the  height  of  the 
summer  temperature.  Thus  in  Chicago  and  Philadelphia,  of  the  deaths 
under  one  year,  32  per  cent  are  due  to  acute  gastro-intestinal  diseases; 
in  New  York,  27  per  cent;  in  Boston,  19  per  cent;  in  London,  only  13 
per  cent.  A  comparison  of  the  mortality  and  temperature  curves  shows 
that  while  the  mean  temperature  rises  gradually  during  April  and  May, 
it  is  not  until  a  certain  temperature  is  reached,  that  any  notable  increase 
in  diarrhoeal  diseases  begins. 

Despite  the  fact  that  since  1886  many  series  of  bacteriological  studies 
of  the  intestinal  discharges  have  been  made  by  Booker  and  Park  in 
this  country,  by  Baginsky,  Escherich,  and  others  in  Germany,  our  knowl- 
edge of  this  subject  is  still  very  incomplete.  The  conditions  are  exceed- 
ingly complicated,  and  the  problem  is  a  very  difficult  one.  So  far  as  is 
now  known,  no  one  form  of  bacteria  can  be  assigned  as  the  cause  of  this 
group  of  diarrhoeas.  There  seems  to  be  evidence  that  the  Shiga  bacillus 
may  produce  diarrhoeal  disease  which  clinically  docs  not  differ  from  this 
type.  But  it  is  wanting  in  so  large  a  proportion  of  cases,  that  it  can 
not  be  regarded  as  a  specific  cause.  With  existing  knowledge  it  seems 
probable  that  there  are  a  number  of  organisms  present  in  the  intestine 
in  disorders  of  digestion,  which,  under  favourable  conditions,  may 
multiply  to  such  a  degree  as  to  produce  serious  disturbances.  But  the 
role  of  the  micro-organisms  may  be  regarded  as  a  secondary  one. 

There  are  certain  cases  in  which  toxic  symptoms  of  a  severe  type 
develop  abruptly  in  children  previously  quite  well.  These  only  are  to 
be  regarded  as  examples  of  acute  milk  poisoning.  Although  the  bacteria 
in  the  milk  may  have  been  previously  destroyed  by  sterilisation,  the 
toxins  produced  by  them  may  still  be  present.  This  is  doubtless  the 
explanation  of  the  simultaneous  development  of  several  cases  in  families 
or  institutions. 

We  can  not  believe  that  direct  contagion  is  the  usual  way  in  which 
this  disease  is  spread.  When  occurring  in  institutions  or  in  families, 
it  usually  happens  that  a  number  of  children  are  attacked  simulta- 
neously rather  than  successively,  this  indicating  a  common  cause,  usu- 
ally to  be  found  in  the  food,  the  surroundings,  or  the  atmospheric  con- 
ditions. 


350  DISEASES  OF  THE  D1GESTI\^  SYSTEM. 

Lesions. — In  the  milder  cases  which  end  in  recovery,  the  anatomical 
clianges  are  negligible.  In  tliose  which  prove  fatal  from  the  disease 
itself,  or  from  some  associated  condition,  the  lesions  are,  in  brief,  a 
superficial  catarrhal  inflammation  affecting  the  entire  gastro-enteric 
tract,  but  varying  much  in  severity  in  the  different  regions  and  in  the 
different  cases.  The  colon,  the  lower  ileum,  and  the  stomach  are  apt  to 
suffer  most,  the  duodenum  and  the  jejunum  least. 

The  Gross  Appearances. — These  may  show  but  little  that  is  abnormal. 
The  walls  of  the  stomach  may  be  coated  with  mucus,  and  the  mucous 
membrane  may  show  intense  congestion,  generally  in  patches,  or  it  may 
be  pale.  The  mucous  membrane  of  the  small  intestine  may  he  pale 
throughout;  there  are  often  irregular  areas  of  congestion,  or  a  very 
intense  congestion  of  a  large  part  of  its  surface,  particularly  in  the 
ileum.  With  this  there  may  be  redness  and  swelling  of  Peyer's  patches 
and  the  solitary  follicles.  In  the  colon  the  mucous  membrane  is  con- 
gested, espei'ially  upon  the  rugje.  The  solitary  follicles  are  usually 
swollen.  The  changes  described  are  not  at  all  uniform,  and  do  not  differ 
very  greatly  from  the  appearances  often  seen  in  the  intestines  when 
patients  have  died  of  other  diseases. 

In  the  cases  classed  clinically  as  cholera  infantum,  the  pathological 
changes  are  more  characteristic.  The  greater  part  of  the  small  intes- 
tine, and  sometimes  the  entire  colon,  are  distended  with  gas,  and  contain 
material  of  a  grayish-white  colour  about  the  consistency  of  a  thin  gruel. 
It  has  a  mawkish  odour,  but  usually  not  a  very  offensive  one.  The 
mucous  membrane  of  the  entire  intestinal  tract  has  in  most  cases  a  pale, 
"  washed-out "  ap|)earance.  Sometimes  this  is  seen  only  in  the  small 
intestine,  while  tliere  are  areas  of  congestion  in  the  colon.  If  cholera  in- 
fantum has  l)een  engrafteii  upon  some  other  pathological  prwess  in  the 
intestines,  as  is  not  infrequent,  there  is  found  post-mortem  evidence  of 
this  in  the  form  of  severe  catarrhal  inflammation,  sometimes  old  ulcera- 
tions. 

The  Microscopical  Appearances. — Unless  autopsies  are  made  very 
soon  after  death — ^at  most  within  four  hours — it  is  not  safe  to  draw 
conclusions  from  the  conditions  found,  as  post-mortem  changes  take  place 
readily,  and  resemble  those  of  the  disease  under  consideration.  This 
applies  particularly  to  the  condition  of  the  epithelium. 

The  essential  lesion  consists  in  degenerative  changes  in  the  epithe- 
lium of  the  stomach  and  intestines.  The  cells  may  still  be  present,  but 
with  the  cell  protoplasm  and  nuclei  so  changed  that  they  do  not  stain 
normally.  In  more  severe  and  prolonged  cases  the  superficial  epithelium 
in  places  is  entirely  destroyed;  these  changes  mark  the  beginning  of 
ileo-colitis. 

The  changes  in  and  about  the  blood-vessels  are  variable.  The  small 
vessels  may  be  distended,  and  there  may  be  hannorrhages  or  an  exuda- 


ACUTE  INTESTINAL  INDIGESTION    AND   IXTr)XICATION.    351 

tion  of  leucocytes  in  their  neighbourhood.  These  a|)j)Cfiran(('s  an;  seen 
either  in  the  mucous  or  submucous  layer.  Poyer's  patches  and  the  lymph 
nodules  may  be  enlarged  from  cell-proliferation.  Pathologically  no  sharp 
line  can  be  drawn  between  these  lesions  and  those  of  the  early  stage  of 
ileo-colitis ;  the  latter  affect  the  lower  ileum  and  colon  chiefly,  often  ex- 
clusively, are  more  advanced,  and  involve  the  deeper  parts  of  the  intes- 
tinal wall. 

Lesions  in  Other  Organs. — These  are  much  less  frequent  and  less 
severe  than  in  the  more  protracted  cases  of  ileo-colitis.  Acute  bronchitis 
and  broncho-pneumonia  are  frequent.  Acute  degeneration  of  the  kidney 
•  is  found  to  some  degree  in  every  case  which  is  severe  enough  to  cause 
death,  and  in  a  few  there  is  acute  nephritis.  In  rare  cases  a  general 
septicaemia,  due  most  frequently  to  the  streptococcus,  is  present.  Degen- 
erative changes  are  sometimes  found  in  the  liver  cells,  and  even  in  the 
nervous  centres. 

Symptoms. — Clinically,  these  cases  may  be  divided  into  three  groups: 
(1)  The  mild  form,  with  definite  local  symptoms,  but  few  general  ones; 
they  may  be  of  short  duration  or  protracted;  (2)  the  severe  form  in 
which  there  are  not  only  local  but  marked  constitutional  symptoms, 
fever,  etc.;  (3)  cholera  infantum,  the  more  severe  and  fatal  type  met 
with. 

The  Mild  Form. — In  infants,  acute  indigestion  is  seldom  limited 
either  to  the  stomach  or  to  the  intestine,  although  in  one  case  the  dis- 
turbance of  the  stomach  is  slight  and  that  of  the  intestine  serious,  and 
in  another  the  reverse  may  be  observed.  In  these  little  patients  the 
intestinal  symptoms  are  more  frequent,  and,  as  a  rule,  more  severe  than 
those  referable  to  the  stomach.  In  older  children  it  is  not  uncommon 
to  see  the  intestinal  symptoms  alone.  In  infants,  if  the  attack  develops 
suddenly,  gastric  symptoms  are  usually  present;  if  more  gradually,  they 
are  usually  absent.  The  local  symptoms  are  colicky  pain,  tympanites, 
and  later  diarrhoea.  The  constitutional  symptoms,  prostration  and 
nervous  disturbances,  are  slight  or  absent.  Pain  is  indicated  by  the 
sharp,  piercing  cry,  great  restlessness,  and  drawing  up  of  the  legs.  Tym- 
panites is  rarely  very  marked.  The  stools  are  always  increased  in  number 
and  are  from  four  to  twelve  a  day.  If  more  frequent  they  are  very 
small.  The  first  stools  are  more  or  less  faecal,  but  this  character  is  soon 
lost.  The  colour  is  at  first  yellow,  then  yellowish-green,  and  finally  often 
grass-green.  This  colour  is  due  to  biliverdin.  If  the  child  has  been 
taking  milk,  masses  of  undigested  milk,  chiefly  fat,  are  present.  The 
reaction  of  the  stools  is  almost  invariably  acid.  The  odour  may  be  sour, 
or  it  may  be  foul.  The  stools  are  much  thinner  than  normal,  and  often 
frothy  from  the  presence  of  gases.  Blood  is  not  present,  nor  is  much 
mucus  seen,  unless  the  symptoms  have  lasted  several  days.  The  micro- 
scope shows,  in  addition  to  food-remains,  epithelial  cells,  usually  of  the 


352  DISEASES  OF  THE  DIGESTI\T5  SYSTEM. 

cylindrical  variety,  which  are  numerous  in  proportion  to  the  severity  and 
duration  of  the  attack.  The  bacteria  are  the  ordinary  forms  found  in 
the  faeces. 

The  course  and  termination  of  the  disease  depend  upon  the  previous 
condition  of  the  patient,  the  nature  of  the  exciting  cause,  and  the  treat- 
ment employed.  In  a  previously  healthy  child,  if  the  cause  is  at  once 
removed  and  proper  treatment  instituted,  the  severe  symptoms  rarely 
last  more  than  a  day  or  two,  and  in  four  or  five  days  the  patient  may  be' 
quite  well.  In  delicate  infants,  a  severe  attack  of  acute  intestinal  in- 
digestion in  the  hot  season  is  likely  to  prove  the  first  stage  of  a  patholog- 
ical process  which  may  continue  until  serious  organic  changes  in  the 
intestine  have  taken  place.  This  result  may  not  follow  the  first  attack, 
but  one  is  often  succeeded  by  others  until  it  occurs.  If  circumstances 
are  such  that  proper  dietetic  treatment  and  general  hygienic  measures 
can  not  be  carried  out,  this  termination  is  very  common. 

In  older  children  most  of  the  cases  seen  are  of  the  milder  type.  The 
onset  is  often  with  vomiting;  pain  is  generally  mild  and  precedes  diar- 
rhoea by  several  hours.  It  is  seldom  localised  but  is  more  often  re- 
ferred to  the  navel.  The  stools  are  loose,  frequent,  and  contain  un- 
digested food,  and  are  of  almost  every  conceivable  colour  and  variety. 
The  temperature,  if  elevated  at  all,  is  so  only  for  a  short  time. 
There  is  general  "anorexia  and  a  coated  tongue.  With  proper  treatment 
the  attack  is  usually  over  in  a  few  days,  being  very  seldom  fol- 
lowed by  the  severer  types  of  diarrhoea,  as  is  so  commonly  the  case  with 
infants. 

The  Severe  Form. — This  may  follow  after  several  days  of  an  ap- 
parently mild  attack,  especially  during  hot  weather  or  if  improperly 
treated.  In  the  cases  developing  suddenly,  the  clinical  picture  is  quite  a 
definite  one. 

An  infant  is  restless,  cries  much,  sleeps  but  a  few  minutes  at  a  time, 
and  seems  in  distress.  The  skin  is  hot  and  dry,  the  temperature  rises 
rapidly  to  102°  or  103°  F.,  sometimes  to  106°  F.,  and  all  the  symptoms 
indicate  the  onset  of  some  serious  illness.  He  may  lie  in  a  dull  stupor, 
with  eyes  sunken,  weak  pulse,  and  general  relaxation,  or  there  may  be 
restlessness,  excitement,  and  even  convulsions.  There  may  be  great 
thirst,  so  that  everything  offered  is  eagerly  taken,  or  everything  may  be 
refused.  Vomiting  may  be  an  early  and  important  symptom.  It  is  first 
of  food,  often  that  which  was  taken  many  hours  before;  retching  con- 
tinues even  after  the  stomach  has  been  emptied,  so  that  mucus,  serum, 
and  sometimes  bile  may  be  ejected.  Vomiting  does  not  usually  persist 
throughout  the  attack,  and  in  many  cases  it  is  absent  altogether.  Diar- 
rhoea is  sometimes  delayed  for  twenty-four  hours  or  even  longer  after 
the  beginning  of  the  grave  constitutional  symptoms.  At  first  there  are 
faecal  stools,  then  great  bursts  of  flatus,  with  the  expulsion  of  a  thin 


ACUTE   INTESTINAL   INDIGESTION   AND  INTOXICATION.     353 

yellow  material  with  an  offensive  odour.  Four  or  five  such  discharges 
may  occur  in  as  many  hours.  At  other  times  the  stools  are  gray,  green, 
or  greenish-yellow,  and  sometimes  brown.  The  characteristic  features 
are  the  amount  of  gas  expelled,  the  colici-cy  pains  preceding  the  dis- 
charges, and  the  foul  odour.  After  the  first  day  the  stools  may  be  almost 
entirely  fluid,  varying  in  number  from  six  to  twenty  a  day,  and  often 
large  even  then.  Their  offensive  character  usually  continues.  After 
two  or  three  days  mucus  appears.  The  microscopical  examination  of  the 
stools  shows  great  numbers  of  separate  epithelial  cells,  and  sometimes 
groups  of  cells  attached  to  a  basement  membrane.  In  addition  there 
may  be  leucocytes  and  some  red  blood-corpuscles. 

In  many  cases  the  free  evacuation  of  the  bowels  is  followed  by  a  drop 
in  the  temperature  and  subsidence  of  the  nervous  symptoms,  and  the 
child  may  fall  asleep.  The  prostration,  though  often  great  in  the  be- 
ginning, may  not  be  of  long  duration.  Under  the  most  favourable  cir- 
cumstances, after  one  or  two  days  of  severe  symptoms,  convalescence  may 
take  place.  The  stools  continue  frequent  for  five  or  six  days,  but  grad- 
ually assume  their  normal  character,  and  recovery  follows.  The  chief 
factors  contributing  to  such  favourable  results  are  a  good  constitution 
on  the  part  of  the  child,  prompt  and  intelligent  treatment  at  the  outset, 
and  proper  feeding  afterward. 

If  the  circumstances  are  not  so  favourable,  if  the  patient  is  a  very 
young  or  delicate  infant,  there  may  be  no  reaction  from  the  first  severe 
symptoms,  and  the  attack  may  terminate  fatally  in  from  one  to  three 
days.  In  such  cases  the  temperature  remains  high;  the  stomach  may 
or  may  not  be  disturbed;  but  the  diarrhoea,  jarostration,  and  nervous 
symptoms  continue,  and  death  occurs  from  exhaustion,  in  coma  or  con- 
vulsions. Instead  of  a  rapidly  fatal  termination,  the  severity  of  the 
early  acute  symptoms  may  abate  somewhat,  and  the  attack  assume  the 
character  of  ileo-colitis,  with  a  lower  but  continuous  temperature  of 
100°  to  102°  F.,  frequent  mucous  stools,  wasting,  etc.  The  urine  is 
scanty  and  concentrated,  and  in  most  of  the  severe  cases  with  very  high 
temperature  contains  a  small  amount  of  albumin,  and  occasionally  a 
few  hyaline  and  granular  casts.  These  are  the  result  of  degenerative 
changes  in  the  renal  epithelium.  In  rare  cases  there  are  evidences  of 
acute  nephritis.     Broncho-pneumonia  is  sometimes  seen. 

It  not  infrequently  happens,  after  the  storm  of  the  acute  attack  with 
its  high  temperature,  intense  prostration,  and  grave  nervous  symptoms 
is  passed,  and  the  stools  are  so  much  improved  that  the  patient  is  re- 
garded as  out  of  danger,  that  all  the  former  symptoms  may  develop  with 
such  rapidity  and  severity  as  sometimes  to  carry  off  the  patient  in  from 
twelve  to  twenty-four  hours.  Such  relapses  are  generally  excited  by 
some  mistake  in  the  diet,  usually  that  of  allowing  milk  too  soon.     The 

amount  of  milk  given  may  be  small,  and  yet  the  symptoms  follow  its 
24 


354 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


are 

the  cause  is  usu- 
some    error    in 


administration  so  soon  that  there  can  be  little  doubt  regarding  the  con- 
nection  between   them    (Fig.    53).      Besides   such   severe  cases,   many 

milder     relapses 
seen 
ally 
diet. 

Cases  withont  Di- 
arrhoea.— Attacks  of 
acute  intestinal  indi- 
gestion with  severe 
intoxication  in  which 
there  is  no  diarrhoea, 
but  constipation  in- 
stead, are  most  puz- 
zling and  frequently 
most  serious.  Fortu- 
nately, they  are  not  of 
common  occurrence.  I 
have,  however,  seen 
several  striking  exam- 
ples with  very  high 
temperature,  grave 
nervous  symptoms, 
and  sometimes  marked 
abdominal  distention  in  which  it  seemed  almost  impossible  to  move  the 
bowels  by  drugs.  Castor  oil,  calomel,  and  salines  have  in  some  cases 
been  tried  in  succession  in  four  or  five  times  the  ordinary  doses  with- 
out the  slightest  effect,  even  when  supplemented  by  frequent  intestinal 
irrigation.  It  has  sometimes  been  nearly  two  days  before  free  move- 
ments were  finally  produced.  These  are  often  exceedingly  foul.  It  is 
somewhat  difficult  to  explain  such  cases.  There  seems  to  exist  for  the 
time  almost  complete  intestinal  paralysis.  The  toxic  materials  are  locked 
up  in  the  small  intestine,  for  the  colon  is  frequently  quite  empty.  When 
one  meets  such  a  case  he  can  appreciate  the  fact  that  diarrhoea  is  a  con- 
servative process  of  the  greatest  possible  value. 

In  children  over  two  years  old  there  are  seen  some  features  which 
differ  from  those  of  the  cases  above  described  as  occurring  in  infants. 
The  attacks  are  more  often  due  to  other  causes  than  to  milk.  Vomiting 
does  not  occur  so  readily  as  in  infants,  pain  is  a  more  prominent  symp- 
tom, and  the  temperature,  as  a  rule,  is  lower.  The  nervous  symptoms  are 
much  less  prominent.  Skin  eruptions,  however,  are  more  frequently 
seen,  particularly  urticaria,  which  is  a  feature  of  most  severQ  attacks, 
and  in  obscure  cases  has  some  diagnostic  value.  Although  often  begin- 
ning with  severe  symptoms,  these  cases  usually  make  good  recoveries; 


FiQ.  53. — Acute  Intestinal  Intoxication  with  Fatal 
Relapse.  Infant  five  months  old;  early  symptoms, 
both  intestinal  and  nervous,  severe;  rapid  improvement 
followed  stopping  milk,  free  catharsis  and  irrigation. 
After  stools  had  been  nearly  normal  for  three  days  re- 
lapse occurred,  apparently  from  adding  milk  to  the  diet, 
although  less  than  two  ounces  a  day  were  given.  Au- 
topsy: Only  mild  intestinal  lesions  were  present;  other 
organs  essentially  normal. 


ACUTE   INTESTINAL   INDIGESTION   AND   INTOXICATION.    355 

there  is  much  less  danger  of  their  going  on  to  the  development  of  ileo- 
colitis than  in  the  case  of  infants. 

Diagnosis. — The  acute  indigestion  manifested  by  vomiting  and  diar- 
rhceal  stools  which  marks  the  beginning  of  so  many  febrile  diseases  in 
infancy,  particularly  scarlet  fever,  pneumonia,  malaria,  and  influenza, 
is  often  difficult  to  distinguish  from  more  severe  attacks  with  intestinal 
intoxication.  The  question  to  decide  is  whetlier  the  digestive  symptoms 
are  the  cause  or  the  result  of  the  fever.  It  is  sometimes  not  until  the 
case  has  been  watched  for  some  time  that  one  can  l)e  certain.  Usually 
where  digestive  symptoms  are  secondary  they  diminish  after  the  first  day 
or  two,  although  the  severity  of  the  general  symptoms  may  steadily  in- 
crease. Where  the  nervous  symptoms  are  prominent  at  the  outset,  it 
is  sometimes  difficult  to  exclude  meningitis.  I  have  seen  many  cases 
where  great  doubt  existed  for  several  days.  One  should  always  hesitate 
to  make  a  diagnosis  of  meningitis  when  marked  diarrhoea  is  present. 

Prognosis. — Attacks  of  intestinal  indigestion  do  not  often  prove 
fatal,  except  in  young  infants  or  those  already  suffering  from  malnutri- 
tion. In  all  cases  the  prognosis  depends  upon  the  previous  health  of  the 
child,  his  surroundings,  the  season  of  the  year,  and  whether  or  not  the 
case  receives  prompt  and  proper  treatment.  A  continuously  high  tem- 
perature and  severe  nervous  symptoms  are  bad  prognostic  signs.  The 
existence  of  rickets,  pertussis,  or  any  other  disease,  greatly  increases  the 
gravity  of  the  attack. 

Prophylaxis. — A  better  understanding  of  the  etiology  brings  with  it 
great  possibilities  in  the  prevention  of  this  disease. 

Prophylaxis  must  have  regard,  first,  to  the  hygienic  surroundings  of 
children,  and  to  all  sanitary  conditions  of  cities.  City  children  should 
be  sent  to  the  country,  whenever  it  is  possible,  for  the  months  of  July 
and  August.  Where  a  long  stay  is  impossible,  day  excursions  do  much 
good.  The  fresh-air  funds  and  seaside  homes  have  done  much  in  New 
York  to  diminish  the  mortality  from  diarrhoeal  diseases. 

The  second  part  of  prophylaxis  relates  to  food  and  feeding.  Mater- 
nal nursing  should  be  encouraged  by  every  possible  means.  Nothing  is 
better  established  than  the  close  relation  existing  between  artificial  feed- 
ing and  diarrhoeal  diseases.  Yet,  as  stated  elsewhere,  it  is  not  artificial 
feeding  per  se,  but  ignorant  iand  improper  feeding.  Among  infants  in 
private  practice  who  are  properly  fed  these  attacks  are  not  common. 

Overfeeding  is  particularly  to  be  avoided  during  days  of  excessive 
heat.  It  is  at  such  times  an  excellent  rule  with  infants  to  diminish  each 
feeding  by  at  least  one-half,  making  up  the  deficiency  with  water,  and  to 
give  water  very  freely  between  the  feedings.  In  summer  all  water  given 
to  infants  or  young  children  should  be  boiled.  Children,  like  adults, 
require  less  food  in  very  hot  weather,  but  more  water.  Infants  cry  more 
from  thirst  and  heat  than  from  hunger,  and  even  those  at  the  breast  are 


356  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

likely  to  be  given  too  much  food.  Infants  should  never  be  fed  more  fre- 
quently, but  always  less  frequently,  during  hot  weather. 

A  very  important  work  in  practical  philanthropy  among  the  poor  of 
our  large  cities  in  summer  is  to  provide  means  for  supplying  pure  milk 
to  infants.  This  has  been  done  on  a  large  scale  in  many  American 
cities,  and  it  is  one  of  the  important  agencies  that  have  affected  a  decided 
reduction  in  the  death-rate  from  diarrhoeal  disease.  It  is  not  enough  to 
furnish  to  the  poor  a  pure,  clean  milk  in  bulk,  or  even  in  sealed  quart 
bottles.  The  advantages  of  such  milk  may  be  entirely  lost  by  the  way 
in  which  it  is  cared  for  in  the  home  or  the  way  in  which  it  is  fed  to 
infants.  Since  the  milk  must  usually  be  kept  at  home  without  ice,  steril- 
isation at  212°  F.  is  advisable.  When  milk  is  distributed  from  milk 
depots,  a  physician  should  be  in  charge  who  can  keep  a  general  super- 
vision over  the  children,  and  advise  as  to  the  quantity  of  food,  number 
of  feedings,  and  the  formula  to  be  used.  His  work  should  be  supple- 
mented by  visits  of  nurses  to  the  homes  of  patients.  An  essential  feature 
is  to  keep  such  close  supervision  over  the  infants  as  to  recognise  at  once 
and  promptly  treat  slight  disturbances  of  digestion. 

But  even  more  important  than  pure  milk  is  the  education  of  the 
poor  in  all  matters  relating  to  infant  feeding  and  hygiene.  In  no  way 
can  this  educational  work  better  be  done  than  in  connection  with  milk 
distribution. 

Hygienic  Treatment. — If  the  attack  is  a  severe  one  and  occurs  in  the 
excessive  heat  of  midsummer,  and  does  not  readily  yield  to  treatment, 
the  child  should,  if  possible,  be  sent  to  a  cooler  place.  Convalescent  cases 
should  also  be  sent  away  on  account  of  the  dangers  of  relapse.  Usually 
the  seashore  is  to  be  preferred  to  the  mountains,  but  this  is  not  so  impor- 
tant as  that  the  child  shall  go  where  it  can  be  taken  most  quickly  and 
can  secure  the  best  food  and  the  best  surroundings.  Children  must  not 
only  be  sent  away;  they  must  be  kept  away  until  quite  recovered.  In 
cases  which  have  become  somewhat  chronic,  more  can  sometimes  be 
accomplished  by  a  change  of  air  'than  by  all  other  means. 

Fresh  air  is  of  the  utmost  importance  for  all  diarrhceal  cases  in  sum- 
mer. No  matter  how  much  fever  or  prostration  there  may  be,  these 
children  do  better  if  kept  out  of  doors  the  greater  part  of  the  day. 
Nothing  is  so  depressing  as  close,  stifling  apartments.  Children  should 
be  kept  quiet,  and  especially  should  not  be  allowed  to  walk,  even  if  they 
are  old  enough  and  strong  enough  to  do  so.  They  can  be  kept  out  in 
carriages,  in  perambulators,  or  in  hammocks. 

The  clothing  should  be  very  light  flannel;  a  single  loose  garment  is 
preferable.  Linen  or  cotton  may  be  put  next  the  skin  if  this  is  very 
sensitive  and  there  is  much  perspiration.  At  the  seashore  and  in  the 
mountains,  care  should  be  taken  that  sufficient  clothing  at  night  is 
fiupplied. 


ACUTE  INTESTINAL  INDIGESTION   AND  INTOXICATION.    357 

Bathing  is  useful  to  allay  restlessness,  as  well  as  for  the  reduction  of 
temperature.  For  the  latter,  only  the  tub  bath  can  be  relied  on.  The 
temperature  of  the  bath  should  be  about  100°  F.  when  the  child  is  put 
into  it,  and  should  then  be  gradually  reduced  to  80°  or  85°  F.  by  adding 
ice.  The  bath  should  be  continued,  with  gentle  friction  of  the  body,  for 
from  five  to  twenty  minutes. 

Scrupulous  cleanliness  should  be  secured  in  the  child's  person  and 
clothing.  Napkins,  as  soon  as  soiled,  should  be  removed  from  the  child 
and  from  the  room  and  placed  in  a  disinfectant  solution.  Excoriations 
of  the  buttocks  and  genitals  are  to  be  prevented  by  absolute  cleanliness 
and  the  free  use  of  some  absorbent  powder,  such  as  starch  and  boric  acid. 

Dietetic  Treatment. — It  is  of  the  first  importance  to  remember  that 
during  the  early  stage  of  the  acute  cases,  digestion  is  practically  arrested. 
To  give  food  at  this  time,  manifestly  can  do  only  harm. 

In  nursing  infants  the  severe  forms  of « the  disease  are  extremely 
rare;  but  the  breast  should  be  withheld  so  long  as  a  disposition  to  vomit 
continues,  and  no  food  whatever  given  for  at  least  twenty-four  hours. 
Thirst  may  be  allayed  by  giving  frequently,  but  in  small  quantities, 
boiled  water  or  thin  barley  or  rice  water.  If  these  are  refused  or  vom- 
ited, absolute  rest  to  the  stomach  will  do  more  than  anything  else  to 
hasten  recovery.  After  the  stomach  has  been  allowed  to  rest  for  twenty- 
four  hours,  it  is  generally  safe  to  permit  a  nursing  child  to  take  the 
breast  tentatively.  The  intervals  of  nursing  should  not  be  shorter  than 
four  hours,  and  the  amount  allowed  at  one  feeding  should  not  be  more 
than  one-fourth  the  usual  quantity.  This  may  be  regulated  by  allowing 
an  infant  to  nurse  at  first  only  two  or  three  minutes.  Between  the  nurs- 
ings may  be  given  boiled  water  or  barley  water.  Nursing  may  be  grad- 
ually increased,  so  that  in  three  or  four  days  the  breast  may  be  taken 
exclusively.  If  there  is  any  reason  to  suspect  the  quality  of  the  breast- 
milk,  such  as  menstruation  or  pregnancy,  it  may  be  necessary  to  stop  the 
nursing  for  a  longer  time. 

In  infants  under  four  months  who  are  being  artificially  fed,  all  food, 
and  especially  milk,  should  be  stopped  at  once.  Milk  should  not  only 
be  withheld  during  the  period  of  acute  symptoms,  but  for  several  days 
thereafter.  Besides  the  articles  mentioned  above  as  suitable  for  the 
period  of  most  acute  symptoms  the  following  substitutes  for  milk  will 
be  found  useful :  rice  or  barley  water  or  whey ;  the  farinaceous  foods, 
and  broth  or  bouillon  made  of  veal,  chicken,  *mutton,  or  beef.  Water 
may  be  allowed  freely  at  all  times  unless  there  is  much  vomiting. 

When  milk  is  begun  it  should  be  remembered  that  the  fat  is  more 
likely  to  disturb  digestion  than  any  other  element.  For  this  reason 
skimmed  milk,  fat-free  milk,  buttermilk,  or  condensed  milk,  are  use- 
ful. The  first  three  mentioned  should  be  sterilised.  At  first  they 
should  be  well  diluted  and  very  gradually  increased  in  strength.     (For 


358  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

details,  see  article  on  Feeding.)  Wet-nurses  are  not  to  be  emplo3ed 
during  the  acute  symptoms,  but  during  "the  period  of  prolonged  malnu- 
trition wiiich  follows  an  acute  attack  they  may  be  of  the  greatest  service. 

The  same  general  principles  of  feeding  should  be  applied  in  older 
children.  All  food  is  to  be  withheld  until  the  vomiting  ceases,  when 
broths  and  beef  juice  may  be  given;  later,  buttermilk  or  kumyss  and 
sterilised  skimmed  milk,  or  thin  gruels.  Solid  food  shouhl  not  ho 
allowed  for  several  days  after  the  stools  have  become  normal. 

Medicinal  and  Mechanical  Treatment. — It  must  be  borne  in  mind 
that  we  are  not  treating  an  inflammation  of  the  stomach  or  intestines, 
although  such  may  be  the  ultimate  result  of  the  process.  The  essential 
condition,  it  should  be  remembered,  is  one  of  indigestion  and  intoxica- 
tion arising  from  the  intestinal  contents — food-remains  from  arrested 
digestion,  altered  secretions,  acids,  irritating  and  toxic  substances  pro- 
duced by  chemical  and  bacterial  action — to  which  not  only  the  constitu- 
tional but  the  local  symptoms  are  chiefly  due.  We  can  hardly  do  better 
than  to  imitate  and  assist  Nature  in  her  treatment  of  this  condition. 
Let  us  consider  what  this  is.  Lest  too  much  food  be  swallowed,  appetite 
is  taken  away;  by  vomiting,  the  stomach  is  emptied;  to  neutralise  the 
acid  poisons  in  the  intestine,  an  alkaline  serum  is  poured  out  from  the 
intestinal  walls;  to  remove  irritant  poisons,  increased  peristalsis  is  ex- 
cited. 

The  first  indication  is,  therefore,  to  evacuate  the  stomach  and  the 
entire  intestinal  tract  at  the  earliest  moment,  and  to  do  this  as  thor- 
oughly as  possible.  Under  no  circumstances  should  the  treatment  be 
begun  with  the  use  of  measures  to  stop  the  discharges.  To  empty  the 
stomach  is  not  necessary  in  every  case,  since  the  initial  vomiting  may 
have  done  this  effectively.  Whenever  vomiting  persists  one  should  im- 
mediately resort  to  stomach-washing.  A  single  washing  is  generally  suf- 
ficient, and  if  employed  at  the  outset  may  do  much  to  shorten  the 
attack.  With  high  fever  and  great  thirst,  it  is  often  advisable  to  leave 
a  few  ounces  of  water  in  the  stomach.  If  the  vomited  matters  have 
been  ver}'  sour,  ten  grains  of  bicarbonate  of  soda  may  be  introduced  with 
the  portion  which  is  to  be  left  behind.  As  a  substitute  for  stomach- 
washing  in  children  over  two  years  old,  or  where  it  can  not  be  employed, 
copious  draughts  of  boiled  water  may  be  given.  This  is  taken  readily, 
and  as  it  is  usuall}-  vomited  almost  at  once  it  may  cleanse  the  stomach 
thoroughly;  but  it  is  interior  to  stomach-washing. 

To  clear  out  the  small  intestine,  only  cathartics  are  available.  For 
the  colon,  we  ma}'  in  addition  employ  irrigation.  Calomel,  castor  oil,  or 
the  salines  may  be  used  as  cathartics,  and  enough  of  any  one  of  them 
must  be  given  not  simply  to  move  the  bowels,  but  to  clear  out  the  intes- 
tinal tract  thoroughly.  There  is  little  danger  from  too  free  purgation 
at  the  outset.     Calomel  has  the  advantage  of  ease  of  administration: 


ACUTE   INTESTINAL  INDIGESTION    AND   INTOXICATION.    359 

one-fourth  of  a  grain  should  be  given  every  fifteen  or  twenty  minutes 
up  to  six  or  eight  doses.  When  the  stomach  is  not  disturbed,  I  prefer 
castor  oil  in  most  cases,  as  it  sweeps  the  whole  canal,  causes  little  grip- 
ing, is  very  certain,  and  its  after-effects  are  soothing.  Two  drachms 
should  be  given  to  a  child  six  months  old,  and  half  an  ounce  to  one  of 
four  years.  Of  the  salines,  the  best  are  the  sulphate  of  soda  and  Rochelle 
salts;  from  one  to  three  drachms  may  be  given,  well  diluted,  divided 
into  four  or  five  doses,  at  twenty-minute  intervals. 

The  occasional  use  of  cathartics  is  an  important  part  of  the  later 
treatment.  Whenever  there  are  signs  of  an  accumulation,  or  fresh  symp- 
toms of  intoxication  develop,  such  as  increase  in  temperature,  nervous 
symptoms,  etc.,  another  thorough  cleaning  out  of  the  intestinal  tract  is 
indicated.  The  accumulation  may  not  be  the  result  of  food,  but  simply 
of  intestinal  secretions.  So  long  as  the  processes  of  fermentation  and 
decomposition  continue  active,  the  indications  are  to  facilitate  elimina- 
tion, not  to  check  the  discharges. 

Early  irrigation  of  the  colon  is  advisable  in  all  cases,  as  it  hastens  the 
effect  of  the  cathartic  and  removes  at  once  much  irritating  and  offensive 
material.  It  should  be  done  two  or  three  times  the  first  day,  but  after- 
ward once  daily  is  generally  sufficient.  A  saline  solution  (one  table- 
spoonful  of  salt  to  two  quarts  of  water),  at  a  temperature  of  about 
100°  F.,  is  to  be  preferred ;  and  a  rectal  tube  well  inserted  should  always 
be  used.  Thorough  initial  evacuation,  no  food,  but  plenty  of  water  for 
twenty-four  hours,  and  careful  feeding  after  that  time,  are  all  the  treat- 
ment that  is  necessary  in  most  cases. 

Other  drugs  are  of  secondary  importance.  Their  value  is  certainly 
very  much  overestimated.  It  may  be  questioned  whether  as  yet  any 
proper  antiseptic  treatment  of  the  gastro-enteric  tract  is  possible. 

Of  the  drugs  which  are  used  to  influence  the  intestinal  process, 
bismuth  is  to  be  preferred.  It  has  the  advantage  that  it  rarely  causes 
vomiting,  and  that  most  of  its  preparations  can  be  given  in  large  doses. 
The  subcarbonate  is  the  safest.  It  may  be  given  in  doses  of  from  five 
to  fifteen  grains  every  two  hours,  to  a  child  of  one  year.  Like  the  sub- 
nitrate  it  is  insoluble  and  is  best  given  suspended  in  mucilage.  It 
usually  blackens  the  stools.  It  may  be  kept  up  throughout  the  attack. 
The  best  results  seen  from  acids  are  in  the  later  stages  and  in  the  sub- 
acute cases;  of  the  dilute  hydrochloric  acid,  from  four  to  ten  drops  may 
be  given,  best  alone,  but  well  diluted.  Alkalies  are  of  value  only  in  the 
acute  stage,  especially  where  there  is  acid  fermentation  in  the  stomach, 
with  vomiting  and  eructations  of  gas.  Lime-water,  bicarbonate  of  soda, 
magnesia,  or  chalk-mixture  may  be  employed.  My  own  experience  leads 
me  to  place  little  reliance  upon  astringents.  They  do  little  good,  and 
often  much  harm.  They  are  indicated  only  in  the  catarrhal  diarrhoea 
which  often  follows  the  symptoms  of  acute  intoxication,  but  may  be 


360  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

advantageously  used  in  this  condition  in  combination  with  opium.  A 
useful  astringent  is  tannalbin,  which  may  be  given  in  two-grain  doses 
every  two  hours  to  an  infant  of  one  year. 

While  opium  in  some  form  is  required  in  many  cases,  as  often  used 
it  undoubtedly  does  great  harm.  The  chief  indications  for  opium  are 
great  frequency  of  movements  and  severe  pain.  It  is  contraindicated 
until  the  intestinal  tract  has  been  thoroughly  emptied  by  cathartics  and 
irrigation;  also  when  the  number  of  discharges  is  small,  particularly  if 
they  are  very  offensive;  it  is  especially  to  be  avoided  in  the  early  stage 
of  very  acute  cases,  and  never  to  be  given  when  cerebral  symptoms  and 
high  temperature  coexist  with  scanty  discharges.  Opium  is  admissible 
in  the  early  part  of  the  disease  after  the  tract  has  been  thoroughly  emp- 
tied. It  is  particularly  indicated  when  there  is  a  persistence  of  large, 
fluid  movements  attended  by  symptoms  of  collapse,  and  in  all  cases 
approaching  the  cholera-infantum  type.  In  such  circumstances  mor- 
phine should  be  given  hypodermicall}'^,  one-sixtieth  of  a  grain  to  an 
infant  of  six  months,  to  be  repeated  in  two  hours  if  no  effect  is  seen. 
Opium  is  useful  during  convalescence,  when  the  administration  of  food 
is  immediately  followed  by  a  movement  of  the  bowels;  and  when  with- 
out an  elevation  of  temperature,  often  with  good  appetite,  the  stools  are 
frequent  and  contain  undigested  food,  because  peristalsis  is  so  active  that 
the  intestinal  contents  are  hurried  along  with  such  rapidity  that  there 
is  not  time  for  complete  intestinal  digestion  and  absorption.  Nothing 
requires  nicer  discrimination  than  the  use  of  opium  in  diarrhoea.  It  is 
wise  to  administer  it  always  in  a  separate  prescription,  and  never  in 
composite  diarrheal  mixtures.  The  dose  should  be  regulated  according 
to  its  effect  upon  the  number  of  stools.  Enough  is  to  be  given  to  produce 
a  distinct  effect — the  diminution  of  pain  and  the  control  of  excessive 
peristalsis — but  never  enough  to  check  the  discharges  entirely,  or  to  cause 
stupor.  The  uncertainty  of  absorption  must  also  be  remembered ;  a  sec- 
ond full  dose  should  not  be  given  until  a  sufficient  time  has  elapsed  for 
the  effect  of  the  first  to  pass  away.  For  an  average  child  of  one  year, 
five  minims  of  paregoric,  one-fourth  minim  of  the  deodorised  tincture,  or 
one-fourth  grain  of  Dover's  powder,  may  be  used  as  an  initial  dose,  to  be 
repeated  every  one,  two,  or  four  hours,  according  to  the  effect  produced. 

Stimulants  are  often  required  in  severe  cases.  The  prostration  is 
great  and  develops  rapidly ;  frequently  almost  no  food  can  be  assimilated 
for  twenty-four  or  thirty-six  hours,  while  the  drain  from  the  discharges 
continues.  The  general  condition  of  the  patient  is  the  best  guide  as  to 
the  time  for  stimulation  and  the  amount  required.  Old  brandy  is  the 
best  preparation  for  general  use.  An  infant  a  year  old  may,  as  a  maxi- 
mum, take  half  an  ounce  of  brandy  in  twenty-four  hours.  Stimulants 
should  always  be  diluted  with  at  least  eight  parts  of  water,  and  be  given 
in  small  quantities,  at  short  intervals. 


ACUTE  INTESTINAL   INDIGESTION  AND   INTOXICATION.     361 

In  cases  of  extreme  prostration,  the  hot  bath,  mustard  to  the  extremi- 
ties, and  sometimes  the  mustard  pack,  are  beneficial.  When  the  drain  is 
rapid  and  very  great,  and  in  all  cases  approaching  the  cholera-infantum 
type,  subcutaneous  saline  injections  should  be  used,  in  the  manner  de- 
scribed under  Cholera  Infantum. 

Finkelstein's  "  Food  Intoxication." — In  the  chapter  upon  Difficult 
Feeding  we  have  already  referred  to  this  author's  classification  of  cases 
indicating  different  degrees  of  nutritional  disturbance.  The  most  severe 
form,  which  by  him  has  been  given  the  name  of  food  intoxication,  can 
more  properly  be  discussed  in  the  present  chapter.  Finkelstein  has 
shown  that  the  causative  factor  in  these  cases  is  not  bacterial  infection 
but  a  failure  in  metabolism,  and  that  the  condition  is  aggravated  and 
continued  by  the  ingestion  of  fat  and  sugar.  The  various  symptoms 
seen  in  this  condition  have  for  some  time  been  well  known,  but  the  credit 
belongs  to  Finkelstein  of  demonstrating  their  association  in  a  single 
clinical  type.  These  symptoms  do  not  arise  in  healthy  infants,  but  in 
those  who  have  previously  suffered  from  minor  disturbances  of  digestion 
and  nutrition,  usually  for  some  time.  Occasionally  they  may  develop 
in  the  course  of  some  one  of  the  general  infectious  diseases. 

In  a  marked  case  with  fully  developed  symptoms  the  characteristic 
clinical  manifestations  of  this  condition  are:  (1)  certain  nervous  symp- 
toms, sometimes  those  of  excitement  and  delirium,  but  more  frequently 
somnolence,  which  may  be  increased  to  deep  stupor  or  coma;  (2)  fever, 
usually  moderate,  but  exceptionally  very  high;  (3)  disturbed  respiration, 
most  frequently  deep  and  rapid;  (4)  diarrhceal  stools  of  great  variety, 
no  special  type  being  characteristic;  (5)  very  rapid  loss  of  weight;  (6) 
a  polymorphonuclear  leucocytosis,  generally  between  20,000  and  30,000; 
(7)  urine  containing  albumin  and  casts;  (8)  the  presence  of  lactose  in 
the  urine,  if  lactose  is  given  in  the  food;  (9)  marked  general  collapse. 
Associated  with  these  characteristic  symptoms  there  may  be  almost  any 
others  which  are  found  in  a  severe  intestinal  condition. 

With  such  symptoms  as  have  been  described  the  usual  course  is  rap- 
idly downward  with  a  fatal  termination.  If  the  condition  is  recognised, 
however,  and  properly  treated,  many  cases  recover.  The  essential  treat- 
ment consists  in  withholding  food  of  every  description  and  giving  water 
in  as  large  quantities  as  can  be  tolerated  without  vomiting.  With  a 
cessation  of  the  most  severe  symptoms  a  gradual  return  to  food  should 
be  made,  the  first  articles  allowed  being  nitrogenous  foods,  such  as  broth, 
white  of  egg,  beef  juice,  and  buttermilk,  or  fat-free  milk  without  addi- 
tional sugar. 

Cholera  Infantum. — This  is  only  one  type  of  acute  intestinal  intoxi- 
cation, yet  clinically  it  differs  from  the  others  sufficiently  to  deserve 
separate  consideration.  It  is  not,  however,  a  frequent  form.  As  yet  it 
has  not  been  connected  with  a  specific  type  of  intoxication  or  infection. 


362  DISEASES  OF  THE  DICJESTIVE  SYSTEM. 

What  it  is  that  determines  the  marked  and  characteristic  symptoms  in 
cholera  infantum  is  entirely  unknown.  The  symptoms  are  due  primar- 
ily to  the  effects  of  some  poison  upon  the  heart,  the  nerve-centres,  and 
the  vaso-motor  nerves  of  the  intestines ;  secondarily  to  the  abstraction  of 
fluid  from  the  various  organs  and  tissues  of  the  body,  especially  the 
nerve-centres. 

Cholera  infantum  rarely  occurs  in  an  infant  previously  healthy.  As 
a  rule,  there  is  some  antecedent  intestinal  disorder.  The  development 
of  the  choleriform  symptoms  is  usually  very  rapid,  and  a  child,  who 
perhaps  has  been  regarded  as  scarcely  ill  enough  to  require  a  physician, 
may  be  brought,  in  the  course  of  five  or  six  hours,  to  death's  door. 

Usually  there  are  general  symptoms,  such  as  prostration  and  a  stead- 
ily rising  temperature,  for  a  few  hours  before  the  vomiting  and  purging, 
or  these  symptoms  may  be  the  first  to  excite  alarm.  Vomiting  may  pre- 
cede diarrhoea,  or  both  may  begin  simultaneously.  The  vomiting  is  very 
frequent.  First,  whatever  food  is  in  the  stomach  is  vomited,  then  serum 
and  mucus,  and  sometimes  there  is  regurgitation  from  the  small  intes- 
tine. If  vomiting  subsides  for  a  time,  it  is  almost  sure  to  begin  anew 
with  the  taking  of  food  or  drink.  The  stools  are  frequent,  large,  and 
fluid,  and  may  occur  once  or  twice  an  hour.  They  are  of  a  pale  green, 
yellow,  or  brownish  colour  in  the  beginning,  but  as  they  become  more 
frequent  they  often  lose  all  colour  and  are  almost  entirely  serous.  The 
sphincter  is  sometimes  so  relaxed  that  small  evacuations  occur  every 
few  minutes.  The  first  stools  are  usually  acid,  later  they  are  neutral, 
and  when  serous  they  are  alkaline.  In  most  cases  they  are  odourless; 
in  rare  instances  they  are  exceedingly  offensive.  Microscopically  the 
stools  show  large  numbers  of  epithelial  cells,  some  leucocytes,  and  im- 
mense numbers  of  bacteria. 

Loss  of  weight  is  more  rapid  than  in  any  other  pathological  condition 
in  childhood;  it  may  be  as  much  as  a  poimd  a  day.  The  fontanel  is 
depressed,  and  in  rare  instances  there  may  be  overlapping  of  the  cranial 
bones.  The  general  prostration  is  great  almost  from  the  outset.  The 
face,  better,  perhaps,  than  any  single  symptom,  indicates  what  a  pro- 
found impression  has  been  made  upon  the  system.  The  eyes  are  sunken, 
the  features  sharpened,  the  angles  of  the  mouth  drawn  down,  and  a 
peculiar  pallor  with  an  expression  of  anxiety  overspreads  the  whole 
countenance,  which  becomes  almost  Hippocratic.  In  the  early  stages 
the  nervous  symptoms  are  those  of  irritation.  Later,  these  symptoms 
give  place  to  dulness,  stupor,  relaxation,  and  coma  or  convulsions. 

The  temperature,  in  my  experience,  has  been  invariably  elevated,  and 
usually  in  proportion  to  the  severity  of  the  attack.  In  cases  recovering, 
it  has  generally  been  from  102°  to  103°  F.,  while  in  fatal  cases  it  has 
risen  almost  at  once  to  104°  or  105°  F.,  and  often  shortly  before  death 
it  has  reached   106°  or  even   108°  F,     Such  temperatures  may  occur 


ACUTE   INTESTINAL  INDIGESTION  AND  INTOXICATION.     363 

with  a  clammy  skin  and  cold  extremities,  and  are  discovered  only  by  the 
thermometer.  The  pulse  is  always  rapid,  and  very  soon  it  becomes  weak, 
often  irregular,  and  finally  almost  imperceptible.  The  respiration  is 
irregular  and  frequent,  and  may  be  stertorous.  The  tongue  is  generally 
coated,  but  soon  becomes  dry  and  red,  and  is  often  protruded.  The 
abdomen  is  generally  soft  and  sunken.  There  is  almost  insatiable  thirst. 
Everything  in  the  shape  of  fluids,  especially  water,  is  drunk  with  avid- 
ity, even  though  vomited  as  soon  as  it  is  swallowed.  Very  little  urine 
is  passed,  sometimes  none  at  all  for  twenty-four  hours;  this  depends 
upon  the  great  loss  of  fluid  by  the  bowels. 

In  the  fatal  cases  there  is  hyperpyrexia,  a  cold,  clammy  skin,  absence 
of  radial  pulse,  stupor,  coma  or  convulsions,  and  death.  The  diarrhoea 
and  vomiting  may  continue  until  the  end,  or  both  may  entirely  cease  for 
some  hours  before  it  occurs.  The  patients  may  pass  into  a  condition 
resembling  the  algid  stage  of  epidemic  cholera,  and  die  in  collapse.  In 
other  cases,  after  the  first  day  of  very  severe  symptoms,  the  discharges 
diminish,  but  the  nervous  symptoms  become  specially  prominent.  There 
is  restlessness  and  irritability  or  apathy  and  stupor.  The  fontanel  is 
sunken ;  the  eyes  are  half  open  and  covered  with  a  mucous  film ;  respira- 
tion is  irregular  and  superficial,  sometimes  even  Cheyne- Stokes;  the  pulse 
is  feeble,  irregular,  or  intermittent ;  the  muscles  of  the  neck  drawn  back ; 
the  abdomen  retracted.  The  temperature  is  not  elevated,  but  normal  or 
subnormal.  From  this  condition  recovery  may  take  place  or  the  symp- 
toms may  merge  into  those  of  ileo-colitis ;  but  much  more  frequent  than 
either  of  the  foregoing  is  the  fatal  termination. 

These  nervous  symptoms  are  ascribed  to  cerebral  anaemia,  cerebral 
hyperaemia  (venous),  oedema  of  the  meninges,  thrombosis  of  the  cerebral 
sinuses,  and  uraemia.  Although  I  have  examined  the  brain  in  almost 
all  my  autopsies  upon  patients  dying  from  diarrhoeal  diseases,  I  have 
never  in  such  cases  seen  sinus  thrombosis,  and  but  rarely  oedema.  Cere- 
bral hyperaemia  was  often  met  with  in  cases  dying  in  convulsions,  but  not 
with  any  regularity  otherwise.  Nor  have  my  observations  upon  the 
kidneys  confirmed  those  of  Kjellberg,  whom  most  of  the  writers  since 
his  day  have  quoted,  as  to  the  great  frequency  of  nephritis.  A  scanty, 
concentrated,  and  hence  irritating  urine  is  the  rule,  and  a  small  amount 
of  albumin  and  an  occasional  hyaline  cast  not  uncommon;  but  either 
clinical  or  pathological  evidence  of  a  serious  amount  of  nephritis  has 
been,  in  my  own  experience,  extremely  rare. 

We  can  hardly  regard  either  the  renal  or  the  cerebral  changes  as  an 
explanation  of  the  nervous  symptoms  of  most  of  these  cases;  they  seem 
rather  to  depend  upon  impeded  circulation  due  to  a  thickening  of  the 
blood,  to  acute  inanition,  and  general  toxaemia. 

An  infrequent  complication  of  cholera  infantum  is  sclerema.  This 
condition  is  found  associated  with  muscular  contractions,  subnormal  tern- 


364  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

perature,  and  other  signs  of  the  most  extreme  depression.  These  cases 
are  invariably  fatal. 

Of  the  children  with  true  cholera  infantum  wliich  have  come  under 
my  notice,  fully  two-thirds  have  died. 

Treatment. — Restricting  the  term  cholera  infantum  to  the  class  of 
cases  described  above,  all  who  have  seen  much  of  the  disease  must  admit 
that  the  results  of  treatment  are  extremely  unsatisfactory,  and  that  the 
most  severe  cases  pursue  their  course  but  little,  if  at  all,  influenced  by 
the  treatment  employed. 

The  best  view  of  the  treatment  will  be  gained  if  we  keep  in  mind  that 
we  are  treating  cases  of  poisoning;  that  the  toxic  materials  cause  great 
depression  of  the  heart  and  the  system  generally  by  acting  on  the  nerve- 
centres,  and  by  paralysing  the  vaso-motor  nerves  of  the  intestine. 

The  main  indications  are:  (1)  to  empty  the  stomach  and  intestine; 
(2)  to  neutralise  the  effect  of  the  poison  upon  the  heart  and  nervous 
system;  (3)  to  supply  fluid  to  the  blood  to  make  up  for  the  very  great 
drain  of  the  discharges;  (4)  to  reduce  the  temperature;  (5)  to  treat 
special  symptoms  as  they  arise. 

For  the  first  indication  we  must  rely  upon  mechanical  means — 
stomach-washing  and  intestinal  irrigation — there  is  no  time  to  wait  for 
cathartics.  For  the  second,  nothing  in  my  hands  has  proved  so  useful 
as  the  hypodermic  use  of  morphine  and  atropine.  I  believe  this  to  be 
more  efficient  than  any  other  means  of  treatment  we  possess.  Morphine 
is  contraindicated  where  the  purging  has  ceased  or  is  slight,  and  where 
there  is  drowsiness,  stupor,  or  relaxation.  The  effects  of  the  dose  should 
always  be  carefully  watched ;  a  small  dose  repeated  is  better  than  a  single 
large  dose.  For  a  child  a  year  old,  not  more  than  gr.  -gV  of  morphine 
and  gr.  ^^  of  atropine  should  be  the  initial  dose.  It  may  be  repeated 
in  an  hour  unless  the  desired  effects  are  produced:  arrest  of  the  vomit- 
ing and  purging  (or  at  least  their  diminution),  improvement  in  the 
heart's  action,  and  in  the  nervous  symptoms. 

For  the  third  indication  the  only  thing  that  can  be  depended  upon  is 
the  injection  of  normal  salt  solution  into  the  cellular  tissue  of  the 
abdomen,  buttocks,  thighs,  or  back.  At  least  half  a  pint  should  be 
used  at  a  time;  it  should  be  injected  in  several  places  and  repeated  in 
the  course  of  every  twelve  hours.  A  very  much  larger  quantity  can 
often  be  used  with  advantage.  This  causes  no  irritation,  and  is  absorbed 
with  surprising  rapidity.  The  injection  is  made  slowly,  and  the  exact 
amount  introduced  at  each  time  measured. 

For  the  reduction  of  temperature,  baths  should  be  used.  They  may 
be  continued  from  ten  to  thirty  minutes,  and  to  be  efficient,  must  be  used 
frequently — as  often  as  every  hour,  if  symptoms  are  threatening.  Iced 
cloths  or  an  ice-cap  should  be  applied  to  the  head.  Cold-water  injections 
are  a  valuable  accessory  to  the  treatment  by  baths.    In  most  cases  noth- 


ACUTE   ILEO-COLITIS.— DYSENTERY.  365 

ing  should  be  allowed  by  the  mouth  except  water.  Caffein,  camphor, 
and  brandy  may  be  used  freely.  While  the  use  of  stimulants  is  indi- 
cated in  every  case,  their  effects  are  disappointing.  Taken  by  the  mouth 
they  are  almost  invariably  vomited.  If  used  at  all,  it  should  be  hypo- 
dermically.  During  the  stage  of  most  acute  symptoms,  to  attempt  to 
give  food  by  the  mouth  is  worse  than  useless.  After  the  stage  of  violent 
symptoms  has  subsided  and  reaction  is  established,  the  subsequent  man- 
agement in  respect  to  feeding  and  medication  should  be  the  same  as  in 
the  cases  considered  in  the  previous  cliapter.  If  cerebral  symptoms  are 
present,  opium  is  to  be  avoided.  For  cold  extremities  and  subnormal 
temperature,  hot  mustard  baths  should  be  used  to  establish  reaction, 
mustard  paste  applied  all  over  the  body,  and  hot-water  bags  or  bottles 
placed  about  the  patient. 


CHAPTEE    YLL 

DISEASES   OF   THE  INTESTINES.— (Continued.) 

ACUTE   ILEO-COLITIS.— DYSENTERY. 
{Enter o-colitis;  Enteritis;  Inflammatory  Diarrhcea.) 

The  term  ileo-colitis  is  a  general  one,  embracing  those  forms  of 
intestinal  disease  in  which  true  inflammatory  lesions  are  present.  In 
the  type  of  cases  described  in  the  previous  chapter  recovery  or  death 
takes  place  before  anything  more  than  superficial  changes  have  oc- 
curred, while  in  ileo-colitis  the  pathological  process  continues  until 
there  have  been  produced  marked  lesions,  often  involving  all  the  walls 
of  the  intestine.  Sometimes  it  is  impossible,  by  symptoms,  to  draw  a 
line  between  them.  This  is  especially  true  of  the  cases  terminating  in 
follicular  ulceration  of  the  colon.  In  certain  other  forms  of  ileo-colitis 
the  evidences  of  a  severe  intestinal  inflammation  are  often  manifest 
from  the  very  outset.  This  difference  is  probably  due  to  a  difference  in 
the  character  of  the  infection.  The  extent  of  the  lesions  depends  much 
upon  the  duration  of  the  process. 

Etiology. — The  predisposing  causes  of  ileo-colitis  are  those  common 
to  diarrhoeal  diseases  in  general,  and  have  already  been  considered.  Al- 
though seen  with  especial  frequency  in  summer,  and  in  children  under 
two  years  old,  it  may  affect  those  of  any  age,  and  occurs  at  all  seasons. 
Epidemics  are  not  uncommon  in  the  early  fall  months.  While  usually 
primary,  ileo-colitis  often  follows  infectious  diseases,  especially  measles, 
diphtheria,  and  broncho-pneumonia.  It  frequently  occurs,  in  institu- 
tions chiefly,  as  a  terminal  infection  in  infants  suffering  from  extreme 
malnutrition  or  marasmus.     All  other  forms  of  intestinal  disease  are 


366  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

predisposing  causes.  The  question  of  contagion  is  unsettled;  if  at  all 
communicable,  it  is  feebly  so.  When  it  occurs  epidemically  a  common 
origin  seems  more  probable  than  that  the  disease  spreads  from  one 
patient  to  another. 

The  only  bacterium  that  up  to  the  present  time  has  been  shown  to 
be  capable  of  producing  this  form  of  intestinal  disease  is  the  B.  dysen- 
terice  of  Shiga.  This  organism,  or,  more  properly  speaking,  this  group 
of  closely  allied  organisms,  has  now  been  found  in  all  parts  of  the  world 
in  a  sufficient  number  of  cases  to  establish  its  etiological  connection  witli 
ileo-colitis.  The  B.  dysenterice  was  shown  by  Shiga,  in  1898  and  1899, 
to  be  the  cause  of  epidemic  dysentery  in  Japan.  In  1900,  Flexner  estab- 
lished its  association  with  tropical  dysentery  in  the  Philippines,  and  in 
1902,  Duval  and  Bassett,  pupils  of  Flexner,  demonstrated  its  presence 
in  a  series  of  cases  of  diarrhoea  in  children  at  Baltimore. 

In  413  cases  of  diarrhoea  studied  in  the  summer  of  1903  this  organ- 
ism was  present  in  270,  It  was  almost  invariably  found  in  cases  show- 
ing blood  and  mucus,  or  much  nmcus  in  the  stools.  Although  usually 
the  h.  dysenterice  is  greatly  outnumbered  by  other  organisms,  it  is  not 
uncommon  to  find  it  in  pure  culture.  A  number  of  minor  differences 
have  been  found  in  the  bacilli  from  different  cases;  there  are,  however, 
two  main  groups,  the  division  being  made  by  reason  of  the  difference  in 
reaction  with  litmus  mannite ;  one  group  is  known  as  the  "  true  Shiga," 
or  "  alkaline  "  type ;  the  other,  as  the  "  Flexner,"  or  "  acid  "  type.  The 
latter  has  been  most  frequently  found  in  the  diarrhoeal  diseases  of  chil- 
dren in  this  country,  although  the  true  Shiga  is  occasionally  present,  and 
in  rare  cases  they  may  be  associated. 

Whether  the  h.  dysenterice  is  present  in  normal  stools  of  liealthy  chil- 
dren is  still  unsettled.  WoUstein  at  the  Babies'  Hospital  failed  to  dis- 
cover its  presence  in  the  stools  of  56  normal  infants.  The  b.  dysenterice 
has  never  been  found  outside  the  body ;  we  are  therefore  entirely  ignorant 
both  of  its  habitat  and  its  mode  of  entry.  There  are  grounds  for  believ- 
ing that  it  appears  at  times  among  the  saprophytic  bacteria  of  the  intes- 
tinal contents. 

The  role  played  by  other  bacteria,  especially  the  streptococcus,  in  the 
production  of  the  deeper  lesions  of  the  intestine  may  be  an  important 
one.  This  appears,  however,  to  be  rather  in  the  nature  of  a  secondary 
invasion. 

Lesions. — It  is  surprising  that,  so  far  as  is  known,  a  single  specific 
cause  can  excite  such  a  variety  of  lesions.  The  nature  of  the  anatomical 
changes  apparently  depends  upon  other  factors,  such  as  the  intensity 
of  the  infection,  the  local  resistance,  and  still  more  upon  the  duration 
of  the  disease. 

The  nature  of  the  lesions  in  ileo-colitis  differs  greatly,  but  tlieir 
position  is  quite  constant:  they  affect  the  lower  ileum  and  the  colon. 


ACUTE   ILEO-COLITIS.— DYSENTERY.  367 

In  ahout  half  the  cases  only  the  colon  is  affected.     The  lesions  of  the 
ileum  are  usually  limited  to  the  lower  two  or  three  feet. 

The  frequency  with  which  the  different  varieties  of  ileo-colitis  were 
found  in  eighty-two  of  my  own  autopsies  was  as  follows: 

Follicular  ulceration 36 

Catarrhal  inflammation 26 

Catarrhal  inflammation  with  superficial  ulceration 6 

Membranous  inflammation 14 

82 

Acute  Catarrhal  Ileo-colitis. — In  the  milder  cases  there  are 
changes  in  the  epithelium  and  infiltration  of  the  mucosa.  In  the  severer 
cases  the  submucosa  is  involved,  and  the  infiltration  of  the  mucosa  may  be 
so  great  as  to  lead  to  necrosis  and  the  formation  of  ulcers. 

Gj-oss  Appearances. — While  the  lower  ileum  and  the  colon  are  most 
seriously  affected,  it  is  not  uncommon  to  find  quite  marked  changes  in  a 
considerable  portion  of  the  small  intestine,  and  even  in  the  stomach.  In 
the  cases  of  short  duration,  the  lesions  are  sometimes  more  marked  in  the 
small  intestine  than  in  the  colon.  The  stomach  contains  undigested  food, 
and  mucus  which  is  commonly  stained  a  dark-brown  colour.  It  may  be 
dilated  or  contracted.  The  mucous  membrane  is  pale  or  congested;  if 
the  latter,  it  is  usually  in  patches,  and  more  about  the  pyloric  orifice. 
The  intestinal  contents  are  generally  green  in  colour,  and  thin.  The 
mucous  membrane  is  often  coated  with  tenacious  mucus.  The  small  in- 
testine is  distended  with  gas,  the  large  intestine  nearly  empty,  except  the 
transverse  colon.  The  mucous  membrane  may  appear  somewhat  swollen. 
In  the  small  intestine  there  are  occasionally  seen  swelling  and  oedema  of 
the  villi,  so  that  they  project  abnormally  and  give  a  plush-like  appear- 
ance. Congestion  is  a  constant  feature,  and  it  may  be  simply  upon  the 
folds  of  the  mucous  membrane,  or  about  the  solitary  follicles,  or  it  may 
be  intense  and  involve  the  whole  intestine  for  some  distance.  Small 
haemorrhagic  areas  are  often  seen  here  and  there,  widely  scattered.  In 
the  most  severe  cases  there  are  marked  thickening  and  uniform  conges- 
tion, and  the  appearance  is  sometimes  much  like  that  seen  in  membran- 
ous inflammation.  The  solitary  follicles  throughout  the  colon  are  usu- 
ally swollen,  projecting  above  the  mucous  membrane  and  about  the  size 
of  a  pin's  head.  Peyer's  patches  may  be  normal,  or  they  may  be  swollen 
and  congested,  with  other  evidences  of  catarrhal  inflammation  in  the 
surrounding  mucous  membrane,  or,  more  rarely,  they  may  be  involved 
when  the  rest  of  the  mucosa  appears  healthy.  The  same  is  true  of  the 
lymph  nodules  of  the  small  intestine.  The  Ij'mph  nodes  of  the  mesentery 
are  usually  swollen  and  acutely  congested,  but  they  may  appear  normal. 

Microscopical  Appearances. — In  interpreting  the  changes  found  in 
the  mucosa,  the  same  precautions  must  be  observed  as  previously  stated. 


368 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


There  is  usually  loss  of  the  superficial  epithelium  and  of  tliat  lining 
the  tubular  glands  at  their  orifices.  Upon  the  surface  of  the  mucosa  and 
within  the  tubular  glands,  fine  granular  matter  is  seen  derived  from  the 
broken-down  epithelium.  The  goblet  cells  are  distended  with  mucus, 
and  do  not  stain  clearly.  The  lumen  of  the  tubular  glands  is  narrowed 
from  pressure  due  to  the  swelling  of  the  lymphoid  tissue  which  separates 
them,  which  is  partly  from  oedema,  and  partly  from  cell  infiltration 
(Fig.  54).  A  thick  layer  of  mucus  and  round  cells,  adhering  closely 
to  the  surface,  may  resemble  a  pseudo-membrane  (Fig.  55).  In  fatal 
cases  of  moderate  severity  the  superficial  portion  of  the  mucosa  is  in- 
filtrated with  round  cells  and  crowded  with  bacteria  of  many  kinds,  the 
depth  to  which  this  infiltration  extends  depending  upon  the  severity 
and  duration  of  the  process.    In  very  severe  cases  there  is  found  a  dense 


FiQ.  54. — Acute  Catarrhal  Inflammation  of  the  Ileum.  At  the  left  is  seen  the  edge 
of  a  Peyer's  patch  (P)  greatly  swollen.  The  most  striking  feature  of  the  lesion  is 
the  loss  of  the  superficial  epithelium,  which  is  shown  in  all  parts  of  the  specimen. 
The  significance  of  this  depends  upon  the  fact  that  the  autopsy  was  made  but  two 
hours  after  death.  At  several  points,  F,  F,  the  tubular  follicles  have  loosened  and 
fallen  out.  The  mucosa,  A,  is  slightly  infiltrated  with  cells,  especially  near  the  Peyer'a 
patch.  The  submucosa,  C,  and  muscular  coats,  D,  E,  are  normal.  V,  V,  are  small 
veins.  History. — Infant,  nine  months  old,  previously  healthy;  sick  three  days  with 
severe  intestinal  symptoms;  temperature,  103°  to  105°  F.  Autopsy. — Acute  catarrhal 
inflammation  of  ileum  and  colon;  Peyer's  patches  red  and  swollen.  The  specimen  is 
taken  from  the  lower  ileum.  The  superficial  charactec  of  the  lesion  is  chiefly  due  to 
the  short  duration  of  the  process. 

infiltration  of  the  mucosa  and  of  the  submucosa  also,  which  in  places 
extends  quite  to  the  muscular  coat.  These  cases  closely  resemble  those  of 
the  membranous  variety,  lacking  only  the  exudation  of  fibrin.  The  lymph 
nodules  of  the  colon  are  swollen  to  a  greater  or  less  degree,  cliiefly  from 
an  increase  in  the  number  of  lymphoid  cells.  This  swelling  may  be  the 
most  prominent  feature  of  the  lesion.  If  the  process  is  sufficiently  pro- 
longed, the  lymph  nodules  may  break  down  and  ulcerate.  The  changes  in 
the  lymph  nodules  of  the  small  intestine  and  in  Peyer's  patches  are  sim- 
ilar to  those  seen  in  the  colon,  but  are  less  marked,  and  frequently  absent 
altogether.    Ulceration  in  Peyer's  patches  is  extremely  rare. 


PLATE   VIII. 


Extensive  Superficial  Ulceration'  of  the  Colox. 

Female  child  nine  months  old ;  symptoms  of  acute  ileo-colitis  of  fifteen  days'  dura- 
tion; temperature,  101°  to  104'5°  F.,  and  from  six  to  eight  stools  daily — thin,  green, 
and  yellow,  but  no  blood. 

Extensive  ulceration  throughout  the  colon,  most  marked  in  descending  portion, 
from  which  specimen  is  taken. 

A  A  are  small  circular  ulcers ;  B  B,  larger  ones  from  coalescence  of  several  of 
these ;  C  C,  large  areas  of  ulceration,  the  mucous  membrane  being  almost  entirely 
destroyed. 


ACUTE  ILEO-COLITIS.— DYSENTERY. 


369 


The  small  veins  and  capillaries  of  the  mucosa  and  submucosa  are 
usually  distended  with  blood ;  small  extravasations  are  very  common,  and 
occasionally  larger  ones  are  seen. 

Catarrhal  inflammation,  except  in  its  very  severe  form,  which  is  not 
frequent,  causes  no  lesions  that  can  not  readily  be  repaired.     The  most 


Fia.  55. — Acute  Catarrhal  Inflammation  of  the  Ileum  ;  Severe  Form.  The  mucosa, 
G,  is  everywhere  densely  infiltrated  with  round  cells,  compressing  the  tubular  follicles, 
and  in  places,  L,  L,  almost  effacing  them.  Upon  the  surface  of  the  mucosa  is  a  thick 
layer  of  cells  and  mucus.  Beneath  this  the  epithelial  arches,  B,  B,  covering  the  villi 
can  be  seen.  The  lesions  are  almost  entirely  of  the  mucosa.  The  only  changes  in 
the  submucosa,  E,  are  groups  of  cells  about  the  small  blood-vessels,  V,  V.  History. — 
Infant  six  months  old;  moderate  diarrhoea  twelve  days;  severe  symptoms  with  high 
temperature  for  six  days.  There  was  intense  inflammation  of  the  entire  colon  and 
lower  three  feet  of  the  ileum.  Intestine  greatly  congested  and  thickened.  Specimen 
is  from  the  ileum. 


persistent  change  is  usually  the  swelling  of  the  lymph  nodules,  which 
may  last  a  long  time,  and  appears  to  be  an  important  factor  in  the 
tendency  to  relapses  and  recurring  attacks.  If  there  is  a  continuance 
of  the  exciting  cause,  or  the  patient's  constitution  is  feeble,  the  process 
may  become  chronic. 

Catarrhal  Inflammation  with  Superficial  Ulceration. — In 
the  most  severe  form  of  catarrhal  inflammation  which  does  not  prove 
fatal  in  the  earlier  stages,  extensive  ulceration  occasionally  takes  place; 
usually  these  ulcers  are  seen  throughout  the  entire  colon,  and  occasion- 
ally a  few  are  found  in  the  lower  ileum.  They  generally  begin  in  the 
mucosa  overlying  the  lymph  nodules,  and  while  they  have  a  wide  super- 
ficial area,  they  do  not  extend  deeper  than  the  mucosa.  The  small 
ulcers  are  circular  and  usually  show  at  the  centre  a  small  granular  body 
— the  lymph  nodule.  The  larger  ulcers  result  from  the  coalescence  of 
several  small  ones,  and  are  irregular  in  shape.  They  may  be  two  or 
three  inches  in  diameter.  Sometimes  for  a  considerable  distance  a  large 
25 


370 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


part  of  the  mucosa  may  be  destroyed.  Often  the  entire  surface  presents 
a  worm-eaten  appearance  (Plate  VIII).  On  microscopical  examination 
there  is  seen,  in  the  greater  part  of  the  ulcer,  complete  destruction  of 
the  mucosa,  the  submucosa  being  densely  packed  with  round  cells  quite 
to  the  muscular  coat. 

Inflammation  of  the  Lymph  Nodules  with  Ulceration  (fol- 
licular ulceration). — Follicular  ulcers  are  found  at  autopsy  in  about  one- 
third  of  the  cases  dying  from  diarrhoeal  diseases.    They  are  rarely  seen 


Fig.  56. — Lymph  Nodule  of  the  Colon  in  the  Early  Stage  of  Ulceration — Follicu- 
lar Ulcer.  The  nodule,  F,  is  much  enlarged,  and  is  breaking  down  and  discharging 
into  the  intestine.  The  other  changes  are  not  marked.  The  superficial  epithelium 
is  gone;  the  mucosa.  A,  shows  a  slight  increase  of  cells,  and  in  the  submucosa,  C,  are 
nests  of  cells  about  the  small  vessels,  V,  V.  History. — Delicate  child,  thirteen  months 
old;  slight  diarrhoea  four  weeks;  severe  symptoms  five  days.  The  colon  wa.s  filled 
with  ulcers  one-twelfth  of  an  inch  in  diameter,  one  of  which  is  shown  in  the  illustration. 


in  those  which  have  lasted  less  than  a  week,  and  not  often  before  the 
middle  of  the  second  week.  The  average  duration  of  the  disease  in 
these  cases  is  about  three  weeks. 

In  thirty-six  cases  in  which  follicular  ulcers  were  found  at  autopsy, 
they  were  present  in  the  small  intestine  alone  in  but  three  cases ;  in  the 
small  intestine  and  in  the  colon  in  six  cases;  in  the  remaining  twenty- 
seven  they  were  present  only  in  the  colon.  When  in  the  small  intestine 
they  were  seen  only  in  the  lower  ileum.  Ulceration  was  seen  a  few  times 
in  one  or  two  of  the  nodules  of  a  Peyer's  patch.  Ulceration  of  the  large  in- 
testine involved  the  whole  colon  in  about  half  the  cases ;  while  in  the  re- 
mainder the  process  was  limited  to  its  lower  portion.  The  deepest  and  also 
the  largest  ulcers  were  usually  in  the  descending  colon  and  sigmoid  flexure. 


PLATE   IX. 


Deep  Follicular  Ulcers  of  the  Colon. 

A  delicate  child,  fourteen  months  old,  sick  twelve  days ;  stools  gieen,  yellow,  brown, 
and  watery;  no  blood  ;  temperature,  100°  to  101°  F. 

The  small  intestine  was  normal ;  ulcers  throughout  colon.  The  specimen  is  from 
descending  colon ;  the  ulcers  are  deep,  and  most  of  them  extend  to  the  muscular  coat. 
(For  microscopical  appearance,  see  Fig.  68.) 


ACT^TE  II.EO-COLITIS.— DYSENTERY. 


371 


In  the  early  stage  these  ulcers  appear  as  tiny  excavations  at  the  sum- 
mit of  the  prominent  lymph  nodules.  Later,  the  whole  nodule  may  be 
destroyed,  and  a  small  round  ulcer  is  formed  from  one-twelfth  to  one- 
fourth  of  an  inch  in  diameter  (Plate  IX).  These  are  quite  deep  and 
have  overhanging  edges ;  when  closely  set  they  give  the  intestine  a  sieve- 
like appearance.  By  the  coalescence  of  several  of  them,  larger  ulcers 
may  form  which  are  an  inch  or  more  in  diameter.  At  the  bottom  of 
these  larger  ones  the  transverse  strias  of  the  circular  muscular  coat  are 
often  plainly  seen.     I  have  never  known  them  to  cause  perforation. 

Microscopical  Appearances. — The  lymph  nodules  are  swollen,  prin- 
cipally from  the  accumulation  within  them  of  round  cells.  This  is  fol- 
lowed by  softening,  which  usually  begins  at  the  summit  of  the  nodule 
and  extends  downward;  the  reticulum  breaks  down,  and  the  cellular 
contents  escape  into  the  intestine  (Fig.  56).  Softening  may  begin  at 
the  centre  of  the  nodule,  which  i-uptures  like  an  abscess.     The  destruc- 


SdJSSS^^Kc 


.^^^m^^mm 


n'P 


J^OCfT-^ 


Fig.  57. — Deep  Follicular  Ulcer  of  the  Colon.  A  deep  ulcer  is  shown  at  F,  a  smaller 
one  at  F' .  The  separation  of  the  mucosa  at  H  is  accidental.  There  is  no  trace  of  the 
lymph  nodule  from  which  the  large  ulcer  had  its  origin.  The  destructive  process  has 
extended  laterally  in  the  submucosa,  C,  and  the  mucosa,  A,  is  falling  in  to  fill  up  the 
space.  In  the  vicinity  of  the  ulcers,  the  submucosa  is  densely  infiltrated  with  round 
cells,  L",  L",  which  also  are  seen  in  the  lymph  spaces  between  the  bundles  of  circular 
muscular  fibres,  L',  L',  and  some  are  seen  in  the  longitudinal  muscular  coat,  L,  L. 
History. — Thirteen  months  old,  delicate;  continuous  diarrhccal  symptoms  for  three 
weeks.  Ulcers  found  throughout  the  colon,  the  largest,  one-half  an  inch  in  diameter. 
The  illustration  shows  one  of  the  small  ones  like  those  in  Plate  IX. 


tion  of  the  whole  nodule  leaves  a  cavity,  which  is  the  follicular  ulcer. 
At  first  the  ulcer  corresponds  in  size  to  the  nodule,  but  infiltration  of 
the  adjacent  tissue  soon  takes  place,  which  may  become  necrotic.  In 
this  way  the  ulcer  extends  chiefly  in  the  submucous  coat.  The  lesion  is 
never  limited  to  the  lymph  nodules ;  but  the  extent  of  the  other  changes 
found  depends  upon  the  severity  and  the  duration  of  the  process.  In 
cases  dying  after  an  illness  of  a  week  or  ten  days,  we  usually  find  only 
moderate  changes  in  the  mucosa,  and  in  the  submucosa  a  slight  infiltra- 


372  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

tion  of  round  cells,  especially  about  the  small  blood-vessels  (Fig.  56, 
V,  V).  In  those  which  have  lasted  three  or  four  weeks  the  ulcers  are 
deeper,  and  all  the  structures  of  the  intestine  in  their  neighbourhood  are 
usually  involved  (Fig.  57).  The  mucosa  is  densely  packed  with  round 
cells,  as  are  also  all  the  tissues  in  the  vicinity  of  the  ulcers ;  even  the  mus- 
cular coat  may  be  infiltrated.  The  ulcers,  however,  rarely  extend  deeper 
than  the  circular  layer. 

Follicular  ulceration  of  the  intestine  in  infancy  usually  terminates 
fatally  if  the  process  is  an  extensive  one.  In  less  severe  cases  recovery 
may  take  place,  the  ulcers  healing  by  granulation  and  cicatrisation  in  the 
course  of  from  four  to  eight  weeks. 

Acute  Membranous  Ileo-colitis. — This  is  the  most  severe  form 
of  intestinal  inflammation  seen  among  children.  The  process  differs 
quite  materially  from  that  described  as  occurring  among  adults.  In 
only  one  of  my  own  cases  was  it  associated  with  membranous  inflamma- 
tion of  any  other  mucous  membrane,  in  that  case  with  membranous  gas- 
tritis. The  most  frequent  type  of  membranous  colitis  is  that  with 
severe  acute  symptoms,  both  constitutional  and  local,  with  a  duration 
of  from  six  to  fourteen  days.  In  young  infants  its  symptoms  and 
course  are  very  irregular,  and  it  may  be  found  at  autopsy  when  no  seri- 
ous intestinal  lesion  has  been  suspected. 

Gross  Appearances. — There  is  visible  to  the  naked  eye  usually  very 
little  pseudo-membrane  and  no  deep  sloughing.  The  lesion  affects  the 
last  two  or  three  feet  of  the  ileum  and  the  entire  colon,  sometimes  only 
the  colon.  It  is  exceedingly  rare  to  meet  with  any  marked  lesions  higher 
in  the  small  intestine.  The  most  marked  changes  are  near  the  ileo-cscal 
valve  or  in  the  sigmoid  flexure  and  the  rectum.  In  the  ileum  they  may 
be  quite  as  severe  as  in  the  colon  (Plate  X).  The  intestinal  wall  is 
firm  and  stiff,  and  is  two  or  three  times  its  normal  thickness.  It  is  not 
thrown  into  deep  folds,  as  is  the  healthy  intestine  wlien  empty.  It  is 
very  rare  to  find  false  membrane  that  can  be  stripped  off  in  patches  of 
any  considerable  size.  When  membrane  exists,  the  colour  is  a  yellowish 
or  grayish  green,  and  the  surface  is  often  fissured,  giving  a  lobulated 
appearance.  In  the  parts  where  no  pseudo-membrane  can  be  seen,  the 
surface  is  usually  of  an  intense  red  colour  and  is  rough  and  granular,  in 
striking  contrast  to  the  normal  glistening  appearance.  Here  and  there 
small  extravasations  of  blood  may  be  seen.  In  the  regions  most  affected,  the 
normal  structures  of  the  mucous  membrane — the  villi,  Peyer's  patches, 
and  solitary  follicles — can  not  be  distinguished.  In  a  single  instance  I 
found  an  exudation  of  fibrin  on  the  peritoneal  surface  of  the  intestine  for 
a  short  distance.  Except  in  tlie  lower  ileum  the  small  intestine  shows 
no  constant  changes,  and  none  are  usually  found  in  the  stomach. 

Microscopical  Changes. — These  (Fig.  58)  are  much  more  uniform 
than  the  gross  appearances.    The  most  characteristic  feature  is  the  exu- 


PLATE    X. 


Membranous  Inflammation  of  the  Ileum. 

A  delicate  child,  eleven  months  old ;  mild  diarrhoea  for  two  weeks  without  fever ; 
acute  severe  symptoms  for  twelve  days ;  temperature,  100"  to  102'5°  F. ;  green  and 
mucous  stools  ;  no  blood. 

The  lesions  involved  the  last  foot  of  ileum  and  entire  colon.  Specimen  is  from 
lower  ileum,  and  shows  the  abrupt  termination  of  the  lesion ;  the  upper  part  shows 
normal  small  intestine ;  A  is  a  Peyer's  patch ;  B  is  the  inflamed  part  of  the  intestine ; 
it  has  a  rough  granular  appearance  and  is  much  thickened. 


ACUTE ,  ILEO-COLITIS.— DYSENTERY. 


373 


dation  of  fibrin,  which  forms  a  distinct  pseudo-membrane  upon  the 
surface  of  the  intestine;  it  may  infiltrate  tlie  mucosa,  and  even  the  sub- 
mucosa.  Fibrin  is  seen  under  the  microscope  in  parts  of  the  specimen, 
which  to  the  naked  eye  show  no  distinct  pseudo-membrane,  but  onl}'^  a 
granular  appearance.  In  rare  cases  a  fibrinous  exudation  may  be  found 
upon  the  peritoneal  covering  of  tlie  intestine.  The  pseudo-membrane  is 
made  up  of  a  fibrinous  network  containing  small  round  cells,  some  red 


Fig.  58. — Membranous  Inflammation  of  the  Colon.  The  intestine  is  covered  with 
a  pseudo-membrane,  M,  which  is  composed  chiefly  of  granular  fibrin;  the  mucosa, 
A,  is  densely  packed  with  round  cells,  and  the  tubular  follicles  have  almost  dis- 
appeared, traces  only  being  left  at  T,  T.  The  submucosa,  C,  is  greatly  thickened, 
partly  from  cells,  but  chiefly  from  fibrin,  which  with  a  high  power  is  seen  to  be  every- 
where in  this  coat,  as  well  as  the  mucosa.  Nests  of  cells  are  seen  in  the  muscular 
coats  at  L,  L.  At  i''  is  a  lymph  nodule  covered  by  pseudo-membrane,  but  breaking 
down  at  its  centre.  V,  V,  are  small  blood-vessels  with  nests  of  cells  about  them. 
History. — Fourteen  months  old;  ill  nine  days;  temperature  101°  to  105°  F.;  all  stools 
containing  blood.  Lesions  found  throughout  colon  and  in  lower  ileum.  Intestine 
greatly  thickened.  Specimen  is  from  ascending  colon,  where  lesion  was  especially 
severe. 


blood-cells,  and  numerous  bacteria.  The  mucosa,  and  usually  the  sub- 
mucosa, are  densely  infiltrated  with  small  round  cells,  which  in  places 
may  be  so  numerous  as  to  efface  the  normal  elements  of  the  intestine. 
The  tubular  follicles  are  in  some  places  quite  destroyed,  not  a  vestige  of 
them  remaining.  In  other  places  they  are  compressed  and  distorted  by 
the  accumulation  of  cells.  The  great  thickening  of  the  intestine  is  due 
partly  to  the  cell  infiltration,  partly  to  the  fibrinous  exudation,  and 
partly  to  oedema.  All  the  blood-vessels,  both  in  the  mucosa  and  sub- 
mucosa, are  gorged  with  blood,  and  many  small  extravasations  are  seen. 


374  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

A  necrotic  process  with  the  formation  of  deep  ulcers  I  have  never  seen 
associated  with  membranous  colitis. 

Associated  Lesions  of  Ileo-colitis. — The  most  important  one  is 
broncho-pneumonia.  It  is  found  in  quite  a  large  proportion  of  the  pro- 
tracted cases,  and  not  infrequently  it  is  the  cause  of  death.  I  think  it  is 
seldom  due  to  an  infection  from  the  intestine,  although  such  a  thing  is 
possible  in  septicsemic  cases.  It  occurs  rather  as  it  does  in  any  other 
protracted  exhausting  disease.  In  a  study  of  sixty  cases,  Spiegelberg 
did  not  find  bacteria  in  the  pulmonary  capillaries,  and  he  regards  in- 
fection through  the  blood  as  not  yet  proved.  Pulmonary  tuberculosis 
is  not  infrequently  met  with  in  hospital  cases,  having  no  relation  to  the 
intestinal  disease.  Peritonitis  is  infrequent.  I  have  met  with  it  but 
once  or  twice,  and  then  it  was  localised  and  of  the  plastic  variety.  In- 
flammations of  the  other  serous  membranes — pleurisy,  pericarditis,  and 
meningitis — are  all  very  rare. 

The  renal  lesions  of  ileo-colitis  have  been  the  subject  of  considerable 
discussion,  some  observers  holding  that  nephritis  is  a  frequent  compli- 
cation of  the  severer  forms  of  diarrhoea,  while  others  have  held  it  to  be 
rare.  The  lesions  I  have  usually  found  in  my  own  cases  coincide  with 
those  described  by  others,  and  consist  in  marked  degeneration  of  the 
epithelium  of  the  tubes  with  but  few  glomerular  or  interstitial  changes. 
In  three  or  four  instances  only  have  I  found  well-marked  lesions  of  acute 
diffuse  nephritis  at  autopsy,  or  seen  its  symptoms  clinically.  I  believe 
it  to  be  a  very  infrequent  though  sometimes  a  most  serious  complica- 
tion. The  lesions  mentioned  as  usually  present  are  properly  classed 
as  acute  degeneration  rather  than  as  inflammation  of  the  kidney.  Its 
causes  are  chiefly  the  irritation  of  toxins,  intensified  no  doubt  by  the 
concentration  of  the  urine.  Degenerative  changes  may  be  found  also 
in  the  heart  muscle,  the  liver,  spleen,  and  even  in  the  central  nervous 
system. 

Considerable  attention  has  been  given  to  a  study  of  the  blood  in 
intestinal  inflammations,  to  determine  how  frequently  and  in  what 
circumstances  a  general  blood  infection  (septicaemia)  from  the  intes- 
tines occurs.  In  the  great  majority  of  the  cases  studied  under  proper 
precautions  the  blood  is  sterile. 

Symptoms. — (1)  Catarrhal  Cases  of  Moderate  Severity. — The  onset  is 
usually  sudden,  often  with  vomiting,  and  for  twelve,  sometimes  twenty- 
four  hours  the  symptoms  may  be  those  of  acute  indigestion:  vomiting, 
pain,  fever,  and  frequent,  thin,  green  or  yellow  stools,  which  are  partly 
faecal  and  contain  undigested  food.  Later  the  discharges  contain  blood 
and  mucus,  are  often  preceded  by  pain  and  accompanied  by  tenesmus. 
The  stools  are  very  frequent,  often  every  half  hour,  and  proportionately 
small,  sometimes  less  than  a  tablespoonful  being  found  upon  the  nap- 
kin after  severe  straining  efforts.     The  mucus  may  be  clear  and  jelly- 


ACUTE   lLE()-COLrriS.     DYSENTERY. 


375 


like,  or  it  may  be  mixed  witli  faecal  matter.  Blood  is  seen  in  some  cases 
in  almost  every  stool,  but  rarely  in  clots,  usually  streaking  the  mucus. 
These  stools  are  almost  odourless.  After  two  or  three  days  the  blood 
usually  disappears,  or  is  seen  only  as  traces  in  an  occasional  stool;  but 
nmcus  is  still  present  in  large  quantities.  The  colour  of  the  discharges 
now  becomes  dark  brown  or  brownish-green.  Prolapsus  ani  is  frequent, 
and  may  occur  with  nearly  every  stool.  Abdominal  pain  is  present,  and 
is  often  quite  intense  just  before  the  stool ;  and  frequently  there  is  ten- 
derness along  the  colon.  For  the  first  twenty-four  hours  the  tempera- 
ture is  usually  high,  from  103°  to  104°  F.     During  the  greater  part  of 


6MOS 

12  MOS 

18 

M 

WEEK 

OF  XOE28  30  32  34   36  38   40   43  44    46   48   50  52   54   56  58   00    03  04   G6   68    70    72  74    ' 

el 

26 
25 
24 
23 

§21 
£20 
19 
18 
17 
16 
15 

1 

1 

\ 

1 

1 

\ 

/ 

1 

\ 

/ 

1 

/ 

/ 

/ 

'-- 

-^ 

7 

~) 

-- 

h 

' 

^ 

^^r' 

1 

-^ 

X 

- 

-J 

' 

1 

<* 

^ 

1 

<^ 

1 

y 

^ 

^ 

^ 

- 

\ 

> 

/ 

1 

-4 

"< 

/ 

1 

^ 

s 

/ 

1 

1 

1 

1 

- 

j^ 

r 

s 

/ 

1 

1 

' 

^ 

\ 

/ 

1 

! 

1 

'  I 

\ 

,/ 

1 

1 

1 

\ 

1 

1 

' 

X' 

1 

1 

t- 

! 

, 

i 

1 

. 

1 

Fio.  59. — ^Weight  Curve  Showing  Loss  from  Ileo-colitis.  Well-noilrished  infant; 
attack  of  measles  at  A  (fortieth  week),  followed  by  ileo-colitis,  which  though  not 
severe  continued  with  exacerbations  during  September  and  October.  At  B  all 
symptoms  had  disappeared  except  occasional  mucus  in  the  stools.  Rapid  improve- 
ment from  this  time,  which  was  continued  during  the  winter,  the  child  being  sent 
to  a  warm  climate ;  it  was,  however,  five  and  a  half  months  before  the  weight  reached 
the  normal  average  line. 


the  attack  it  ranges  from  99°  to  102°  F.  There  is  considerable  prostra- 
tion; the  loss  in  weight  is  usually  marked  and  continuous;  appetite  is 
lost;  the  tongue  is  coated  and  the  general  appearance  of  the  children  in- 
dicates serious  illness,  although  no  really  grave  symptoms  are  present. 
Convalescence  is  always  slow,  and  it  may  be  months  before  the  lost 
weight  is  regained   (Fig.  59). 

In  the  milder  cases  the  symptoms  point  to  inflammation  of  the  lower 
part  of  the  colon  only.  The  constitutional  symptoms  are  not  at  all 
marked.  The  temperature  may  not  be  above  101°  F. ;  the  tongue  may 
remain  clean  and  the  appetite  good ;  the  child  may  be  bright  and  active, 
and  hardly  seem  at  all  ill,  and  yet  have  from  six  to  eight  small  mucous 
and  bloody  stools  a  day. 

The  duration  of  the  acute  symptoms  is  usually  about  a  week,  and 
yet  in  such  cases,  even  though  the  child  was  previously  in  good  condition 


376  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

and  properly  treated,  recovery  is  slow.  The  first  symptom  of  improve- 
ment is  generally  the  disappearance  of  blood  from  the  stools,  which  at 
the  same  time  become  less  frequent,  and  the  pain  and  tenesmus  cease. 
Gradually  the  stools  assume  more  of  a  faecal  character,  but  mucus  is 
likely  to  persist  for  two  or  three  weeks;  it  may  be  seen  in  all  stools,  or 
only  occasionally.  In  some  cases  both  the  mucus  and  blood  disappear 
and  the  stools  become  thin,  brown,  or  green,  like  those  of  an  ordinary 
diarrhoea.  Although  the  early  stage  of  very  acute  symptoms  may  last 
but  a  few  days,  if  there  is  a  continuance  for  three  or  four  weeks  of  the 
brown,  mucous  stools,  with  emaciation  and  slight  fever,  ulceration  is 
probably  present.  This  is  likely  to  occur  if  the  child  is  in  poor  condition, 
if  its  surroundings  are  bad,  or  if  it  is  improperly  treated  at  the  outset. 
Eelapses  are  readily  excited,  but  cases  like  the  above  are  rarely  fatal 
except  in  delicate  infants.  This  is  the  most  common  form  of  ileo-colitis 
which  terminates  in  recovery. 

(2)  The  Severe  Catarrhal  Form. — This  form  of  ileo-colitis,  like  that 
just  described,  is  usually  primary.  The  symptoms  closely  resemble  those 
of  the  membranous  variety,  and  a  diagnosis  from  it  is  to  be  made  only 
by  the  absence  of  pseudo-membrane  from  the  stools.  The  most  rapid 
case  I  have  seen  lasted  only  three  days,  but  the  usual  duration  is  from 
one  to  two  weeks.  The  temperature  is  steadily  high ;  the  stools  continue 
very  frequent  and  generally  contain  blood;  there  is  great  prostration, 
dry  tongue,  sordes  on  the  lips  and  teeth,  and  prominent  nervous  symp- 
toms. Death  usually  occurs  from  exhaustion  and  profound  sepsis  while 
the  acute  symptoms  are  at  their  height.  If  the  patient  survives  this 
stage,  the  case  may  drag  on  for  four  or  five  weeks,  very  much  like  one 
of  follicular  ulceration,  and  then  terminate  in  recovery  or  in  death  from 
slow  asthenia,  broncho-pneumonia,  or  from  an  acute  exacerbation  of 
the  intestinal  symptoms.  The  autopsy  in  such  cases  usually  reveals  the 
presence  of  artificial  ulcers.  If  recovery  is  to  be  the  outcome,  after 
the  symptoms  have  been  nearly  stationary  for  a  long  time,  there  is  seen 
a  gradual  improvement  first  in  the  general  and  then  in  the  local  con- 
ditions. Convalescence  is  very  slow,  often  interrupted  by  relapses,  and 
it  may  be  months  belore  the  patient  is  quite  wdl.  In  some  cases  the 
child  never  regains  his  former  vigour. 

(3)  Follicular  Ulceration — Ulcerative  Inflammation  of  the  Nodules. 
— Follicular  ulceration  is  often  preceded  by  other  forms  of  intestinal 
disease.  It  is  not  very  frequently  met  with  in  infants  under  six  months 
of  age.  The  great  majority  of  those  affected  are  in  poor  condition  at 
the  time  of  the  attack. 

To  understand  the  symptoms  of  these  cases,  it  must  be  remembered 
that  follicular  ulceration  is  a  terminal  process  following  other  forms  of 
diarrhoea.  It  may  be  preceded  by  one  or  more  acute  attacks,  or  by  a 
protracted  subacute  attack.     On  account  of  the  feeble  resistance  of  the 


ACUTE  ILEO-COLITIS.— DYSENTERY. 


377 


child  or  the  continuance  of  the  exciting  cause,  the  pathological  process 
gradually  extends  to  the  lymph  nodules  of  the  intestine,  chiefly  the 
colon,  which,  as  already  described,  pass  successively  through  the  stages 
of  swelling,  softening,  and  ulceration.  The  onset  of  the  illness  may 
therefore  be  abrupt,  with  vomiting  and  high  fever;  or  gradual,  without 
vomiting  and  with  very  little  fever.  The  patient  may  be  ill  for  a  week 
before  the  exact  type  which  the  disease  is  assuming  can  be  positively 
determined.  It  is  not  possible  to  mark  the  transition  from  acute  gastro- 
enteric intoxication  to  follicular  ileo-colitis.  Usually  the  latter  may  be 
assumed  to  exist  whenever,  after  a  very  acute  onset,  there  is  a  continued 
temperature,  and  when  the  stools  habitually  contain  large  quantities  of 
mucus  without  blood. 


DAY 

1 

2 

3 

4 

E 

6 

7 

8 

9 

^ 

It 

12 

13 

14 

18 

16 

17 

18 

19 

20 

21 

22 

23 

24 

28 

26 

27 

28 

29 

30 

81 

32 

1? 

34 

DATE 

OCT. 

16 

17 

18 

19 

20 

21 

22 

23 

24 

2S 

26 

27 

28 

29 

30 

31 

ibv 

•2 

3 

4 

5 

6 

' 

8 

9 

10 

11 

12 

13 

14 

18 

16 

17 

18 

K 
u 

z 
z 

I 
< 

uT 

1 

a 
z 

81 

106" 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 
96° 
OOL8 

.1 

"  ' 

-I 

'•' 

"" 

... 

•  I 

"  ■ 

>.i 

"' 

"• 

"■' 

... 

«i 

••■■ 

•  ■ 

.. 

"•■ 

... 

.... 

... 

... 

... 

.. 

.... 

... 

.... 

... 

.. 

... 

.... 

.1 

"' 

• 

A 

V 

] 

/ 

/ 

/^ 

A 

k 

\ 

/ 

/I 

f 

y 

p 

f 

lA 

n 

» 

u 

r 

J 

1 

V 

n 

/ 

s, 

A 

r^ 

/ 

r\ 

- 

\ 

/ 

'^ 

1 

u 

\ 

u 

A 

^ 

\/ 

\, 

fv 

/■ 

\- 

r^ 

V 

7 

_6. 

J_ 

3 

2 

a 

3 

6 

_i. 

5 

_*_ 

i 

5 

5 

2 

3 

3 

3 

5 

5 

4 

4 

6 

4 

e 

4 

4 

2 

5 

5 

_3_ 

5 

i 

2 

Fig.  60. — Temperature  Chart  of  Ileo-colitis,  Fataii  on  Thirty-fourth  Day. 
Autopsy  showed  follicular  ulcers  throughout  the  colon. 

Vomiting  is  not  a  feature  of  these  cases ;  but  it  is  often  present  at  the 
onset.  Throughout  the  attack  it  is  easily  excited  by  injudicious  feeding 
or  medication.  The  temperature  is  seldom  high,  except  at  first ;  its  usual 
range  is  from  99°  to  101°  F. ;  toward  the  close,  even  of  fatal  cases,  it  may 
be  scarcely  above  the  normal.  The  accompanying  chart  (Fig.  60)  is  a 
very  good  illustration  of  the  course  of  the  temperature  in  cases  begin- 
ning abruptly  and  ending  fatally. 

The  stools  are  seldom  very  frequent,  the  number  being  from  four 
to  eight  a  day.  The  most  constant  feature  is  the  presence  of  mucus, 
which  is  mixed  with  the  stools  and  usually  abundant.  Blood  is  not  gen- 
erally present,  and  a  large  amount  of  blood  is  extremely  rare.  It  was 
absent  entirely  in  more  than  half  of  my  cases  in  which  the  diagnosis 
was  confirmed  by  autopsy.  A  small  quantity  of  blood  early  in  the  attack 
is  not  uncommon,  depending  here  upon  congestion.  Large  hasmorrhages 
from  ulcers  I  have  never  seen.  The  colour  of  the  stools  is  most  fre- 
quently dark  green  or  brown.  Fluid  stools  are  seen  only  during  exacerba- 
tions. The  odour  is  usually  offensive,  particularly  in  protracted  cases. 
The  microscope  shows  epithelial  cells  in  great  numbers,  and  very  often 
an  abundance  of  small  round  cells,  which  may  be  looked  upon  as  the 
most  constant  sign  of  ulceration. 


378  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

The  failure  in  nutrition  and  steady  loss  in  weight  are  very  constant 
in  these  cases.  As  emaciation  goes  on,  the  skin  hangs  in  loose  folds  on 
the  thighs;  it  becomes  dry  and  scaly  and  loses  its  elasticity,  and  occa- 
sionally small  petechial  spots  are  seen  upon  the  abdomen.  The  skin  over 
the  buttocks  becomes  excoriated,  and  bed-sores  form  over  the  heels,  the 
sacrum,  or  the  occiput.  The  abdomen  may  be  moderately  distended,  or 
it  may  be  relaxed  and  soft.  Tenderness  is  not  usually  present.  The 
appetite  is  lost,  and  in  most  cases  great  difficulty  is  experienced  in  getting 
children  to  take  a  proper  amount  of  nourishment.  Contimied  aversion 
to  food  is  an  unfavourable  symptom.  Occasionally,  when  there  is  fever, 
fluids  are  taken  eagerly.  A  returning  appetite  is  always  an  encouraging 
sign.  The  mouth  is  often  dry,  the  tongue  coated,  sometimes  dry  and 
brown ;  there  may  be  sordes  upon  the  lips  and  teeth.  Superficial  ulcers 
form  upon  the  mucous  membrane  of  the  mouth,  and  often  thrush  is 
seen.  The  urine  is  usually  diminished,  high-coloured,  and  loaded  with 
urates.  Albumin  and  casts  are  rarely  present.  In  only  two  or  three 
cases  have  I  seen  nephritis  severe  enough  to  be  a  factor  in  the  result. 
Tenesmus  and  prolapsus  ani  are  uncommon. 

The  average  duration  of  the  fatal  cases  is  about  three  weeks;  their 
course  is  often  marked  by  exacerbations  and  remissions.  If  recovery 
takes  place,  convalescence  is  always  very  slow  and  relapses  are  easily 
excited. 

Very  few  of  these  cases  recover  completely.  Even  those  who  survive 
the  primary  illness  are  likely  to  suffer  from  intestinal  symptoms  for 
many  months.  Fatal  relapses  are  often  brought  on  by  injudicious  feed- 
ing when  the  children  are  apparently  almost  well.  The  general  health 
is  usually  so  undermined  that  the  patients  continue  to  suffer  from  all  the 
symptoms  of  malnutrition,  and  ultimately  succumb  to  an  attack  of  some 
intercurrent  acute  disease. 

The  diagnosis  of  ulceration  is  to  be  made  from  the  case  as  a  whole 
rather  than  from  any  special  symptoms.  If  a  delicate  infant,  who  has 
previously  been  prone  to  diarrhoeal  attacks,  has  green  mucous  stools  with 
low  fever,  and  these  symptoms  continue  with  unabated  severity  for  ten 
or  twelve  days,  ulceration  is  probable.  If  such  symptoms  continue  for 
three  or  four  weeks  with  steadily  failing  strength  and  loss  of  weight,  the 
diagnosis  is  almost  certain.  If,  on  the  contrary,  after  three  or  four  days 
of  acute  symptoms  there  is  improvement  in  the  stools  and  occasionally 
some  which  are  quite  faecal  in  character,  even  though  it  may  be  a  week 
or  more  before  the  mucus  disappears,  we  may  be  quite  certain  that  no 
ulcers  have  formed. 

(4)  The  Membranous  Form. — This  is  the  gravest  form  of  iiiflamina- 
tion  of  the  intestines  seen  in  children,  and  its  symptoms  are  more  often 
obscure  than  are  those  of  any  other  variety.  This  is  particularly  true 
when  it  affects  young  infants.    There  may  be  at  the  onset  and  through- 


ACUTE  ILEC)-COLTTIS.- DYSENTERY. 


379 


DAY 

1 

2 

3 

4 

5 

e 

7 

8 

DATE 

JULY 

16 

17 

18 

19 

20 

21 

22 

23 

t 

I 
z 

IT 

X 

i 

u 
ec 

3 

i 

a 
81 

106° 
105" 
104* 
103° 
10»° 
101° 
100° 
99° 
98' 
»T* 
96° 
00  LS 

M.E 

ME 

M.E 

M.E 

M.E 

M.E. 

M.E 

M.E. 

-.E. 

M.E. 

1/ 

. 

f 

\, 

Y 

V 

A 

A 

A 

1 

V 

\ 

f  V 

5 

7 

11 

7 

7 

9 

14 

4 

_J 

out  the  course  of  the  disease  severe  local  and  constitutional  S3'mptoms; 
or  with  well-marked  constitutional  symptoms,  the  local  symptoms  may 
be  slight  or  of  very  doubtful  character,  so  that  it  is  often  mistaken  for 
some  other  disease. 

In  the  first  form  it  closely  resembles  the  most  severe  cases  of  catar- 
rhal inflammation.  The  disease  begins  abruptly,  with  vomiting,  high 
temperature,  and  several  large,  fluid  stools.  The  vomiting  does  not 
often  continue  after  the  first  twenty-four  hours.  The  temperature  is  at 
first  from  103°  to  105°  F.,  and  its  course  may  be  steadily  high  (Fig.  61), 
or  remittent.  The  abdomen  is  often 
tender  and  sometimes  swollen.  There 
is  severe  pain,  and  at  times  tenesmus, 
with  prolapse  of  the  rectum.  This  is 
intensely-  congested,  and  sometimes 
shows  patches  of  pseudo-membrane 
upon  its  surface,  thus  establishing 
the  diagnosis. 

The  stools  often  resemble  those 
of  the  catarrhal  variety,  except  that 
blood  is  more  constantly  present  and 
usually  more  abundant,  but  the  only 
positive  point  of  difference  is  the 
presence  of  shreds  or  flakes  of  pseudo- 
membrane.  If  the  stools  are  thor- 
oughly washed  with  water  these  may  be  seen  as  small  gray  opaque 
masses,  which  are  then  easily  distinguished  from  the  transparent  mucus. 
Large  shreds  of  membrane  are  seldom  seen  in  children.  Both  blood  and 
mucus  sometimes  disappear  from  the  stools,  which  may  consist  only  of 
dirty  water.  Under  the  microscope  there  may  be  seen  epithelial  cells, 
red  blood-cells,  and  round  cells  in  great  numbers. 

The  presence  of  cerebral  symptoms  in  these  cases  of  membranous 
ileo-colitis  may  lead  to  great  obscurity  in  the  diagnosis.  This  is  most 
frequently  true  at  the  onset.  There  may  be  high  temperature,  great 
prostration,  vomiting,  stupor,  delirium,  and  even  convulsions;  and  such 
symptoms  may  for  two  or  three  days  completely  mask  the  intestinal  con- 
dition. As  the  case  progresses,  however,  the  intestinal  symptoms  come 
more  and  more  into  prominence,  and  the  cerebral  symptoms  usually  sub- 
side. But  sometimes  this  is  not  the  case.  I  once  saw  a  case  closely 
watched  for  two  weeks  by  three  physicians  of  large  experience,  who  were 
agreed  in  the  diagnosis  of  a  cerebral  lesion,  but  not  as  to  its  nature, 
which  showed  at  autopsy  only  the  lesions  of  membranous  colitis.  There 
was  a  continuous  but  irregular  fever,  stupor,  retracted  abdomen,  opis- 
thotonus, unequal  pupils,  and  at  times  irregular  respiration.  Two  or 
three  days  before  death  the  first  blood  appeared  in  the  stools,  and  at 


Fia.    61.  —  Temperature    Chart    of 
Membranous  Colitis;  Fatal. 


380 


DISEASES   OF  THE   DIGESTIVE   SYSTEM. 


the  same  time,  during  extensive  rectal  prolapse,  a  false  membrane  was 
seen. 

Membranous  colitis  is  also  obscure  when  it  affects  young  infants. 
Every  year  a  number  of  these  cases  are  seen  at  the  Babies'  Hospital. 
The  prominent  symptoms  are:  rather  high,  continuous  temperature, 
usually  /ranging  between  101°  and  104°  F.,  but  following  no  distinct 
curve  (Fig.  62)  ;  wasting,  which  is  not  rapid  but  progressive;  frequent 


D»J             «      1      "     1    »»     1    11     1     12    1     la    1     14    1    15     1    10     1    17     1     IS    1    1«     1    20    1    21     1     22      |     2)     |     21    |     25    |    20    |    27    | 

106* 

«»«; 

oi  103 
5  lOii" 
d  lOl' 
"  100* 

3  »» 

^    »8 
97* 
96 

~.  O                 «                                  O                 »               W              I.              IJ             .-.              .1              W             .«              11              i:i               IV               2U              .1              „             i>             SI 

M.    E.  H.  E    M.  £.  M.  E.  M.  E.  M    E.  H.  £.  M.  E.  M.  E.   M.  E    M    E.  M.  E.  M.  E.  U.   E.  M.    E.    M.   E.  M.  E.  M.  E    M.  G.  M.  E. 

-V                       ^           A                   I-       ^^     I    t        -.%    -^    '^^t 

'                     7^v--»     4^-A       A-    t       2^1    I    4    ^Zl^    1-i    24 

^       -y^-       ttl^A^t      K    l-i'J    t^4-^       SZ    ^14      ^l^ 

t       Zt       '  ^^^    tqiiP    X4      Al    1       t^    ut    it^t 

y     /M       /         N    V        i     /  \  /        I  /     /-  -  '         If-       t 

vZ    4^^                    ll    t    t      ^1    I    L          4 

5r^^^4l3Z-ii--^--" t..t.±. ii 

\                      I                       "  'Z      -  ■-  ■                      p     Y      ^L_ 

.    1 

FiQ.  62. — Temperature  Chart  of  Membranous  Colitis.  Infant  fourteen  months 
old,  Babies'  Hospital.  Symptoms  for  the  first  two  weeks  obscure,  suggesting  first 
pneumonia,  afterward  meningitis.  Intestinal  symptoms  for  the  last  two  weeks  only, 
never  very  severe;  stools  four  to  six  daily,  generally  green,  thin,  with  much  mucus  at 
times,  and  once  or  twice  traces  of  blood.  Culture  four  days  before  death  showed 
streptococci  and  colon  bacilli.  Autopsy:  No  lesion  of  importance  except  mem- 
branous colitis  involving  entire  colon ;  a  slight  catarrhal  enteritis. 


stools,  which  have  no  constant  or  striking  characteristics.  They  are 
usually  thin,  yellow  or  greenish  in  colour,  often  containing  no  mucus  or 
blood.  Occasionally  for  a  day  the  stools  may  be  almost  normal  in  ap- 
pearance. In  number  they  average  five  or  six  a  day,  but  often  for  days 
only  two  or  three.  Outside  of  a  hospital  where  ■  autopsies  are  regularly 
made  these  cases  are  usually  overlooked  and  considered  as  obscure  pneu- 
monia, tuberculosis,  septicaemia,  typhoid,  etc. 

The  duration  of  membranous  ileo-colitis  is  usually  from  one  to  three 
weeks.  Death  takes  place  from  sepsis,  exhaustion,  or  from  complica- 
tions. It  is  probable  that  almost  every  case  of  the  severity  described 
terminates  fatally  when  it  occurs  in  an  infant.  In  older  children  the 
prognosis  is  much  better  as  to  life,  but  in  them  the  acute  attack  may 
be  followed  by  the  chronic  form  of  the  disease. 

Diagnosis. — Ileo-colitis  is  to  be  distinguished  chiefly  from  typhoid 
fever,  intussusception,  and  meningitis.  Typhoid  is  distinguished  by  tlie 
slower  invasion,  more  constant  temperature,  enlargement  of  the  spleen, 
tympanites,  and  most  of  all  by  the  Widal  reaction  and  the  eruption. 
Acute  colitis  should  not  be  confounded  with  intussusception ;  yet  the 
records  of  intussusception  show  that  a  very  large  proportion  of  the  cases 
were  regarded  in  the  beginning  as  cases  of  dysentery.  In  intussuscep- 
tion, although  we  have  a  sudden  onset  with  acute  pain,  tenesmus,  vomit- 
ing, and  marked  prostration,  there  is  rarely  fever.    The  later  symptoms 


ACUTE  ILEO-COLITIS.— DYSENTERY.  381 

— absolute  constipation,  tumour,  stercoraceous  vomiting,  and  collapse — 
have  nothing  in  common  with  colitis.  The  membranous  form  may  be 
confounded  with  meningitis,  and  in  some  cases  a  differential  diagnosis 
is  impossible  except  by  lumbar  puncture.  Marked  diarrhoea,  even 
though  the  stools  are  not  characteristic,  should  always  make  one  doubt 
meningitis. 

A  diagnosis  between  the  different  varieties  of  ilco-colitis  is  not  always 
possible.  Follicular  ulceration  is  distinguished  by  its  lower  temperature, 
rather  subacute  course,  infrequency  of  blood  in  the  stools,  and  by  the 
fact  that  it  is  usually  preceded  by  diarrhceal  attacks  which  are  often 
prolonged. 

In  the  catarrhal  form,  the  symptoms  of  an  acute  inflammation  of 
the  colon  are  usually  manifest  from  the  outset — bloody  stools,  pain, 
tenderness,  tenesmus,  and  fever.  In  the  membranous  variety  such  symp- 
toms are  sometimes  seen;  but,  as  a  rule,  the  local  symptoms  are  less 
pronounced,  while  the  constitutional  symptoms,  especially  those  relating 
to  the  nervous  system,  are  usually  marked.  The  course  is  usually  shorter 
and  more  intense  than  in  the  other  forms. 

An  agglutination  reaction  of  the  B.  dysenterice  with  the  serum  of 
affected  children  is  usually  present.  But  for  general  use  in  diagnosis 
this  is  not  of  great  assistance.  It  is  subject  to  considerable  variation. 
Moreover,  it  is  seldom  present  until  the  end  of  the  first  week  of  the  dis- 
ease, by  which  time  the  nature  of  the  attack  is  evident  by  clinical  symp- 
toms. Agglutination  in  the  higher  dilutions  is  seen  only  with  the  par- 
ticular type  of  organism  with  which  the  infant  is  infected. 

Prognosis. — The  younger  the  patient  the  worse  the  outlook.  The 
prognosis  is  rendered  unfavourable  by  extreme  summer  heat  and  by 
prolonged  previous  attacks  of  intestinal  disturbance.  The  outlook  is 
worse  in  secondary  than  in  primary  cases.  In  a  given  case  bad  prog- 
nostic symptoms  are:  continuous  high  temperature,  the  persistence  of 
much  blood  in  the  stools,  and  severe  nervous  symptoms.  The  prognosis 
is  always  worse  in  institutions  than  in  private  practice. 

Prophylaxis.^ — What  has  been  said  regarding  general  prophylaxis  in 
the  previous  chapter,  applies  equally  well  to  cases  of  ileo-colitis. 

Special  emphasis  should  be  placed  upon  the  necessity  of  energetic 
early  treatment  of  all  the  milder  forms  of  diarrhoea,  and  particularly 
the  cases  of  acute  intestinal  indigestion  and  intoxication,  in  order  that 
the  process  may  be  arrested  before  serious  anatomical  changes  have  taken 
place.  Equal  stress  should  be  laid  upon  the  importance  of  prompt  and 
intelligent  treatment  at  the  very  beginning  of  the  cases  with  a  sudden 
onset. 

Hygienic  Treatment. — The  general  plan  recommended  in  the  pre- 
vious chapter  should  be  followed  here.  A  change  of  air  is  desirable  for 
most  cases  as  soon  as  the  acute  inflammatory  symptoms  have  subsided. 


382  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

In  the  protracted  cases  which  drag  on  a  subacute  course,  this  change 
will  often  do  more  than  anything  else.  Plenty  of  fresh  air  is  necessary 
in  all  cases.  The  indications  for  bathing  are  the  same  as  in  other  cases 
of  acute  diarrhoea.  It  is  undesirable  to  crowd  these  patients  in  institu- 
tions, as  they  always  do  better  when  separated. 

The  diet  during  the  acute  stage  should  be  the  same  as  in  other  forms 
of  acute  diarrhoea.  In  the  protracted  cases  the  diet  presents  great  dif- 
ficulties, as  the  children  have  little  or  no  appetite,  and  soon  come  to 
refuse  everything  in  the  shape  of  food  that  is  offered.  In  infancy,  in 
the  early  stage  only,  barley  or  rice  water  should  be  given.  In  the  later 
stage  the  articles  which  are  most  to  be  depended  upon  are  skimmed 
milk,  which  has  been  sterilised,  buttermilk  which  should  be  diluted 
according  to  the  conditions  present,  and  animal  broths.  Especially  to 
be  avoided,  not  only  in  the  acute  stage  but  during  convalescence,  are 
cream,  all  top-milk  mixtures,  and  also  the  malted  foods.  Infants,  when 
very  ill,  are  much  more  likely  to  take  too  little  than  too  much  food.  A 
careful  record  should  be  kept  of  the  amount  actually  taken  in  each 
twenty-four  hours.  In  no  case  should  food  be  given  oftener  than  every 
three  hours,  and  usually  the  intervals  should  be  longer,  water  and  stinm- 
lants  being  allowed  between  the  feedings.  In  older  children  the  diet 
during  the  acute  stage  should  be  much  the  same  as  in  infants.  At  a  later 
period,  rare  scraped  beef,  kumyss,  buttermilk,  skimmed  milk,  and  zoo- 
lak  will  be  found  useful,  and  during  convalescence,  eggs,  boiled  milk,  or 
milk  gruels  made  with  rice  or  barley.  Special  care  should  be  given  to 
the  diet  for  a  long  time.  For  months  after  an  acute  attack  th^  intes- 
tines are  very  easily  deranged.  Relapses  are  excited  by  changes  in  the 
temperature,  by  great  fatigue  or  exhaustion,  but  most  of  all  by  improper 
feeding.  Especially  in  older  children  should  such  articles  as  cream, 
oatmeal,  potatoes,  com,  tomatoes,  green  vegetables,  and  all  fruits  be 
withheld  for  a  long  time.  I  have  seen  a  single  peach,  given  to  a  child 
two  years  old,  excite  a  dangerous  relapse,  and  a  few  raisins  a  fatal 
one. 

Medicinal  and  Mechanical  Treatment. — Cases,  the  early  stage  of 
which  is  marked  by  vomiting  and  thin  diarrhoeal  stools,  are  to  be  man- 
aged at  the  outset  according  to  the  plan  outlined  in  the  previous  chapter, 
viz.,  free  purgation,  irrigation  of  the  colon,  and  stopping  all  food.  When 
the  symptoms  of  acute  inflammation  are  evident  from  the  outset,  as 
shown  by  the  frequent  bloody  and  mucous  stools  with  tenesmus  and 
pain,  the  measures  to  be  depended  upon  are  castor  oil  or  saline  cathar- 
tics, irrigation  of  the  colon,  and  later  opium  and  bismuth  by  the  mouth. 
Castor  oil  should  be  administered  in  a  full  dose  at  the  outset — one 
drachm  at  six  months,  two  drachms  at  one  year,  and  half  an  ounce 
at  four  years.  Its  primary  effect  is  to  clear  the  intestines,  and  its  sec- 
ondary effect  is  soothing.    The  salines  may  be  used  as  described  in  the 


ACUTE   ILEO-COLITIS.— DYSENTERY.  383 

previous  chapter.  If  the  stomach  is  at  all  irritable,  calomel,  one-fourth 
grain  every  half-hour  for  five  or  six  doses,  may  be  substituted.  Opium 
is  usually  required  on  account  of  the  pain,  tenesmus,  and  great  frequency 
of  stools.  The  dose  should  bo  regulated  l)y  the  severity  of  these  symp- 
toms. The  deodorised  tincture  and  paregoric  are,  I  think,  preferable 
to  other  preparations.  Repeated  small  doses  are  better  than  a  single  large 
dose.  It  is  very  important  that  opium  should  be  withheld  for  at  least 
twelve  hours  after  the  initial  purgative. 

As  the  pathological  process  is  principally  in  the  colon,  and  most 
severe  in  the  lower  half  of  the  colon,  it  can  often  be  much  more  effectively 
treated  by  injections  than  by  drugs  given  by  the  mouth.  Irrigation  of 
the  colon  is  one  of  our  most  valuable  means  of  treatment  in  these  cases. 
For  general  purposes  a  saline  solution  at  100°  to  104°  F.  should  be 
employed.  One  or  two  quarts  should  be  given  at  one  time;  it  should 
be  injected  high  into  the  colon  through  a  rectal  tube,  and  early  in  the 
disease  repeated  at  least  twice  a  day.  When  the  tenesmus  is  very  great 
and  blood  abundant,  small  injections  of  either  hot  water  (106°  to  110°  F.) 
or  ice  water  may  be  used,  and  later  astringent  injections. 

The  most  useful  astringent  is  tannic  acid  of  which  one  drachm  may 
be  added  to  a  pint  of  hot  water.  Whether  injections  are  to  be  used 
regularly  or  not  will  depend  much  upon  the  patient.  If  they  are  well 
borne,  they  may  be  given  once  or  twice  a  day  during  the  attack;  but  if 
at  every  attempt  to  give  them  the  child  struggles,  screams,  and  resists, 
they  may  do  more  harm  than  good.  Complete  rest  is  a  very  important 
part  of  the  treatment. 

For  cases  not  influenced  by  the  measures  mentioned,  or  those  not 
seen  at  the  outset,  bismuth  should  be  tried,  but  it  is  of  no  use  whatever 
unless  large  doses  are  administered.  From  two  to  four  drachms  of  the 
subcarbonate  should  be  given  in  twenty-four  hours  to  a  child  two  years 
old,  and  proportionate  doses  to  older  children.  This  may  be  suspended 
in  mucilage.  Tenesmus  and  pain  are  sometimes  relieved  by  the  injection 
of  three  or  four  ounces  of  a  starch  solution  to  which  from  five  to  ten 
drops  of  laudanum  are  added.  Severe  tenesmus,  when  not  controlled 
thus,  and  when  associated  with  prolapsus  ani,  is  sometimes  immediately 
relieved  by  a  suppository  containing  cocaine.  Not  more  than  one-fourth 
grain  should  be  used  for  a  child  of  three  years. 

Although  a  serum  has  been  produced  which  protects  animals  against 
inoculation  with  the  B.  dysenterice,  its  use  in  the  treatment  of  the  various 
forms  of  ileo-colitis  in  children  has  not  been  followed  by  any  very  strik- 
ing benefit. 

Alcoholic  stimulants  are  needed  in  many  cases.  They  are  indicated 
by  a  weak  pulse,  cold  extremities,  and  great  general  prostration,  no 
matter  at  what  stage  in  the  disease  these  symptoms  are  seen.  Brandy 
is  usually  to  be  preferred.     Generally  not  more  than  fifteen  or  twenty 


384 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


drops  every  tliree  hours  are  needed  for  an  infant  one  year  old.     Brandy 
should  always  be  well  diluted. 

In  cases  where  sjTnptoms  have  lasted  two  or  three  weeks,  and  the 
active  ones  have  subsided,  where  the  tempefature  is  scarcely  above  100° 
Y.,  and  the  stools  reduced  to  four  or  five  a  day,  it  is  wise  to  stop 
all  medication  and  attend  only  to  the  feeding,  with  irrigation  of  the 
colon  every  two  or  three  days.  One  is  often  surprised  at  this  stage  to 
find  that  patients  do  better  without  drugs  than  with  them.  The  prevail- 
ing tendency  is  to  overdose  cases  of  this  type.  Careful  attention  to  diet, 
judicious  stimulation,  occasional  irrigation  of  the  bowel,  with  change  of 
air,  will  do  much  more  than  any  amount  of  medication.  During  con- 
valescence general  tonics  are  required,  such  as  arsenic,  iron,  nux  vomica, 
and  wine. 

CHRONIC   ILEO-COLITIS. 

The  severe  forms  of  chronic  ileo-colitis  follow  acute  ileo-colitis,  usu- 
ally the  catarrhal  or  follicular  form,  as  the  membranous  is  so  severe 
that  the  patients  rarely  survive  the  acute  stage.  There  may  be  only  a 
chronic  catarrhal  inflammation  of  the  mucous  membrane,  or  ulcers  may 
be  present.  The  milder  forms  are  usually  the  result  of  chronic  intestinal 
indigestion. 

Lesions. — Catarrhal  Form. — In  its  milder  form  it  is  fairly  common, 
but  in  its  severe  form  it  is  exceedingly  rare.  There  may  be  changes  in 
a  large  part  of  the  small  intestine  and  in  the  stomach,  as  well  as  in  the 
lower  ileum  and  colon. 


Fia.  63. — Chronic  Catarrhal  Inflammation  of  the  Ileum.  The  lesions  affect  the 
mucosa,  A,  almost  exclusively.  It  is  somewhat  thickened;  there  is  extensive  de.struc- 
tion  of  the  tubular  follicles,  remains  being  seen  at  T,  T;  there  is  a  great  increase  in 
the  cells,  and  some  new  connective  tissue  in  the  mucosa.  Large  new  blood-vessels 
are  seen  at  C,  C.  History. — Delicate  child,  thirteen  months  old;  diarrhceal  symptoms 
for  four  months;  during  the  first  two  weeks  there  was  high  fever;  at  death  weighed 
eight  pounds.  The  gross  changes  at  the  autopsy  were  very  slight.  The  section  is 
from  the  middle  ileum. 


The  gross  appearance  of  the  intestine  often  differs  very  little  from 
the  normal.  The  mucous  membrane  is  usually  of  a  dull  gray  or  slate 
colour.    Pigmentation  may  occur  as  striae  in  the  mucous  membrane,  but 


CHRONIC   ILEO-COLITIS.  385 

more  frequently  it  is  limited  to  Peyer's  patches  and  the  solitary  lymph 
nodules;  these,  as  well  as  the  mesenteric  lymph  nodes,  are  generally 
swollen. 

The  microscopical  changes  are  usually  marked.  Tlic  lesion  is  chiefly 
one  of  the  mucosa  (Fig.  63).  The  important  features  are  a  disappear- 
ance of  very  many  of  the  tuhular  glands,  and,  in  the  small  intestine,  of 
the  villi  also.  There  is  a  very  marked  cell  proliferation  in  the  adenoid 
tissue  of  the  mucosa,  and  if  the  disease  has  existed  long  enough  there 
may  he  a  production  of  new  connective  tissue.  The  solitary  lymph 
nodules  show  usually  nothing  hut  cell  hyperplasia.  The  lesions  are  not 
uniformly  distrihuted,  but  occur  in  patches  throughout  the  intestine. 
When  present  in  the  stomach,  they  are  of  the  same  kind  as  those  described 
in  the  intestine,  although  rarely  so  severe.  In  milder  cases  the  gross 
appearances  may  show  very  little  change  to  the  naked  eye,  except  swell- 
ing of  the  lymph  nodules.  Under  the  microscope  there  may  be  found 
more  or  less  extensive  cell  infiltration  of  the  mucosa,  but  rarely  any 
destructive  changes  or  new  connective  tissue. 

Ulcerative  Form. — This  is  rather  rare,  for  the  reason  that  in  infancy 
a  very  large  proportion  of  the  cases  die  during  tlie  acute  stage. 

The  ulcers  are  nearly  always  of  the  follicular  variety ;  occasionally 
they  are  broad  and  shallow.  If  the  patient  dies  after  an  illness  of  from 
six  to  eight  weeks,  the  appearances  do  not  differ  essentially  from  those 
described  in  acute  cases.  If  life  is  prolonged  from  two  to  four  months, 
ulcers  are  found  in  various  stages  of  repair.  Follicular  ulcers  require 
from  one  to  three  months  for  cicatrisation,  and  the  broad  superficial 
ulcers  even  a  longer  time.  It  is  very  doubtful  whether  stricture  ever 
results  from  these  ulcers  in  children.  The  mucous  membrane  shows 
almost  invariably  evidences  of  more  or  less  extensive  chronic  catarrhal 
inflammation.  Among  the  very  rare  lesions  are  cysts  of  the  colon. 
Fully  developed  cysts  I  have  seen  but  once.  The  child  had  an  attack 
of  acute  ileo-colitis,  which  became  chronic,  lasting  about  five  months. 
He  never  regained  his  health,  and  died  one  year  later  from  intercurrent 
disease.  In  the  descending  colon  and  rectum,  about  twenty  cysts  the 
size  of  a  pea,  and  many  smaller  ones,  were  found.  They  had  a  thin, 
translucent  covering.  On  section,  a  thick,  transparent,  gelatinous  ma- 
terial escaped.  They  were  situated  in  the  submucosa,  and  were  un- 
doubtedly produced  by  the  dilatation  of  some  of  the  tubular  glands  whose 
orifices  had  been  obliterated. 

Associated  Lesions. — The  important  ones  are  in  the  lungs,  the  most 
common  being  hypostatic  congestion,  subacute  or  chronic  broncho-pneu- 
monia, more  rarely  pulmonary  tuberculosis.  It  is  rare  to  find  the  lungs 
perfectly  healthy.  The  liver  is  often  found  extremely  fatty  in  cases 
associated  with  great  wasting,  but  in  no  case  have  I  seen  hepatic  abscess. 
The  kidneys  usually  show  a  more  or  less  intense  cloudy  swelling,  and 
26 


386  DISEASES  OF  THE  DIGESTR'E  SYSTEM. 

sometimes  there  may  be  well  marked  nephritis.  Dropsical  effusions  into 
the  serous  cavities  are  rare. 

Symptoms. — In  the  milder  cases  there  are  only  the  symptoms  of 
chronic  intestinal  indigestion  with  the  constant  presence  of  mucus  in  the 
stools,  usually  in  large  amount. 

The  severe  cases  are  usually  seen  in  autumn,  and  are  generally  the 
sequel  of  acute  attacks  occurring  during  tlie  summer. 

The  signs  of  active  inflammation  have  passed  away;  the  temperature 
is  usually  normal;  there  is  no  pain  or  tenderness.  There  is,  however, 
no  improvement  in  the  general  condition,  and  either  the  weight  remains 
stationary,  or  the  child  continues  to  lose  slowly  until  it  is  little  more 
than  a  skeleton.  The  face  is  pinched,  the  eyes  sunken,  and  the  cheeks 
hollow.  The  lips  are  pale,  often  fissured,  and  bleed  readily.  The  fon- 
tanel is  depressed.  The  body  is  so  small  that  the  head  seems  much  too 
large.  The  skin  hangs  in  loose  folds  on  the  thighs.  The  mouth  is  often 
the  seat  of  thrush,  of  catarrhal,  herpetic,  or  rarely  of  ulcerative  stomatitis. 
The  tongue  may  be  heavily  coated,  but  is  more  often  dry,  glazed,  and 
red. 

Although  they  seldom  cry  for  food,  as  a  rule  these  children  will  take 
nearly  everything  given  them,  and  in  almost  unlimited  amount.  Not- 
withstanding that  it  is  retained,  the  more  they  are  fed  the  more  rapid 
seems  the  wasting.  A'omiting  is  not  common,  and  seldom  occurs  except 
from  overloading  the  stomach  or  during  acute  exacerbations. 

The  stools  are  rarely  frequent,  five  or  six  a  day  being  the  average; 
often  there  may  be  only  two  or  three  a  day  for  a  Aveek  at  a  time.  They 
are  thinner  than  normal,  but  are  not  often  fluid.  They  usually  contain 
mucus  of  a  green  or  brownish  colour,  often  in  large  quantity,  but  rarely 
blood.  The  stools  may  consist  almost  entirel)'^  of  a  green  or  greenish- 
brown  fluid.  They  are  large  in  proportion  to  the  amount  of  food  taken. 
Undigested  food  is  always  present  in  quantity,  and  upon  the  diet  de- 
pends verj'  much  the  gross  appearance  of  the  stool,  the  odour  of  which 
is  almost  always  offensive.  Pus  is  often  found  under  the  microscope, 
but  is  rarely  visible  to  the  naked  eye.  A  form  of  stool  believed  to  be 
characteristic  of  wide-spread  inflammation  of  the  mucous  membrane 
with  atrophy  of  the  tubular  glands  is  one  of  nearly  normal  consistence, 
homogeneous,  dark  brown  in  colour,  and  very  offensive. 

Prolapsus  ani  is  not  so  frequent  as  in  the  acute  cases;  but  when  it 
occurs  it  is  generally  more  difficult  to  control.  Flatulence  and  colic  are 
prominent  symptoms  in  some  cases,  but  absent  altogether  in  many  others. 
As  a  rule,  there  is  neither  abdominal  pain  nor  tenderness.  The  abdomen 
is  usually  distended,  and  in  most  cases  the  enlargement  is  uniform,  but 
sometimes  there  is  marked  epigastric  prominence,  which  is  more  often 
from  dilatation  of  the  transverse  colon  than  of  the  stomach.  Although 
the  mesenteric  glands  are  enlarged,  they  can  not  be  felt  through  the 


CHRONIC   ILEO-COLITIS.  387 

abdominal  walls.  Tlie  skin  is  dry  and  scaly,  and  in  the  worst  rases  fre- 
quently covered  with  small  petechias  over  the  abdomen  and  lower  ex- 
tremities. About  the  anus,  and  over  the  sacrum,  thighs,  genitals,  and 
sometimes  the  feet,  there  are  excoriations,  and  not  infrequently  ulcera- 
tions. The  temperature  is  elevated  only  during  exacerbations,  or  from 
inflammatory  complications.  A  subnormal  temperature  is  frequently 
met  with.  I  have  occasionally  seen  it  95°  F.  in  the  rectum.  The  urine 
often  contains  an  excessive  amount  of  indiean.  Dropsy  is  often  present 
without  albuminuria.  The  weight  is  stationary,  or  steadily  falls  to  an 
almost  incredible  degree.  I  have  seen  one  infant  weighing  but  eight 
pounds  at  thirteen  months;  another,  thirteen  pounds  at  two  years  and 
four  months.  Ulcers  of  the  cornea  are  not  uncommon.  Nervous  symp- 
toms are  always  present.  The  children  are  cross  and  irritable,  sleep 
badly,  and  frequently  have  a  low,  whining  cry,  which  is  continued  much 
of  the  time.  Sometimes  they  are  dull,  apathetic,  and  quite  indifferent 
to  their  surroundings.  Persistent  opistliotonus  is  occasionally  seen; 
and  there  may  be  contractions  of  the  extremities,  but  rarely  general 
convulsions. 

The  duration  of  the  disease  is  from  two  months  to  a  year.  The 
progress  is  irregular,  and  marked  by  periods  of  improvement,  during 
which  for  a  time  the  patient  may  hold  his  own,  or  even  gain  in  weight. 
Any  trivia]  cause  may  excite  a  relapse,  and  the  downward  progress  is 
rapid.  Death  often  occurs  during  one  of  these  exacerbations,  or  it  may 
be  due  to  broncho-pneumonia,  tuberculosis,  or  slow  asthenia. 

Diagnosis. — It  is  important  to  distinguish  the  cases  with  marked 
cachexia  and  slow  convalescence,  although  ultimately  resulting  in  com- 
plete recovery,  from  those  which  present  at  a  certain  stage  almost  iden- 
tical symptoms,  and  yet  go  on  steadily  downward,  terminating  fatally. 
The  difference  in  these  cases  is  really  a  difference  in  the  character  and 
extent  of  the  lesions.  The  first  group  are  probably  cases  of  superficial 
catarrhal  inflammation,  or  of  follicular  inflammation  which  has  not  gone 
on  to  ulceration,  these  lesions  being  capable  of  repair.  The  second  group 
are  the  cases  of  ulceration,  in  which  complete  recovery  from  the  lesions 
is  impossible,  and  repair  only  partial,  if  indeed  any  occurs.  In  dis- 
tinguishing between  these  groups  the  most  important  guide  is  the  nature 
of  the  symptoms  during  the  antecedent  acute  attack.  The  longer  the 
acute  symptoms  have  lasted  and  the  higher  the  temperature,  the  greater 
probably  is  the  extent  of  the  lesions,  and  the  more  severe  their  character. 

The  diagnosis  of  chronic  ileo-colitis  from  general  tuberculosis  is 
often  difficult.  Except  for  those  whose  general  condition  is  extremely 
bad  the  differential  diagnosis  can  usually  be  made  by  the  cutaneous 
tuberculin  test.  Tuberculosis  is  more  likely  to  be  met  with  in  institu- 
tions, among  the  poor  of  cities,  and  in  children  previously  delicate  and 
with  a  tuberculous  family  history. 


388  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

Prognosis. — The  prognosis  depends  upon  the  child's  previous  condi- 
tion, upon  the  duration  of  the  intestinal  symptoms,  upon  our  ability 
to  carry  out  proper  treatment,  upon  the  presence  of  complications;  but, 
most  of  all,  upon  the  severity  and  extent  of  the  intestinal  lesions.  The 
possibility  of  error  always  exists  in  estimating  the  gravity  of  the  lesions, 
so  that  no  case  should  be  considered  hopeless.  The  most  unpromising 
cases  sometimes  end  in  complete  recovery.  If,  however,  continuous 
symptoms  have  existed  for  eight  or  ten  weeks  without  any  sign  of  im- 
provement, recovery  is  extremely  doubtful.  The  patient  may  linger  for 
two  or  three  months  longer,  but  usually  only  to  be  carried  off  by  the 
first  acute  disturbance  which  occurs. 

Treatment. — No  greater  mistake  is  made  than  to  give  these  children 
week  after  week  the  various  diarrhoea-mixtures,  with  the  expectation 
that  ultimately  the  formula  which  exactly  meets  the  particular  case  will 
be  found.  Drugs  are  to  be  used  only  for  the  relief  of  special  symptoms. 
Thus,  a  dose  of  opium  may  be  needed  when  the  movements  are  unusually 
frequent,  or  castor  oil,  or  calomel  occasionally  when  the  stools  are 
particularly  offensive.  The  essential  and  important  part  of  the  treat- 
ment consists  in  injections,  careful  feeding,  and  change  of  air.  Astrin- 
gent enemata,  however,  are  of  some  value.  They  should  not  be  given 
continuously,  but  from  time  to  time  should  be  omitted  for  a  week  or  two 
to  see  what  the  condition  of  the  stools  is  without  them.  I  have  seen 
several  cases  of  the  milder  variety  where  the  constant  use  of  such  injec- 
tions seemed  to  be  an  important  factor  in  keeping  up  the  production  of 
mucus.  The  colon  should  first  be  washed  with  a  large  amount  of  a  tepid 
salt  solution,  and  then  four  or  five  ounces  of  the  astringent  solution 
injected,  and  held  in  place  by  compressing  the  buttocks  for  half  an  hour. 

Alcohol  is  often  useful  but  it  should  be  given  in  moderate  amounts 
and  well  diluted.  Port  or  sherry  is  often  better  than  brandy  or  whiskey. 
The  diet  advised  for  later  stages  of  the  acute  cases  should  be  continued. 
Fat  and  starchy  foods  should  be  excluded  for  a  long  time  and  then  given 
in  small  quantities  and  cautiously.  The  fat  of  cow's  milk  especially 
should  be  avoided;  olive  oil,  however,  can  usually  be  given  at  an  earlier 
period  and  in  many  cases  is  borne  surprisingly  well.  Kumyss  and  zoo- 
lak,  skimmed  milk,  and  buttermilk  are  useful.  To  these  articles  may 
be  added,  beef  juice,  rare  scraped  beef,  and  the  whites  of  fresh  eggs, 
partially  cooked.  The  diet  should  be  directed  according  to  its  effect 
upon  the  stools.  Much  information  may  be  obtained  by  thoroughly  wash- 
ing the  stools  and  examining  the  residue.  Nutrition  may  be  promoted 
to  some  degree  by  inunctions  of  cocoa  butter,  cod-liver  oil,  or  some 
other  form  of  fat. 

The  patients  should  be  placed  in  th€  best  possible  surroundings;  in 
no  disease  is  a  change  of  air  more  to  be  '^esired  than  in  this.  They 
should  be  in  the  open  air  as  much  as  possible  but  should  be  kept  warm, 


AMYLOID   DEGENERATION   OF  THE   INTESTINES.  389 

for  their  temperatures  quickly  fall  to  subnormal.  The  danger  of  relapses 
and  acute  exacerbations  continues  long  after  the  primary  attack  has  sub- 
sided. 

AMCEBIC   COLITIS. 

Amoebic  colitis  is  rare  in  cliildren ;  it  is  particularly  so  in  infants, 
probably  owing  to  the  fact  that  nearly  all  the  water  taken  at  this  age 
is  boiled.  Most  of  the  cases  in  children  thiis  far  reported  have  been 
observed  in  warm  climates,  although  Amljerg  has  recorded  five  which 
occurred  in  Baltimore,  the  youngest  child  being  two  years  and  eight 
months  old. 

The  symptoms  in  the  few  cases  that  have  been  reported  in  children 
have  differed  in  no  important  particular  from  the  disease  as  seen  in 
adults.  In  exceptional  cases  the  onset  may  be  abrupt  and  the  attack 
may  run  an  acute  course,  terminating  fatally  in  two  to  three  weeks. 
Such  cases  are  characterised  by  much  abdominal  pain  and  tenderness, 
frequent  mucous  and  bloody  stools  containing  amoebae,  and  some  fever, 
which,  however,  seldom  reaches  102°  F. 

More  frequently  this  acute  onset  is  followed  by  a  su])acute  or  chronic 
form  of  the  disease,  or  the  disease  may  be  subacute  from  the  lieginning. 
The  protracted  cases  are  the  type  of  the  disease  most  frequently  seen. 
They  are  very  obstinate  to  treatment.  Periods  of  constipation  and 
apparent  recovery  often  alternate  with  exacerbations  in  which  the  bloody 
and  mucous  stools  return,  with  pain,  tenesmus,  and  slight  fever.  The 
duration  may  be  from  a  few  months  to  one  or  two  years.  Death  may 
finally  occur  from  exhaustion  with  extreme  wasting,  or  from  some  com- 
plication, such  as  haemorrhage,  abscesses  of  the  liver  being  very  rare  in 
children.  The  diagnosis  from  other  forms  of  colitis  is  made  only  by  the 
discovery  of  amoebae  in  a  freshly  voided  stool. 

The  general  treatment  is  the  same  as  for  other  forms  of  acute  or 
subacute  colitis.  The  special  treatment  for  the  purpose  of  destroying 
the  amoebae  is  the  use  of  injections  of  quinine  which  may  be  employed 
in  solutions  varying  in  strength  from  1  to  5,000  to  1  to  250. 

AMYLOID   DEGENERATION  OF  THE   INTESTINES. 

This  is  rarely  met  with  in  infants.  It  is  not  so  infrequent  in  older 
children,  where  it  is  associated  with  amyloid  changes  in  the  liver,  spleen, 
and  kidneys,  usually  as  a  result  of  prolonged  suppuration  in  connection 
with  bone  tuberculosis.  It  is  sometimes  met  with  in  syphilis.  The  ileum 
is  the  part  of  the  intestine  most  affected.  The  process  begins  in  the 
walls  of  the  arterioles  and  capillaries,  particularly  of  the  villi,  and  later 
involves  the  vessels  of  the  submucosa;  subsequently  the  epithelium  may 
be  affected.     The  mucous  membrane  in  these  cases  is  pale,  somewhat 


390  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

translucent.  The  condition  is  recognised  by  the  application  of 'the  iodine 
test;  the  affected  villi  become  of  a  brownish-red  or  mahogany  colour. 
Amyloid  degeneration  produces  no  definite  symptoms.  Diarrhoea  is 
frequent  but  by  no  means  constant.  The  anaemia  and  waxy  cachexia 
which  are  present  are  probably  dependent  much  more  upon  the  associated 
lesions  of  the  liver  and  kidneys  than  upon  the  changes  in  the  intestines. 


TUBERCULOSIS  OF  THE   INTESTINES  AND   MESENTERIC   LYMPH 
NODES    (MESENTERIC   GLANDS). 

These  two  conditions  are  usually,  but  not  invariably,  associated,  and 
may  be  conveniently  considered  together. 

Frequency. — In  a  series  of  386  autopsies  upon  tuberculous  cases 
from  my  own  hospital  records,  the  intestines  were  involved  in  40  per 
cent.  The  great  majority  of  the  patients  were  under  three  years  of  age. 
In  131  autopsies  upon  tuberculous  cases  published  in  the  Pendlebury 
Hospital  Reports,  the  intestines  were  involved  in  50  per  cent.  These 
patients  were  mainly  between  four  and  fourteen  years  old.  In  209  autop- 
sies upon  tuberculous  children,  chiefly  infants,  reported  by  Miiller,  the 
intestines  were  involved  in  28  per  cent.  In  1,346  autopsies  collected  by 
Biedert  there  were  intestinal  lesions  in  31.  G  per  cent.  These  figures 
show  that  tuberculosis  of  the  intestines  is  not  one  of  the  most  frequent 
forms  in  children,  and  that  it  is  rather  less  frequent  in  infancy  than  at 
a  later  age.  It  is  most  common  from  the  third  to  the  eighth  year.  The 
mesenteric  lymph  nodes  were  tuberculous  in  44  per  cent  of  my  own 
autopsies,  and  in  59  per  cent  of  the  Pendlebury  cases;  occurring  thus 
in  both  series  with  slightly  greater  frequency  than  tuberculosis  of  the 
intestines. 

Etiology. — In  the  great  majority  of  cases  the  mesenteric  lymph  nodes 
are  infected  from  the  intestines.  It  is  possible,  but  I  believe  exceptional, 
for  the  infection  to  occur  through  the  general  circulation.  With  tuber- 
culous ulcers  of  the  intestine,  the  lymph  nodes  are  invariably  found  by 
inoculation  in  animals  to  be  tuberculous;  although  they  may  not  yet  be 
caseous.  The  infection  of  the  intestinal  mucous  membrane  is  from 
bacilli  in  the  canal.  Much  stress  has  been  laid  upon  tuberculous  milk 
as  a  means  by  which  children  are  infected.  Primary  tuberculosis  of  the 
intestines  is  in  this  country  relatively  a  rare  condition.  I  have  records 
of  less  than  a  dozen  such  cases  in  nearly  four  hundred  autopsies  upon 
tuberculous  patients.  When  it  does  occur,  however,  primary  tubercu- 
losis of  the  intestine  has  been  in  my  cases  more  often  due  to  a  bacillus 
of  the  bovine  than  of  the  human  type;  the  inference,  therefore,  is  prob- 
ably justified  that  tuberculous  milk  was  the  source  of  the  infection.  The 
intestinal  lesions  most  frequently  found  are,  however,  mild  in  character 
and  usually  associated  with  and  probably  secondary  to  an  advanced  pul- 


TUBERCULOSIS  OF  THE   INTESTINES.  391 

nionary  process.  They  are  doubtless  due  to  swallowing  tuberculous 
sputum.     In  such  cases  the  human  type  of  bacillus  is  found. 

Lesions. — Intestines. — The  usual  seat  is  the  small  intestine,  chiefly 
the  jejunum  and  lower  ileum.  With  extensive  disease  the  large  intes- 
tine may  also  be  involved,  most  frequently  the  caecum,  and  exceptionally 
it  alone  may  be  affected.  Tuberculous  ulcers  may  be  found  in  the 
appendix. 

The  early  deposits  appear  as  tiny  yellow  nodules,  generally  widely 
scattered  and  affecting  Peyer's  patches.  Usually,  however,  ulcers  are 
present,  and  often  only  ulcers  are  seen.  Their  size  and  number  vary 
greatly;  there  may  be  only  live  or  six  tiny  ulcers,  or  there  may  be  forty 
or  fifty,  the  largest  being  two  or  three  inches  in  diameter.  They  very 
frequently  involve  Peyer's  patches.  The  typical  tuberculous  ulcer  is  of 
irregular  shape,  with  rounded  borders  and  with  its  longest  diameter  at 
right  angles  to  the  intestinal  axis.  When  large,  it  may  nearly  encircle 
the  gut.  The  ulcers  are  excavated;  they  have  overhanging,  infiltrated 
edges  of  a  deep-red  colour.  The  surface  is  covered  with  granulations. 
In  those  which  have  partially  healed  a  distinct  puckering  of  the  intestine 
occurs,  which  is  especially  noticeable  upon  the  peritoneal  surface.  The 
small  ulcers  involve  the  mucosa  only;  the  larger  and  older  ones  the 
submucosa  and  the  muscular  coats,  and  not  infrequently  also  the  serous 
coat.  Perforation  may  occur,  but  rarely  into  the  general  peritoneal  cav- 
ity, as  a  localised  plastic  inflammation  precedes  it.  There  may  be  ad- 
hesions of  adjacent  intestinal  coils,  and  fistula?  may  form,  owing  to  ulcer- 
ation at  the  point  of  contact.  With  these  severe  cases  there  is  always 
associated  more  or  less  extensive  tuberculous  peritonitis,  frequently  of 
the  ulcerative  variety.  Like  other  tuberculous  processes,  the  infiltration 
and  ulceration  may  cease  at  any  stage,  and  cicatrisation  follow.  If  the 
ulcers  have  been  large  ones,  there  is  always  some  narrowing  of  the  lumen 
of  the  intestine.  Stricture  is  rarely  seen  because  most  patients  die  from 
the  genera]  disease  before  it  has  had  time  to  occur.  Monti  has  reported 
a  case  of  obstruction  at  the  ileo-caecal  valve,  due  to  an  old  tuberculous 
cicatrix,  in  an  infant  of  twenty-one  months.  One  has  come  under  my 
observation  in  a  child  of  nine  years,  in  which  the  obstruction  was  in  the 
colon,  just  beyond  the  ileo-caecal  valve. 

Mesenteric  Lymph  Nodes. — Usually  these  tuberculous  lymph  nodes 
are  from  half  an  inch  to  an  inch  in  diameter;  occasionally  they  may 
reach  the  size  of  a  hen's  egg.  From  a  fusion  of  several  of  them,  tumours 
of  considerable  size  may  be  formed.  I  have  seen  one  such  mass  as  large 
as  the  head  of  a  child  at  birth. 

The  process  is  the  same  as  that  which  occurs  in  other  lymph  nodes 
of  the  body.  There  is  a  tuberculous  inflammation,  followed  by  caseation, 
softening  and  abscess,  or  by  calcification.  Localised  peritonitis  is  found 
in  all  the  marked  cases;  this  is  usually  plastic,  but  may  be  suppurative 


392  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

when  due  to  the  rupture  of  an  abscess.  Pressure  upon  the  vena  cava 
may  lead  to  dropsy  in  the  lower  extremities.  Ollivier  has  reported  a  case 
in  which  thrombosis  of  the  vena  cava  occurred.  Pressure  upon  the  portal 
vein  may  lead  to  ascites  and  dilatation  of  the  superficial  abdominal  veins. 
There  may  be  pressure  upon  the  thoracic  duct. 

Symptoms. — The  symptoms  of  intestinal  tuberculosis  are  exceedingly 
irregular.  Ulcers  are  very  frequently  found  at  autopsy  when  there  have 
been  no  marked  intestinal  symptoms ;  this  is  especially  true  of  the  small 
ulcers  usually  seen  in  infants.  On  the  other  hand,  diarrhoea  is  not 
uncommon  in  cases  of  advanced  general  tuberculosis  where  no  ulcers  are 
present.  It  is  the  most  frequent  symptom,  and  may  be  exceedingly  ob- 
stinate. The  stools  do  not  differ  essentially  from  those  in  chronic  ileo- 
colitis, except  in  the  occurrence  of  haemorrhages  and  in  the  presence  of 
tubercle  bacilli.  Haemorrhages  are  not  very  frequent,  but  they  may  be 
80  large  as  to  be  the  cause  of  death.  This  occurred  in  one  of  my  cases, 
an  infant  nine  months  old,  the  blood  coming  from  a  single  ulcer  in  the 
ileum.  Haemorrhage  is  more  common  in  older  children.  In  some  cases 
localised  abdominal  pain  or  tenderness  is  present.  In  advanced  cases 
the  symptoms  of  intestinal  ulceration  are  usually  mingled  with  those  of 
peritonitis,  and  there  are  also  present  the  enlarged  mesenteric  lymph 
nodes,  which  may  aid  in  the  diagnosis.  In  the  vast  majority  of  cases, 
these  nodes  are  recognised  only  by  deep  palpation.  The  tumours  are 
generally  felt  as  irregular  nodular  masses,  lying  close  against  the 
spine,  not  movable,  and  sometimes  tender  on  pressure.  Other  tu- 
mours from  deposits  in  the  peritonaeum  may  be  present  anywhere  in 
the  abdomen;  they  may  be  superficial  or  deep.  The  other  symptoms 
are  due  to  the  complications  already  mentioned  and  to  tuberculosis 
elsewhere. 

Diagnosis. — The  only  positive  evidence  of  intestinal  tuberculosis  is 
the  discovery  of  the  bacilli  in  the  stools.  They  are  here  to  he  carefully 
differentiated  from  smegma  and  other  forms  of  acid-fast  bacilli.  In  the 
absence  of  such  evidence,  the  disease  is  differentiated  from  simple  ileo- 
colitis, first,  by  the  signs  of  tuberculosis  elsewhere  in  the  body,  espe- 
cially in  the  lungs,  these  being  almost  invariably  involved;  secondly,  by 
the  slow  onset  and  gradual  development  of  the  symptoms,  while  in 
chronic  ileo-colitis  an  acute  attack  has  almost  invariably  preceded. 
Large  haemorrhages  always  suggest  tuberculosis.  A  positive  reaction 
to  the  tuberculin  test  is  of  much  assistance  in  diagnosis. 

The  large  mesenteric  glands  are  recognised  only  as  abdominal  tu- 
mours. 

Prognosis. — This  depends  altogether  upon  the  extent  of  the  tubercu- 
lous disease  elsewhere,  as  it  is  extremely  rare  for  the  intestinal  lesion  to 
be  the  cause  of  death.  Once  formed,  the  ulcers  probably  remain,  cica- 
trisation being  very  rare,  and  then  only  partial 


CHRONIC   INTESTINAL  INDIGESTION.  393 

Treatment. — The  only  symptom  which  ordinarily  demands  treatment 
is  the  diarrhoea.  When  severe,  this  is  to  be  managed  much  as  in  cases 
of  ileo-colitis,  except  that  irrigation  of  the  colon  is,  of  course,  not  called 
for.  The  chief  reliance  must  be  upon  diet  and  internal  medication.  The 
drugs  which  are  most  useful  are  bismuth,  opium,  and  creosote;  the  last 
mentioned  should  be  given  in  pills  coated  with  shellac. 


CHAPTER    VIII. 

DISEASES   OF   THE   INTESTINES. —(Continued.) 

CHRONIC   INTESTINAL   INDIGESTION. 

As  the  larger  and  more  complex  part  of  the  process  of  digestion  goes 
on  in  the  intestine,  intestinal  indigestion  is  a  more  common  and  more 
complicated  "disturbance  than  is  gastric  indigestion.  In  many  cases  we 
find  the  two  associated,  but  in  perhaps  the  majority  the  symptoms  relate 
entirely  to  the  intestinal  process.  The  conditions  seen  in  young  infants 
are  so  different  from  those  in  older  children  that  the  cases  may  be  best 
considered  separately. 

In  Young  Infants. 

The  general  causes  are  the  same  as  those  mentioned  in  connec- 
tion with  chronic  gastric  indigestion :  constitutional  debility,  either  con- 
genital or  acquired,  unfavourable  surroundings,  and  previous  attacks 
of  acute  disease.  Chronic  intestinal  indigestion  is  especially  common 
during  the  first  six  months,  and  is  seen  both  in  nursing  infants  and  in 
those  who  are  artificially  fed.  In  the  case  of  breast-fed  infants,  the 
mother  is  often  highly  nervous,  delicate,  and  anasmic,  and  may  be  taking 
large  quantities  of  fluids  of  every  description,  for  the  purpose  of  main- 
taining an  abimdant  flow  of  milk.  Why  it  is  that  the  milk  causes  so 
much  disturbance  can  not  always  be  discovered  even  by  the  most  careful 
analysis.  Sometimes  the  trouble  is  simply  that  the  milk  is  too  rich, 
chiefly  in  fat.  Disturbances  may  come,  although  rarely,  from  over- 
feeding. 

In  infants  who  are  being  fed  upon  cow's  milk,  the  most  common 
cause  is  that  the  fat  is  excessive;  sometimes  it  is  the  sugar,  and  it  may 
be  both.  When  once  begun  a  striking  intolerance  of  both  fat  and  sugar 
persists  for  a  long  time.  Another  very  important  cause  is  the  use  of 
farinaceous  foods  too  early,  in  too  large  quantities,  and  often  insuf- 
ficiently cooked. 

lesions. — Strictly  speaking,  chronic  indigestion  is  a  functional  dis- 
order without  anatomical  changes.     When  the  condition  has  lasted  for 


394  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

many  weeks  or  months,  as  often  happens,  there  may  result  a  low  grade  of 
catarrhal  inflammation  in  the  colon,  frequently  attended  by  hyperplasia 
of  the  lymph  nodules  of  the  mucous  membrane,  and  sometimes  by  a 
similar  process  in  the  mesenteric  lymph  nodes.  Chronic  indigestion 
may  be  the  principal  and  the  only  symptom  in  cases  of  chronic  ileo- 
colitis which  follow  acute  attacks. 

Sjnnptonis. — The  general  symptoms  are  those  of  malnutrition,  or  in 
the  more  severe  form,  those  of  marasmus.  These  liave  already  been  fully 
described,  and  need  only  be  mentioned  here.  The  most  important  are, 
stationary  or  falling  weight,  anaemia,  poor  circulation,  often  subnormal 
temperature,  almost  constant  fretfulness  and  crying,  with  very  little 
quiet  sleep.  The  tongue  may  be  coated  or  quite  clean.  The  appetite  is 
often  good,  these  infants  taking  food  whenever  given,  and  in  an  almost 
unlimited  quantity.  There  are  few  cases  in  which  occasional  vomiting 
does  not  occur,  but  it  is  rarely  persistent. 

So  far  as  the  intestinal  condition  is  concerned,  the  cases  may  be 
divided  into  those  with  diarrhoea  and  those  with  constipation.  It  may 
happen  that  the  same  child  will  suffer  for  a  long  time  from  diarrhoea 
and  then  from  constipation,  or  the  reverse;  but  usually  one  condition 
or  the  other  is  habitual.  The  diarrhoeal  stools  are  thin,  green,  and 
contain  undigested  food  and  mucus.  They  vary  in  number  from  three 
to  six  or  eight  in  twenty-four  hours.  They  are  commonly  passed  with- 
out pain,  although  there  may  be  flatulence.  The  stools  have  usually  a 
sour,  unpleasant  odour,  but  they  are  rarely  foul.  They  may  be  irritat- 
ing to  the  skin,  and  cause  troublesome  excoriations  or  intertrigo.  In 
some  cases  the  stools  contain  but  little  solid  matter,  the  character  being 
that  of  yellowish-green  water.  In  most  of  the  cases,  after  the  process 
has  lasted  two  or  three  weeks,  mucus  is  present,  and  may  then  become  a 
constant  feature. 

If  there  is  constipation,  the  stools  are  usually  gray  or  white;  they 
are  smooth  and  pasty  or  like  hard  balls  and  passed  after  much  straining, 
often  coated  with  mucus  and  sometimes  streaked  with  blood.  These 
stools  contain  an  excessive  amount  of  fat,  especially  in  the  form  of 
soaps  and  also  a  larger  proportion  of  inorganic  matter  than  is  normal, 
particularly  calcium  salts.  Often  the  bowels  will  not  move  for  days 
except  after  the  use  of  laxatives  or  enemata.  The  latter  frequently  have 
but  little  effect,  as  the  rectum  may  be  empty.  Constipated  cases  are 
especially  prone  to  suffer  much  from  flatulence  and  colic,  the  attacks  of 
which  may  be  very  severe. 

The  duration  of  these  symptoms  is  indefinite.  There  is  little  or  no 
tendency  to  spontaneous  improvement,  and  they  may  drag  on  for  several 
months  or  iintil  the  problem  of  diet  is  solved.  The  progress  of  these 
cases  is  marked  by  frequent  exacerbations,  during  which  there  is  vomit- 
ing, and  usually  fever.     Such  symptoms  are  generally  dependent  upon 


CHRONIC   INTESTINAL  INDIGESTION.  395 

intestinal  toxsemia.  A  low  irregular  fever  may  continue  for  days  or  even 
weeks.  Although  the  general  symptoms  of  failing  nutrition  are  present 
in  most  cases,  a  mild  degree  of  chronic  intestinal  indigestion  with  fre- 
quent loose  movements  may  sometimes  last  for  months,  during  which 
the  patients  may  gain  steadily  in  weight  and  give  every  indication  of 
being  well  nourished.  This  is  much  more  common  in  nursing  infants 
than  in  those  who  are  artificially  fed. 

Diagnosis. — It  is  not  generally  difficult  to  determine  that  an  infant  is 
suffering  from  chronic  intestinal  indigestion;  but  one  should  endeavour 
to  go  further  in  his  diagnosis  and  discover  which  of  the  elements  of  the 
food  is  causing  the  chief  disturbance.  Much  valuable  information  may 
be  gained  from  a  careful  history  of  what  has  already  been  tried  in  the 
case;  often  some  gross  error  can  be  detected  in  the  proportions  of  the 
food  elements,  the  quantity  of  food  given  or  its  preparation.  Difficulty 
with  the  fat  is  sometimes  indicated  by  loose  movements,  usually  of  a 
yellow  or  yellowish-green  colour.  Sometimes  they  are  clay  coloured, 
smooth  and  formed,  with  a  peculiarly  offensive  odour;  there  may  be 
vomiting  or  the  regurgitation  of  food  in  small  quantities.  Difficulty 
with  the  sugar  is  often  associated  with  flatulence,  colic,  and  diarrhoea, 
with  thin,  sour,  irritating  stools.  Difficulty  with  the  starch  leads  to 
much  flatulence  and  colic,  diarrhoea  alternating  with  constipation,  and 
offensive  stools.  One  may  find  the  foregoing  symptoms  in  any  combina- 
tion, for  although  in  the  beginning  the  trouble  may  be  with  but  a  single 
element  of  the  food,  this  is  rarely  true  when  the  child  comes  under 
observation.  By  carefully  noting  the  symptoms  which  follow  the  use 
for  a  few  days  of  a  simple  milk  formula,  such  as  fat  1  per  cent,  sugar 
5  per  cent,  protein  0.9  per  cent  (one-fourth  whole  milk),  one  can  often 
arrive  at  a  conclusion  as  to  which  element  of  the  food  is  producing 
the  most  disturbance. 

Prognosis. — This  depends  almost  entirely  upon  how  early  the  cases 
come  under  treatment  and  how  they  are  managed.  There  is  very  little 
tendency  to  spontaneous  improvement  or  recovery.  The  outlook  is  much 
better  in  cases  with  constipation  than  in  those  with  diarrhoea.  In  the 
latter,  progress  is  very  difficult  as  the  intolerance  of  food  is  so  great 
that  increase  in  weight  is  well-nigh  impossible.  The  existence  of  chronic 
intestinal  indigestion  is  one  of  the  most  important  predisposing  causes 
of  more  serious  forms  of  intestinal  disease. 

Treatment. — Drugs  have  no  part  in  the  treatment  of  these  cases,  ex- 
cept now  and  then  for  particular  symptoms,  such  as  diarrhoea,  constipa- 
tion, or  colic.  These  infants  are  cured  by  proper  dietetic  and  hygienic 
measures,  and  by  these  alone.  The  diet  has  already  been  discussed  in  the 
chapter  on  Infant-Feeding,  and  the  general  management,  not  less  im- 
portant, in  the  chapter  on  Malnutrition. 


396 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


In  Older  Children. 

Chronic  intestinal  indigestion  is  especially  common  in  children  from 
the  first  to  the  fifth  year.  With  the  younger  children,  solid  food  has 
generally  been  given  too  early  and  in  too  large  quantities.  The  articles 
from  which  most  trouble  is  seen  are  imperfectly  cooked  cereals,  vegetables 
of  all  kinds,  but  especially  potato.  Often  the  diet  is  composed  almost 
entirely  of  farinaceous  foods  and  bread.  The  condition  often  follows 
an  attack  of  acute  diarrhoea  or  dysentery.  Children  suffering  from 
rickets  are  particularly  liable  to  be  affected.  The  disease  is  seen  in 
all  grades  of  society. 

Symptoms. — The  clinical  picture  which  these  cases  present  is  a  very 
common  one,  and  the  symptoms  are  quite  uniform.  The  patients  are 
generally  very  thin,  with  very  small  extremities,  a  small  amount  of  fat, 

and  a  large  protuberant  abdomen  (Fig. 
G4).  There  is  much  flatulence,  and  usu- 
ally there  is  marked  tympanites.  Such 
cbildren  are  pale,  anaemic,  and  sallow  in 
complexion ;  they  have  dark  rings  under 
the  eyes;  they  are  fatigued  on  slight  ex- 
ertion; they  are  very  cross,  irritable,  and 
emotional  to  an  unnatural  degree.  Tliey 
are  hard  to  amuse,  hard  to  control,  and 
altogether  exceedingly  difficult  patients  to 
deal  with.  Their  growth  is  retarded  if  the 
symptoms  have  lasted  long.  They  are 
much  below  the  average  in  height  and 
weight,  but  mentally  often  quite  preco- 
cious. One  of  my  patients  at  five  years 
weighed  twenty-two  pounds  and  was  thirty- 
three  inches  tall.  The  sleep  is  always  un- 
natural and  disturbed;  and  at  night  they 
toss  about  their  cribs,  waking  frequently, 
crying  out  and  often  grinding  their  teeth, 
this  sometimes  leading  to  the  diagnosis  of 
intestinal  worms.  They  perspire  very  read- 
ily, and  suffer  from  cold  extremities. 

The  bowels  are  usually  constipated,  the 
stools  being  of  a  light  gray  colour  or  nearly 
white.  The  odour  from  the  discharges  is 
usually  extremely  foul.  This  condition  may  alternate  with  diarrhoea.  The 
stools  are  then  not  very  frequent,  rarely  exceeding  four  or  five  a  day,  but 
they  are  large,  gray,  green,  or  l)rown  in  colour,  often  frothy,  offensive,  and 
always  contain  undigested  food.    They  are  in  many  cases  excited  by  the 


Fig.  64.  —  Chronic  Intestinal 
Indigestion.  —  Patient  four 
years  old;  symptoms  of  three 
years'  duration,  following  at- 
tack of  acute  ileo  -  colitis. 
Height,  34  inches;  circumfer- 
ence of  abdomen,  221  inches; 
weight,  24  pounds. 


CHRONIC   INTESTINAL   INDIGESTION.  397 

taking  of  food.  From  time  to  time,  in  many  patients,  large  quantities  of 
mucus  are  passed;  in  some  cases  this  comes  to  be  a  constant  feature  of 
the  disease.  Large  quantities  of  gas  are  expelled.  Pain  is  not  a  very 
common  symptom  in  most  cases.  The  appetite  is  capricious  and  usually 
poor,  though  some  patients  will  eat  everything  offered.  The  tongue  may 
be  coated;  but  unless  the  stomach  is  also  affected  it  is  usually  clean  and 
the  breath  is  not  offensive. 

The  nervous  symptoms  which  these  patients  present  are  exceedingly 
varied,  and  often  of  the  most  puzzling  character.  In  many  cases  they 
are  so  severe  and  so  persistent  as  to  lead  to  the  diagnosis  of  organic 
disease  of  the  brain.  In  addition  to  the  condition  of  general  nervous 
irritability,  there  may  be  tetany,  fainting  attacks  resembling  somewhat 
the  seizures  of  petit  mat,  exaggerated  reflexes,  attacks  of  dulness  or  some- 
times stupor,  with  retracted  abdomen,  irregular  pulse  and  respiration, 
and  other  symptoms  strongly  suggestive  of  tul)ercuk)us  meningitis.  Con- 
vulsions are.  not  uncommon.  They  are  usually  accompanied  by  fever, 
and  may  be  repeated  at  intervals  of  a  few  minutes.  There  is  almost  no 
end  to  the  combinations  of  nervous  symptoms  wliich  these  patients  may 
present.  Most  of  them  are  toxic  in  their  origin.  The  skin  shows  fre- 
quently eruptions  of  erythema  or  of  urticaria. 

Slight  fever  is  sometimes  present  for  weeks,  tiie  temperature  usually 
varying  between  99°  and  101.5°  F.  Sometimes  for  several  days  it  may 
be  normal,  and  occasionally  may  rise  to  102°  or  103°  F.  during  a  slight 
exacerbation  in  the  symptoms.  The  urine  of  most  of  these  patients  con- 
tains a  great  excess  of  indican;  the  amount  present  indicates  very  ac- 
curately the  degree  of  intestinal  putrefaction,  and  often  fluctuates  reg- 
ularly with  the  nervous  symptoms. 

Intercurrent  attacks  of  acute  indigestion,  with  diarrhoea  and  vomit- 
ing, are  common  and  quite  easily  excited.  The  course  and  duration  of 
these  symptoms  are  indefinite.  In  the  most  severe  forms,  if  untreated, 
the  patients  gradually  waste  until  they  die  from  exhaustion,  or  fall  easy 
victims  to  any  acute  disease  which  they  may  happen  to  contract.  There 
is  but  little  tendency  to  spontaneous  recovery. 

Herter  has  called  special  attention  to  a  type  of  this  disease  associated 
with  marked  arrest  in  growth  to  which  he  gave  the  name  Intestinal 
Infantilism.  In  several  such  cases  studied  he  found  a  failure  of  reten- 
tion of  calcium  and  magnesium  salts  over  a  prolonged  period  of  time. 
To  this  he  ascribed  the  arrested  development  of  the  skeleton.  Associated 
with  this,  there  were  present  in  all  cases  evidences  of  excessive  intestinal 
putrefaction.  The  bacteriology  of  the  condition  he  believed  to  be  char- 
acteristic, viz.,  a  preponderance  of  the  h.  bifidus,  with  great  diminution 
or  entire  absence  of  the  b.  coli. 

Prognosis. — This  depends  upon  the  duration  of  the  symptoms,  the 
general  condition  of  the  patient  at  the  time  treatment  is  begun,  and  upon 


398  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

how  thoroughly  it  can  be  carried  out.  Tlie  symptoms,  in  the  great 
majority  of  cases,  have  existed  for  several  months  at  the  time  the  case 
comes  under  observation.  Generally,  the  greater  the  mistakes  in  feed- 
ing have  been,  and  the  greater  the  violation  of  hygienic  and  dietetic 
rules,  the  better  the  prognosis.  A  child  who  has  developed  chronic 
intestinal  indigestion  of  a  severe  type,  in  spite  of  the  fact  that  the 
hygienic  surroundings  were  good,  and  when  the  dietetic  errors  were  not 
flagrant,  is  not  nearly  so  hopeful  a  subject  for  treatment  as  one  whose 
hygienic  surroundings  have  been  poor  and  whose  diet  has  been  especially 
bad.  In  cases  like  the  latter,  a  removal  of  the  causes  and  the  institution 
of  proper  methods  of  treatment  almost  invariably  result  in  immediate 
and  striking  improvement,  unless  the  general  vitality  of  the  patient  has 
been  reduced  to  a  very  low  point.  In  the  other  cases,  where  the  mistakes 
have  been  less  marked,  and  the  condition  is  due  more  to  constitutional 
than  to  local  causes,  the  improvement  is  slower  and  less  striking.  Thus, 
as  a  rule,  hospital  patients  improve  more  rapidly  than  those  seen  in 
private  practice. 

Treatment. — In  no  class  of  cases  that  the  physician  is  called  upon  to 
treat  are  results  more  satisfactory  than  in  many  of  those  of  chronic  intes- 
tinal indigestion,  when  intelligent  co-operation  can  be  secured.  If  the 
parents  themselves  are  lax  in  discipline,  and  are  unable  to  control  the 
child,  an  efficient  trained  nurse  should  be  secured,  into  whose  hands  the 
exclusive  management  of  the  child  should  be  placed.  The  essential  part 
of  the  treatment  is  diet  and  general  management.  In  the  second  and 
third  years  the  most  important  thing  is  to  stop  all  starchy  food  for  a 
considerable  time,  and  put  the  patient  upon  an  exclusive  diet  of  rare 
beef  or  beef  juice  and  skimmed  milk  or  buttermilk.  After  some  im- 
provement has  occurred  carbohydrates  may  be  added,  some  of  these  in 
the  form  of  maltose,  but  chiefly  as  a  well-cooked  starchy  food.  The 
number  of  feedings  should  not  be  more  than  four  a  day  during  the 
second  year,  and  three  or  four  a  day  for  children  during  the  third  and 
fourth  years.  These  should  always  be  at  regular  intervals,  and  nothing 
whatever  given  between  meals.  The  meat  should  be  rare  scraped  beef- 
steak or  mutton  chop;  from  one  to  three  tablespoonfuls  may  be  allowed 
once  a  day.  The  white  of  egg  may  be  given  early,  and  after  a  time,  the 
whole  egg.  Kumyss  and  zoolak  and  buttermilk  are  often  of  very  great 
value.  Although  at  first  they  are  taken  with  difficulty,  in  many  cases  a 
fondness  for  them  is  very  soon  acquired. 

After  improvement  has  been  going  on  for  two  months,  bread  may  be 
added,  at  first  in  small  quantities  and  once  a  day.  This  should  prefer- 
ably be  stale,  cut  thin  and  dried  in  the  oven  until  it  is  crisp,  and  given 
without  butter.  Two  or  three  times  a  week  raw  oysters  may  be  tried. 
Mutton,  chicken,  or  beef  broth,  without  vegetables,  may  be  given  occa- 
sionally in  the  place  of  one  of  the  milk  feedings.     After  this  diet  has 


CHRONIC   INTESTINAL   INDIGESTION.  399 

been  kept  up  for  three  or  four  months,  if  improvement  continues,  one 
of  the  green  vegetables  thoroughly  cooked  and  strained  may  be  added 
once  a  day.  A  striking  feature  of  these  cases  is  their  marked  intolerance 
of  the  fat  of  cow's  milk.  This  must  be  withheld  for  a  long  period.  The 
form  of  fat  which  these  patients  can  take  best  is  usually  olive  oil,  which 
furnishes  a  valuable  means  of  increasing  weight.  Beginning  with  one 
teaspoonful  three  times  a  day  the  quantity  may  be  increased  to  two  or 
three  times  this  amount.  This  restricted  diet  should  be  continued  for 
at  least  a  year  or  until  all  the  symptoms  have  disappeared.  Potato  and 
oatmeal  should  be  forbidden  for  a  long  time. 

Intestinal  irrigation  is  useful  for  brief  periods  in  some  cases  in  which 
there  is  much  mucus  passed.  But  it  should  not  be  forgotten  that  con- 
tinued irrigation  often  keeps  up  the  production  of  mucus.  Astringents 
should  not  be  used,  but  only  a  warm  saline  solution. 

The  constipation  can  sometimes  ])e  controlled  by  the  diet  alone;  but 
in  most  cases  drugs  are  needed  also.  Calomel  frequently  seems  to  exert 
a  very  beneficial  influence,  even  when  the  consti})ation  is  not  severe.  It 
is  often  wise  to  administer  a  full  dose  every  week  or  ten  days.  In  some 
patients  castor  oil  acts  more  satisfactorily.  It  may  be  objectionable,  how- 
ever, from  its  tendency  to  aggravate  the  constipation.  As  laxatives  in 
this  condition  I  have  found  the  greatest  satisfaction  from  the  use  of 
preparations  of  cascara  and  the  compound  licorice  powder.  Alidominal 
massage  is  also  useful. 

Drugs  directed  against  the  process  of  putrefaction  are  extremely  un- 
satisfactory even  in  older  children,  but  sometimes  diminution  in  the 
amount  of  flatulence  follows  the  use  of  subgallate  of  bismuth,  carbonate 
of  creosote,  salol,  or  salicylate  of  soda.  General  tonics  are  required, 
and  may  add  materially  to  the  improvement  of  the  patients.  Altogether 
the  best  is  nux  vomica.  It  may  be  given  in  combination  with  the  bitter 
wine  of  iron  just  before  meals  three  times  a  day.  Cod-liver  oil,  partic- 
ularly in  the  early  stage,  is  badly  borne. 

Relapses  are  easily  excited  by  indiscretion  in  diet,  and  parents  should 
be  impressed  at  the  very  beginning  with  the  necessity  of  adhering  rigidly 
to  the  diet  prescribed,  for  a  long  period.  It  very  often  happens  that  the 
improvement  which  is  seen  after  one  or  two  months  of  careful  treatment 
is  so  marked  as  to  lead  the  parents  to  the  belief  that  a  cure  has  been 
accomplished,  so  that  they  relax  their  vigilance  and  allow  improper 
articles  of  food  which  are  almost  certain  to  induce  a  relapse.  If  the  case 
is  an  aggravated  one,  and  the  symptoms  of  long  standing,  it  is  wise  to 
tell  parents  at  the  outset  that  a  year's  treatment  is  the  minimum  in 
which  anything  permanent  can  be  accomplished. 

The  general  treatment  of  the  patient  must  not  be  overlooked.  Proper 
clothing,  regular  exercise  in  the  open  air,  cool  sleeping  rooms,  massage, 
and  sponging  every  morning  with  cold  water,  are  all  of  very  great  im- 


400  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

portance,  and  contribute  almost  as  mucli  to  the  results  obtained  as  the 
special  measures  adopted.     (See  chapter  on  Malnutrition.) 

An  elastic  abdominal  bandage  giving  moderate  support  not  only 
adds  to  the  comfort  of  these  patients  but  to  some  degree  prevents  the 
excessive  distention  likely  to  occur  on  account  of  the  loss  of  muscular 
tone  in  the  abdominal  walls. 

The  improvement  in  the  nervous  symptoms  of  the  patient  is  one  of 
the  first  things  noticed,  and  is  often  marked  in  a  few  days  after  the 
beginning  of  treatment.  From  an  irritable,  fretful,  peevish  child  the 
patient  is  sometimes  totally  changed  in  disposition  in  a  few  weeks,  so 
as  to  become  quiet,  affectionate,  docile,  and  playful. 

INTESTINAL  COLIC. 

The  term  colic  is  applied  to  any  severe  paroxysmal  pain  occurring  in 
the  intestines.  It  may  be  due  to  many  causes.  The  colic  of  lead  and 
arsenic  poisoning  are  both  very  rare  in  children;  but  colickly  pains  are 
present  in  appendicitis,  intussusception,  ileo-colitis,  and,  in  fact,  in  all 
the  severe  forms  of  intestinal  inflammation.  Colic  may  be  due  to  swal- 
lowing certain  substances,  especially  foreign  bodies  and  the  seeds  of 
fruits;  and  in  rare  cases  it  may  be  excited  by  the  presence  of  round- 
worms when  they  are  numerous.  In  all  the  conditions  mentioned,  colic 
is  only  one  of  the  symptoms,  although  it  may  be  a  very  prominent 
one. 

The  peculiar  colic  of  infancy  is  clearly  caused  by  spasm  of  the  mus- 
cular wall  of  the  intestine.  It  is  a  heightened  reflex  from  irritation  of 
which  we  have  many  other  illustrations  at  tins  period  of  life.  The 
cause  of  the  irritation  is  usually  the  presence  of  some  undigested  food 
in  the  intestine.  Colic  is  therefore  essentially  a  symptom  of  indigestion. 
Flatulence  and  colic  are  very  often,  but  not  always,  associated.  Colic 
is  always  increased  by  the  coexistence  of  constipation,  which  in  many 
cases  is  its  sole  cause.  Almost  any  of  the  elements  of  the  food  may  give 
rise  to  colic. 

Sugars  and  starches  may  produce  it  by  causing  excessive  fermenta- 
tion and  flatulence.  Fats  are  less  frequently  at  fault;  but  the  presence 
of  large  unabsorbed  masses  in  the  intestine  may  be  a  sufficient  cause  of 
irritation.  The  actual  pain  in  colic  is  partly  from  distention,  but  chiefly 
from  muscular  spasm.  In  some  of  the  most  severe  cases  of  colic  it  is 
possible  that  the  spasm  may  be  accompanied  by  a  slight  transient  in- 
tussusception. Colic  may  follow  chilling  the  surface  of  the  body.  In 
these  cases,  also,  muscular  spasm  appears  to  be  the  pi'incipal  factor  in 
causing  the  pain.  The  colicky  period  of  infancy  is  chiefly  the  first 
three  months;  after  this  time  the  peculiar  susceptibility  gradually 
passes  off. 


CHRONIC  CONSTIPATION.  401 

Symptoms. — Tliese  are  in  most  cases  so  tj'pical  as  to  be  easily  recog- 
nised. The}'  are  always  more  severe  in  delicate  and  highly  nervous  chil- 
dren. In  the  severe  attacks  there  is  contraction  of  tlie  features,  a  loud 
paroxysmal  cry,  subsiding  for  a  few  moments  and  then  l>eginning  with 
renewed  intensity,  drawing  up  of  the  lower  extremities,  and  in  male  in- 
fants contraction  of  the  scrotum.  ^N'ith  tliese  symptoms  the  abdomen  is 
usually  found  tense  and  hard.  With  the  expulsion  of  the  gas,  the  symp- 
toms subside  at  once,  and  the  child  usually  falls  asleep.  In  the  most 
severe  attacks  there  may  be  considerable  prostration,  cold  extremities, 
and  perspiration.  When  the  symptoms  are  less  severe  there  is  only  con- 
tinual fretfulness,  and  the  child  can  not  sleep.  When  colic  is  habitual 
there  are  very  few  hours  in  the  twenty-four  when  the  child  seems  to  be 
entirely  comfortable.  In  nursing  infants  there  may  at  times  Vje  difficulty 
in  distinguishing  the  cry  of  colic  from  that  of  hunger,  as  infants  suffer- 
ing from  colic  will  usually  take  food  eagerly,  and  this  is  often  followed 
by  temporary  relief.  In  colic,  however,  the  pain  soon  returns,  and  often 
is  more  severe  than  before.  The  cry  of  colfc  is  usually  violent  and 
paroxysmal;  that  of  hunger  is  apt  to  be  prolonged  and  continuous,  and 
is  not  accompanied  by  the  other  sxTuptoms  mentioned  as  indicating  ab- 
dominal pain.  In  older  children  the  less  frequent  causes  of  colic  men- 
tioned at  the  beginning  of  this  article,  especially  appendicitis,  should  be 
borne  in  mind. 

Treatment — When  colic  is  due  to  flatulence  of  the  intestine,  nothing 
given  by  the  mouth  has  much  effect  in  relieving  the  symptoms.  Cer- 
tainly food  should  not  be  given.  The  purpose  of  treatment  during  the 
attack  is  to  assist  the  child  to  get  rid  of  the  gas;  as  this  is  usually  in 
the  colon,  the  most  efficient  means  is  by  massage  or  enemata.  At  first 
an  injection  of  four  or  five  ounces  of  lukewarm  water  should  be  used. 
If  this  is  not  successful,  two  ounces  of  cold  water  with  half  a  teaspoonful 
of  glyc-erin  may  be  tried.  This  rareh'  fails  to  start  peristalsis  and  expel 
the  gas.  In  conjunction  with  these  measures,  dry  heat  should  be  applied 
to  the  abdomen  by  means  of  hot  flannels  or  a  hot-water  bag,  and  the 
feet  should  be  well  warmed.  In  cases  of  colic  not  associated  with  flatu- 
lence, when  the  pain  is  probably  the  result  of  muscular  spasm,  opium 
in  some  form  is  required  in  addition  to  heat  or  counter-irritation.  The 
treatment  between  the  attacks  and  the  treatment  of  habitual  colic  should 
be  directed  toward  the  constipation  and  the  indigestion,  upon  which  they 
depend. 

CHRONIC  CONSTIPATION. 

Constipation  may  be  said  to  exist  whenever  the  stools  are  less  fre- 
quent, harder,  and  drier  than  normal.     During  the  first  six  months  in- 
fants usually  have  two  movements  a  day.    Many,  however,  have  only  one ; 
but  if  this  is  normal  in  character  the  child  is  not  constipated.    In  other 
27 


402  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

cases,  although  there  are  two  and  even  three  stools  a  day,  they  may  all 
be  small,  dry,  and  hard,  having  all  the  characters  oi"  constipated  stools, 
and  the  case  should  be  treated  accordingly. 

Etiology. — The  causes  of  chronic  constipation  are  many  and  far- 
reaching.  It  may  be  due  to  a  diminution  in  the  secretion  of  the  intes- 
tinal glands  or  of  the  liver.  The  movements  are  then  hard,  dry,  very 
light-coloured,  and  are  associated  with  much  flatulence  and  other  signs 
of  intestinal  indigestion.  Very  often  the  principal  factor  in  constipation 
is  insufficient  muscular  contraction  in  the  intestine.  The  faBcal  masses 
are  then  propelled  so  slowly  and  remain  so  long  in  the  intestine  that 
the  fluid  portion  is  absorbed,  the  residue  becoming,  in  consequence,  so 
dry  and  hard  that  it  is  difficult  to  expel.  In  other  cases  constipation 
is  due  to  tlie  fact  that  there  is  insufficient  volume  to  tlie  stools,  as  may 
be  the  case  when  the  food  leaves  very  little  residue.  Constipation  may 
depend  also  upon  local  causes,  as,  for  example,  where  an  evacuation  of 
the  bowels  is  resisted  on  account  of  pain  from  fissure  of  the  anus  or  from 
haemorrhoids.  Although  not  the  primary  cause,  this  condition  may  be 
sufficient  to  keep  up  the  constipation  indefinitely.  It  may,  in  rare  cases, 
be  due  to  a  congenital  condition,  such  as  narrowing  or  twisting  of  the 
large  intestine  at  some  point.  Another  rare  cause  seen  especially  in 
infancy  is  tonic  spasm  of  the  anal  sphincter.  The  most  important  causes 
of  constipation  may  be  grouped  under  two  heads :  diet,  and  conditions 
giving  rise  to  muscular  atony. 

Diet. — In  breast-fed  infants  the  trouble  is  usually  a  lack  of  fat  and 
low  total  solids  in  the  milk.  In  those  who  are  artificially  fed  it  is 
often  because  the  fat  is  too  low,  and  sometimes  because  both  the  fat  and 
the  protein  are  too  low,  the  stool  lacking  volume.  In  other  cases  the 
cause  of  constipation  is  indigestion,  in  still  others  the  use  of  sterilised 
milk.  During  the  second  and  third  years  the  cause  may  be  too  much 
cow's  milk,  particularly  that  which  has  been  boiled,  or  the  use  of  an 
excessive  amount  of  starchy  food.  In  older  children  the  cause  may 
be  an  excess  of  starchy  food  and  a  lack  of  sufficient  green  vegetables, 
meat,  and  fruit. 

Muscular  Atony. — The  most  common  cause  of  muscular  atony  is 
habit ;  in  a  large  number  of  cases  lack  of  proper  training  is  the  principal 
etiological  factor.  If  the  inclination  to  liave  a  stool  is  regularly  disre- 
garded it  soon  ceases  to  be  felt.  The  ordinary  irritation  from  faecal 
masses  produces  no  response  whatever.  The  longer  such  a  condition 
continues  the  more  obstinate  does  it  become.  This  is  an  important 
factor  in  all  cases.  Another  potent  cause  of  muscular  atony  is  rickets. 
In  this  disease  the  muscular  walls  of  tlie  intestine  suffer  like  the  muscles 
of  the  extremities,  and  become  incapable  of  doing  their  work.  Again, 
any  form  of  malnutrition  in  which  there  is  feeble  muscular  tone  may 
cause  or  aggravate  constipation.     It  is  often  seen  as  a  sequel  to  acute 


CHRONIC   CONSTIPATION.  403 

attacks  of  diarrhoeal  diseases,  particularly  when  these  have  heen  pro- 
longed. Want  of  sufficient  muscular  exercise  is  a  frequent  cause.  There 
are  many  children  who  rarely  sulfer  from  constipation  in  summer  when 
they  have  plenty  of  out-of-door  exercise,  who  very  often  do  so  in  winter 
when  such  exercise  is  wanting.  A  loss  of  muscular  tone  is  not  an  infre- 
quent result  of  the  prolonged  and  indiscriminate  use  of  purgative  drugs 
or  enemata. 

Symptoms. — In  many  cases  no  symptoms  are  present  except  the  local 
ones,  the  general  health  being  excellent  and  the  nutrition  in  no  way 
disturbed.  In  the  majority,  however,  there  are  symptoms  of  greater  or 
less  severity,  depending  somewhat  upon  the  cause  of  the  constipation. 
There  may  be  simply  flatulence  and  colicky  pains,  or  the  irritation  of 
the  hardened  faecal  masses  may  produce  a  slight  catarrhal  inflammation 
of  the  sigmoid  flexure  and  the  rectum,  so  that  mucus  and  sometimes 
traces  of  blood  may  be  passed  with  the  stool.  Haemorrhoids  may  develop 
even  in  infancy,  and  frequently  the  constant  straining  leads  to  the  pro- 
duction of  hernia.  In  many  cases  there  are  from  time  to  time  nervous 
symptoms  resulting  apparently  from  the  absorption  of  various  toxic  ma- 
terials from  the  intestine.  There  may  be  headache,  dulness,  fretfulness, 
disturbed  sleep,  and  associated  signs  of  intestinal  indigestion.  The 
urine  often  contains  indican  in  excess,  and  there  may  be  slight  fever. 

Diagnosis. — This  includes  the  discovery  of  the  cause  and  the  principal 
seat  of  the  constipation.  To  arrive  at  the  former  the  most  careful  and 
thorough  investigation  should  be  made  of  the  child's  diet  and  habits.  It 
is  desirable  to  determine  whether  the  seat  of  trouble  is  the  rectum,  the 
upper  part  of  the  colon,  or  the  small  intestine.  If  a  suppository  is 
almost  immediately  followed  by  a  normal  stool,  one  may  be  sure  that 
the  rectum  only  is  at  fault,  and  that  it  needs  but  a  little  extra  stimulus 
to  make  it  do  its  work.  This  is  common  in  infants  who  are  too  young 
to  make  any  voluntary  efforts.  In  such  cases  there  are  no  other  symp- 
toms present.  In  others,  the  white  or  gray  stools,  marked  flatulence, 
ofl'ensive  breath,  and  general  irritability,  leave  no  doubt  of  the  fact  that 
the  trouble  is  due  to  indigestion. 

Treatment. — This  is  always  difficult,  and  in  obstinate  cases  must  be 
continued  for  a  long  time.  The  co-operation  of  an  intelligent  mother 
or  nurse  is  absolutely  indispensable.  To  establish  the  habit  of  regular 
stools  should  be  the  first  step,  for  without  this  regularity  nothing  can 
be  done.  Even  in  infants  only  a  few  months  old  proper  habits  are  often 
easily  formed  if  the  child  is  put  upon  the  chamber  or  chair  invariably  at 
the  same  hour.  When  a  local  stimulus  is  required  in  addition  an  oiled 
glass  rod  or  a  gluten  suppository  may  be  inserted.  An  older  child  must 
be  taught  to  heed  the  first  impulse  to  evacuate  the  bowel.  Eegular 
habits  can  hardly  be  formed  unless  the  same  time  each  day  is  chosen 
for  the  movement.    That  to  be  preferred  is  soon  after  the  morning  meal, 


404  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

as  taking  food  into  the  stomach  usually  starts  a  peristaltic  wave  which 
is  continued  throughout  the  intestine.  With  older  children  breakfast 
should  be  early  enough  to  allow  ample  time  for  this  duty  before  the 
other  engagements  of  the  day;  and  nurses  should  be  impressed  with 
the  importance  of  the  early  formation  of  proper  habits  on  the  part  of 
their  charges.  Stretching  the  sphincter  under  an  anaesthetic  is  some- 
times of  great  benefit,  especially  where  tonic  spasm  is  present. 

Food. — With  nursing  infants  who  get  good  breast-milk  constipation 
is  rare.  When  the  milk  is  low  in  fat,  constipation  is  not  uncommon. 
For  the  measures  by  which  such  milk  can  be  improved,  see  chapter  on 
Breast  Feeding. 

In  feeding  cow's  milk,  constipation  is  overcome  by  getting  the  pro- 
portions of  protein  and  fat  which  are  suited  to  the  infant.  It  is  more 
apt  to  occur  with  infants  where,  on  account  of  digestive  symptoms,  modi- 
fications of  whole  milk  or  skimmed  milk  are  given  instead  of  those 
from  top-milk.  The  laxative  effects  of  maltose  and,  to  a  less  degree,  of 
lactose,  should  be  remembered  (see  Infant  Feeding),  With  most  infants 
during  the  first  year,  constipation  may  be,  if  not  cured,  at  least  pre- 
vented, by  proper  milk  modification. 

During  the  second  year  children  who  suffer  from  constipation  may  be 
benefited  by  reducing  the  amount  of  milk  and  giving  a  limited  quan- 
tity— not  over  three  or  four  ounces  a  day — of  thin  cream.  Improve- 
ment may  often  be  brought  about  by  using  the  coarse  farinaceous  foods. 
Meat  broth  and  beef  juice  are  quite  laxative  on  account  of  their  ex- 
tractives and  salts.  Fruits  are  valuable  in  all  these  cases;  but  only  the 
juice  should  be  given  until  a  child  is  eighteen  or  twenty  months  old. 
That  of  almost  any  fresh  fruit  may  be  employed.  At  two  years  pulpy 
fruits  may  be  given,  but  only  after  cooking;  also  baked  apples,  stewed 
prunes,  and,  in  summer,  peaches,  plums,  and  pears,  in  small  quantities; 
but  berries  should  be  avoided.  Fresh  fruits  should  not  be  given  until 
after  three  years  and  then  in  moderate  quantities  only. 

For  older  children  who  are  on  a  mixed  diet  the  amount  of  starchy 
food  should  be  moderate.  Milk  should  be  given  rather  sparingly.  It  is 
sometimes  advisable  to  stop  milk  altogether  and  give  only  cream,  from 
three  to  four  ounces  of  which  may  be  allowed  daily.  It  may  be  used 
with  the  breakfast  cereal,  mixed  with  potato  or  rice,  added  to  soups  or 
broths,  and  taken  in  various  other  ways.  All  bread  should  be  made  from 
whole  wheat  or  unbolted  flour.  Bran  biscuits  are  also  useful.  Meat  and 
broth  may  be  allowed  freely,  also  green  vegetables,  one  of  which  should 
be  given  every  day.  All  fruits  allowed  infants  may  be  used,  but  in  larger 
quantities,  and  in  addition  raw  apples.  Of  the  dried  fruits,  only  dates, 
prunes,  and  figs  are  permissible,  and  these  only  after  cooking.  Fresh 
fruit  is  preferably  given  in  the  morning,  oranges  being  especially  useful 
when  taken  on  rising.     A  caution  is  necessary  in  the  use  of  fruits  and 


CHRONIC   CONSTIPATION.  405 

coarse  foods  for  constipated  children.  It  often  happens  that  constipa- 
tion is  only  one  of  the  symptoms  of  a  chronic  intestinal  indigestion,  and 
the  use  of  such  foods  as  those  mentioned,  while  it  may  cause  the  howels 
to  move,  aggravates  the  primary  condition.  They  produce  abdominal 
pain,  flatulence,  and  the  discharge  of  mucus  in  the  stools.  The  admin- 
istration of  some  mild  laxative  even  over  a  considerable  period  is  often 
much  less  objectionable. 

Either  hot  or  cold  water,  when  taken  an  hour  before  breakfast,  may 
be  of  considerable  benefit  to  older  children.  The  sparkling  waters,  like 
Vichy  or  Apollinaris,  are  often  better  than  plain  water. 

Massage,  when  properly  employed,  is  useful  in  conjunction  with  other 
measures,  but  rarely  succeeds  alone.  It  should  be  given  for  five  or  ten 
minutes  after  retiring  and  just  before  rising. 

A  proper  amount  of  active  muscular  exercise  is  necessary  and 
should  be  made  a  part  of  the  treatment  in  every  case.  Yale  has  called 
attention  to  the  importance  of  posture  during  the  stool,  he  having 
found  that  in  many  cases  a  cure  was  effected  simply  by  substituting 
a  low  seat  on  a  nursery  chair  or  closet  for  the  high  one  previously 
used. 

Suppositories. — In  many  cases,  particularly  in  young  infants  who 
are  not  old  enough  to  initiate  the  muscular  effort,  a  slight  stimulus  to 
the  rectum  is  all  that  is  required.  The  cone  of  oiled  paper  has  a  great 
reputation  in  domestic  practice  and  is  not  objectionable.  It  may  be  of 
assistance  in  establishing  the  habit  of  a  daily  movement  at  a  regular 
time.  Soap  suppositories  produce  a  more  marked  irritation;  although 
their  immediate  effect  is  quite  satisfactory,  they  should  not  be  continued 
indefinitely.  They  are,  however,  less  objectionable  than  glycerin  sup- 
positories. The  latter,  for  an  immediate  effect,  are  convenient  and 
usually  efficient;  but  their  frequent  use,  especially  in  infants,  is  likely 
to  set  up  a  catarrhal  proctitis.  The  gluten  suppositories  produce  less 
irritation  and  are  consequently  slower  in  their  effect,  but  they  have  not 
the  disadvantages  of  the  soap  or  glycerin.  Medicated  suppositories  are 
often  efficient;  if  drugs  must  be  employed,  they  are  perhaps  open  to  the 
fewest  objections  when  used  in  this  way.  The  following  are  the  best 
drugs  for  this  purpose,  the  dose  being  that  for  a  child  of  two  or  three 
years:  ext.  nux  vomica,  gr.  -^^  ;  ext.  belladonna,  gr.  ^^;  ext.  hyoscyamus, 
gr.  ^\;  sulphur,  gr.  ij ;  purified  aloes,  gr.  ^;  aloin,  gr.  ■g'j .  A  good  com- 
bination is  aloin,  gr.  ^\;  ext.  belladonna,  gr.  -g^;  ext.  nux  vomica,  gr.  ^; 
ol.  theobrom.,  gr.  x.  In  obstinate  cases  this  may  be  used  night  and 
morning,  and  later  at  night  only.  After  some  improvement  has  occurred 
the  aloin  may  be  omitted.  Many  of  the  proprietary  suppositories  con- 
tain the  ingredients  mentioned,  particularly  belladonna,  the  dose  of 
which  is  often  considerably  larger  than  should  be  given.  Suppositories 
are  chiefly  useful  when  the  trouble  is  in  the  rectum  and  lower  colon; 


406  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

but  very  little  is  to  be  expected  from  them  when  it  is  higher  in  the 
intestine. 

Enemata. — These  should  be  restricted  to  cases  in  which  only  tem- 
porary relief  is  desired.  An  injection  of  an  ounce  of  sweet  oil  may 
facilitate  the  passage  of  very  hard  and  dry  stools,  and  a  regular  nightly 
repetition  of  this,  or  a  somewhat  larger  amount,  for  several  weeks  will 
often  break  up  a  constipated  habit.  Injections  of  soap  and  water  may 
be  used  to  soften  hard  faecal  accumulations.  For  immediate  effect  an 
injection  of  one  or  two  drachms  of  glycerin  in  an  ounce  of  water  is  per- 
haps the  most  efficient  means  at  our  command.  Cases  of  faecal  impac- 
tion are  rarely  met  with  in  children.  They  are  to  be  managed  as  in 
adults,  by  repeated  injections  of  warm  water  or  of  ox-gall,  and  sometimes 
by  mechanical  removal.  For  continuous  use  enemata  of  water  are  not 
to  be  advised,  for  larger  and  larger  quantities  are  required  to  produce 
the  effect. 

Medicinal  Treatment. — This  is  the  least  important  part  of  tlie  man- 
agement of  chronic  constipation.  No  plan  is  worse  than  to  give  some 
active  purgative  every  third  or  fourth  day  and  trust  matters  to  take 
care  of  themselves  the  rest  of  the  time.  The  most  valuable  drugs  are 
stimulating  laxatives,  such  as  cascara,  nux  vomica,  belladonna,  hyos- 
cyamus,  and  phenolphthalein.  These  are  particularly  useful  in  atonic 
constipation  associated  with  rickets  and  following  diarrliffial  diseases,  but 
they  are  valuable  in  all  cases.  With  most  drugs  the  prolonged  use  of 
small  doses  is  better  than  the  occasional  use  of  large  ones.  Calomel  is 
indicated  in  cases  attended  with  dry,  very  white  stools  and  marked  flatu- 
lence; one-fourth  to  one-half  grain  of  the  tablet  triturates  may  be  given 
for  two  or  three  successive  nights  in  conjunction  with  other  means. 
Cascara  may  be  used  either  in  the  form  of  the  elixir,  dose  from  one-half 
to  one  drachm,  or  the  fluid  extract,  from  one  to  five  drops.  Ehubarb, 
either  in  the  form  of  the  syrup  or  the  mixture  of  rhubarb  and  soda,  may 
be  given  occasionally,  but  it  is  not  adapted  to  continuous  use.  Of 
salines,  magnesia  and  phosphate  of  soda  are  best  for  continuous  use  in 
infants.  All  the  preparations  of  malt  possess  slight  laxative  properties, 
and  are  useful  in  conjunction  with  dietetic  and  other  medicinal  means; 
any  of  the  extracts  of  malt  may  be  employed.  Castor  oil  should  seldom 
be  given  for  chronic  constipation.  Olive  oil  is  often  of  assistance  in  the 
treatment  of  the  constipation  both  of  infants  and  older  cliildren.  To  the 
former  the  usual  dose  is  one  teaspoonful  three  times  a  day ;  to  the  latter, 
two  or  three  times  this  amount  should  be  given.  Agar-agar  by  rendering 
the  faecal  mass  softer  and  more  easily  expelled  frequently  proves  a  most 
effective  remedy  for  older  children.  It  should  be  broken  up  into  fine 
fragments  and  mixed  with  the  cereal  when  eaten  or  it  may  be  cooked 
with  it.    The  dose  is  three  or  four  teaspoonfuls. 


INTUSSUSCEPTION.  407 

HYPERTROPHY  AND   DILATATION   OF  THE  COLON 

{Hirshprung' s  Disease). 

It  is  probable  that  in  many  eases  of  ehronie  constipation,  especially 
among  rachitic  infants,  a  considerable  degree  of  dilatation  of  the  colon 
occurs.  However,  it  seems  to  be  but  a  temporary  condition,  disappearing 
by  the  third  or  fourth  year. 

There  is  another  form  of  dilatation  which  may  be  permanent  and  is 
generally  believed  to  be  of  congenital  origin;  it  is  associated  with  a 
marked  degree  of  hypertrophy  of  the  muscular  walls  of  the  colon.  Cases 
have  been  observed  both  in  infants  and  in  older  children.  The  prom- 
inent symptoms  are  two:  obstinate  constipation,  which  in  most  of  the 
cases  has  continued  from  early  infancy,  and  is  sometimes  so  severe  that 
the  patients  have  gone  for  two  weeks  without  a  movement  of  the  bowels ; 
and  distention  of  the  abdomen,  which  may  be  extreme,  but  which  may 
disappear  and  the  abdomen  become  perfectly  flat  after  the  fgeces  and 
flatus  have  been  discharged.  There  is  usually  emaciation,  and  from  time 
to  time  there  may  be  diarrhoea.  Death  may  occur  in  infancy,  or  the 
patients  may  live  to  adult  life. 

In  the  cases  which  have  come  to  autopsy  there  has  been  found  an 
enormous  dilatation  of  the  large  intestine,  chiefly  of  the  transverse  colon 
and  tiie  sigmoid  flexure.  In  one  reported  case,  in  a  boy  of  three  years, 
the  colon  was  four  inches  in  diameter,  and  held  fourteen  pints  of  water. 
In  none  of  the  cases  was  there  stricture  at  any  point.  The  mucous  mem- 
brane has  almost  invariably  been  found  ulcerated,  this  clearly  being  a 
secondary  process.  The  muscular  walls  have  been  greatly  hypertrophied. 
Medical  treatment  is  palliative  only.  An  artificial  anus  has  been  made 
in  several  cases  with  at  least  temporary  benefit.  The  complete  removal 
of  the  large  intestine  has  also  been  performed  for  this  condition. 

INTUSSUSCEPTION. 

Intussusception  consists  in  the  invagination  of  one  portion  of  the 
intestine  into  another.  It  occurs  most  frequently  in  infancy,  being  at 
this  age  the  most  common  cause  of  acute  intestinal  obstruction.  The 
accident  is  not  a  common  one,  but  the  life  of  the  patient  generally  de- 
pends upon  its  prompt  recognition. 

Varieties. — Usually  the  upper  part  of  the  intestine  is  invaginated  into 
the  lower,  although  the  reverse  is  occasionally  seen.  Intussusceptions 
may  occur  at  any  point  in  the  intestinal  tract.  Those  of  the  small  intes- 
tine are  called  enteric;  those  of  the  colon,  colic;  and  those  occurring  at 
the  ileo-caecal  valve,  ileo-ccecal  (Fig.  65).  Of  90  cases  under  ten  years 
of  age,  in  which  the  variety  was  determined  by  autopsy  or  operation,  75 
were  ileo-csecal,  9  colic,  and  6  enteric.     In  the  ileo-caecal  form  a  few 


408  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

inches  of  the  ileum  pass  through  the  ileo-caecal  valve,  and  then  invagina- 
tion of  the  colon  occurs.  Cases  in  which  the  ileum  passes  through  the 
valve,  but  without  invagination  of  the  colon,  are  sometimes  classed  sep- 
arately as  an  ileo-colic  variety. 

Intussusceptions  of  the  dying,  as  they  have  been  called,  are  met  with 
in  my  experience  in  about  eight  per  cent  of  all  autopsies  made  upon 


Fig.  65. — Ileo-c^cal  Intussusception. 
A  specimen  removed  from  a  child  in  the  New  York  Infant  Asylum. 

infants;  they  are  not  often  found  in  children  over  two  years  of  age. 
They  are  descending,  enteric,  easily  reducible,  and  multiple — usually 
from  eight  to  twelve  invaginations  are  present.  They  are  more  fre- 
quently in  the  jejunum  than  in  the  ileum.  They  usually  involve  but 
two  or  three  inches  of  the  intestine,  but  may  include  ten  or  twelve 
inches.  They  are  found  in  autopsies  upon  patients  dying  of  all  varieties 
of  disease,  and  are  probably  produced  in  the  death  agony.  Such  intus- 
susceptions are  without  symptoms,  and  are  of  no  clinical  importance. 

Etiology. — Of  358  collected  cases  under  ten  years,  the  following  are 
the  ages  reported :  under  four  months,  28  cases ;  from  four  to  six  months, 
113;  seven  to  nine  months,  71;  ten  to  twelve  months,  18;  one  to  two 
years,  32;  two  to  ten  years,  96.  Three-fourths  of  the  cases  which  occur 
in  childhood  are,  therefore,  in  the  first  two  years,  and  one-half  of  them 


INTUSSUSCEPTION.-  409 

between  the  fourth  and  ninth  months.  The  greater  frequency  in  infancy 
is  attributed  to  the  thinness  of  the  intestinal  walls,  the  greater  mobility 
of  the  caecum  and  ascending  colon,  and  the  presence  of  other  intestinal 
derangements  at  this  age. 

Males  are  more  often  affected  than  females.  Of  268  cases  in  which 
the  sex  was  mentioned,  there  were  174  males  and  94  females.  For  this 
fact  there  is  no  explanation.  The  exciting  causes  of  an  attack  are  ex- 
tremely obscure.  The  great  majority  of  cases  occur  in  children  who  were 
apparently  in  perfect  health.  Some  previous  intestinal  disorder  was 
present  in  about  three  per  cent  of  the  cases  I  have  collected — diarrhoea, 
d3'sentery,  colic,  chronic  indigestion,  and  constipation,  all  being  men- 
tioned. In  four  cases  the  intussusception  was  ascribed  to  injury  of  the 
abdomen.  The  association  with  the  general  diseases  is  too  infrequent  to 
be  of  any  importance. 

Lesions. — Notlmagel's  animal  experiments  have  shown  conclusively 
that  intussusceptions  are  formed  by  the  irregular  action  of  the  muscular 
walls  of  the  intestine.  They  can  be  produced  or  released  at  will  by  vary- 
ing the  application  of  the  electrical  current.  In  the  artificial  intussus- 
ception there  is  first  a  contraction  of  a  certain  part  of  the  intestine,  and 
if  this  ceases  abruptly  the  normal  gut  l)elow  this  ])()int  turns  upward  and 
folds  over  upon  the  contracted  portion,  thus  forming  a  minute  intus- 
susception (Fig.  66,  A).  When  once  begun,  the  intussusception  in- 
creases solely  at  the  expense  of  the  external  layer  (Fig.  66,  B).  Thus, 
while  the  apex  of  the  tumour  D  remains  unchanged,  the  part  of  the 
sheath  at  A  passes  to  B  and  then  to  C,  so  that  the  lower  part  of  the 
intestine  is  drawn  over  the  upper,  rather  than  the  upper  crowded  into 
the  lower.  The  mechanism  of  the  invagination  was  apparently  the  same 
when  a  part  of  the  intestine  was 
first  paralysed  by  crushing,  as  in 
the  cases  in  which  a  spasm  of  the 
intestine  was  first  produced.  Fig.  66,  A. 


Fig.  66,  B. — Mechanism  of  Intussusception.     (Treves.) 

There  is  little  doubt  that  pathological  intussusceptions  are  produced 
in  the  same  way  as  in  these  experiments.  As  the  invagination  takes 
place,  the  mesentery  is  drawn  in  with  the  bowel,  and  always  lies  between 
the  sheath  and  the  inner  layer.  To  allow  intussusception  to  occur,  the 
mesentery  must  be  unduly  long,  stretched,  or  lacerated.  Its  attachment 
to  the  spine  causes  the  intussusception  to  describe  an  arc  of  a  circle,  the 
concavity  of  which  is  always  toward  the  spine.  It  also  causes  a  puckering 
of  the  tumour.     Invagination  does  not  necessarily  produce  either  ob- 


410  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

struction  or  strangulation,  but  usually  both  are  present,  and  are  the 
chief  causes  of  the  symptoms.  Traction  upon  the  mesentery  leads  to 
obstruction  in  its  vessels,  causing  congestion,  oedema,  haemorrhages,  and 
even  gangrene.  Obstruction  is  chiefly  due  to  swelling.  It  may  be  due  to 
dragging  of  the  mesentery,  which  brings  the  apex  of  the  tumour  against 
the  side  of  the  gut,  or  to  bending  of  the  intussusception.  Intussusception 
is  usually  of  all  the  coats  of  the  intestine.  I  have,  however,  seen  one, 
the  exact  nature  of  which  was  determined  by  operation,  in  which  only 
the  mucosa  and  submucosa  were  involved.  The  invagination  was  at  the 
ileo-caecal  valve.  The  symptoms  were  characteristic  except  for  the  ab- 
sence of  tumour. 

The  great  cause  of  irreducibility  in  the  first  two  or  three  days  is 
swelling.  I  have  several  times  seen  at  autopsy  or  operation  the  intus- 
susception easily  reduced,  except  the  last  two  or  three  inches  of  the 
caecum  or  ileum,  which  was  swollen  to  the  thickness  of  from  a  fourth 
to  half  an  inch.  Adhesions  may  prevent  reduction,  but  rarely  before  the 
fourth  day;  they  are  often  absent  as  late  as  the  sixth  or  seventh  day. 
They  are  usually  between  the  internal  and  middle  layers  of  the  intus- 
susceptum,  and  are  due  to  local  peritonitis.  In  chronic  cases,  however, 
they  form  the  principal  obstacle  to  reduction.  Other  causes  of  irreduci- 
bility are  twisting  of  the  tumour  and  pinching  of  the  prolapsed  intestine, 
especially  of  the  ileum  by  the  ileo-caecal  valve. 

Gangrene  and  sloughing  of  the  gangrenous  portion  of  the  intestine 
occur  much  more  often  in  acute  than  in  chronic  cases.  Portions  of 
intestine  were  passed  per  anurn  in  24  of  362  cases  under  ten  years,  or 
about  six  per  cent ;  but  only  two  of  these  were  in  infants.  Toward  the 
end  of  the  second  week  is  the  time  when  the  separation  of  the  sloughs  is 
to  be  looked  for.  The  amount  of  intestine  discharged  varies  from  a  few 
inches  to  several  feet.  Two  cases  are  on  record  in  which  the  entire  colon 
was  passed,  the  patients  recovering,  but  dying  several  months  later  from 
other  causes.  At  the  autopsies  the  ileum  was  found  attached  to  the  lower 
part  of  the  rectum  just  above  the  anus.  In  acute  cases  gangrene  occurs 
about  the  upper  end  of  the  tumour,  and  the  intestine  usually  comes  away 
in  one  large  mass.  In  chronic  cases  shreds  of  intestine  may  be  discharged 
for  several  weeks. 

Symptoms. — The  clinical  picture  of  a  case  of  intussusception  is  a 
striking  one,  and  when  acute  the  symptoms  are  so  uniform  that,  once 
seen,  it  can  scarcely  be  overlooked  a  second  time.  The  patient,  usually 
between  six  and  twelve  months  of  age,  is  taken  suddenly  ill  with  severe 
pain  and  vomiting;  the  pain  recurs  paroxysmally  every  few  minutes, 
and  the  vomiting  being  first  of  the  contents  of  the  stomach,  and  after- 
ward bilious.  There  may  be  one  or  two  loose  faecal  stools,  then  only 
blood  or  blood  and  mucus  are  passed  without  any  admixture  of  faeces. 
The  general  symptoms  are  those  of  great  prostration,  or  even  collapse — 


INTUSSUSCEPTION.  411 

pallor,  feeble  pulse,  apathy,  and  normal  or  sul^normal  temperature.  The 
abdomen  is  relaxed.  A  tumour  is  present  in  the  left  iliac  fossa,  or  it 
may  be  felt  per  rectum.  Later  there  is  tympanites ;  the  vomiting  and 
pain  continue;  there  is  a  steady  increase  in  the  prostration,  and  toward 
the  end  a  rapidly  rising  temperature  which  may  reach  105°  or  106°  F. 
before  death  occurs  from  collapse.  If  the  symptoms  continue  longer  the 
signs  of  peritonitis  are  added.  In  subacute  cases  the  onset  is  less 
abrupt,  and  pain,  vomiting,  and  constipation  less  constant  and  less  severe; 
but  the  same  symptoms  are  present.  In  chronic  cases  the  onset  is  witli 
vague,  indefinite  intestinal  symptoms;  pain,  vomiting  and  bloody  dis- 
charges are  usually  wanting;  there  is  progressive  wasting  and  more  or 
less  diarrhoea,  but  only  the  presence  of  the  tumour  leads  to  the  recogni- 
tion of  the  condition. 

In  subacute  or  chronic  cases  the  diagnosis  is  much  more  difficult. 
The  general  symptoms  may  be  wanting  entirely.  Vomiting  is  usually 
absent;  constipation  is  less  marked  and  there  may  be  none.  The  only 
diagnostic  feature  is  the  presence  of  the  tumour,  usually  accompanied 
by  evidences  of  catarrhal  colitis,  discharge  of  mucus,  etc. 

Onset. — Of  193  cases  under  ten  years  in  which  data  upon  this  point 
could  be  obtained,  the  onset  was  sudden  in  181  and  gradual  in  12  cases. 
By  far  the  most  frequent  symptoms  of  onset  are  pain  and  vomiting.  In 
a  smaller  number  of  cases  the  initial  symptom  is  diarrhoea  or  a  dis- 
charge of  blood  and  mucus. 

Pain. — This  is  rarely  continuous,  but  is  intermittent,  recurring  in 
paroxysms  like  those  of  ordinary  colic,  but  of  great  severity.  No  pain  in 
infancy  is  to  be  compared  with  it.  The  child  sometimes  shrieks  so  as  to 
be  heard  all  over  the  house.  Pain  is  a  prominent  symptom  in  over  three- 
fourths  of  the  cases,  and  is  very  rarely  absent.  It  is  generally  more 
marked  for  the  first  two  days,  but  may  continue  throughout  the  attack. 
In  a  few  cases  the  pain  is  localised,  being  usually  referred  to  the  region 
of  the  umbilicus. 

Vomiting  is  more  marked  at  the  onset,  but  may  continue  throughout 
the  attack.  Like  the  pain,  it  is  more  frequent  in  the  acute  cases.  It  is 
due  to  intestinal  obstruction.  Vomiting  is  present  in  fully  four-fifths 
of  all  cases.  Usually  it  is  persistent  and  often  projectile.  If  food  is 
given,  vomiting  often  occurs  as  soon  as  it  reaches  the  stomach.  Stercora- 
ceous  vomiting  occurs  in  about  fifteen  per  cent  of  the  cases  in  children 
under  ten  years,  but  is  not  common  in  infancy.  It  is  rarely  present 
before  the  third  or  fourth  day.  Although  a  bad  sign,  it  is  not  by  any 
means  a  fatal  one,  as  nearly  one-half  the  cases  in  which  it  has  been  noted 
have  recovered;  it  is  to  be  regarded  as  indicating  complete  intestinal 
obstruction  rather  than  strangulation. 

Tumour. — This  is  one  of  the  most  important  symptoms  for  diagnosis 
because  of  its  frequency  and  its  peculiar  charactei;.    It  is  present  early  in 


412 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


tlie  disease,  often  in  a  few  hours  after  the  initial  symptoms.  The  follow- 
ing table  shows  the  frequency  with  which  a  tumour  was  present  in  the 
different  varieties,  and  the  position  wliich  it  occupied  in  each.  The 
anatomical  variety  was  determined  either  by  autopsy  or  operation. 

The  Relation  between  the  Tumour  and  the  Different  Varieties  of  Intussusception 
in  188  Cases  under  Ten  Years. 


Seat  of  Intubsusception. 

Seat  of  Tumour. 

Heo- 
csecal. 

Ileo- 
colic. 

CoUc. 

Enteric. 

Not 
stated. 

Total. 

Region  of  caecum 

"  "  ascending  colon 
"  "  transverse  colon 
"  "  descending  colon 
"       "  sigmoid  flexure . 

Rectum 

Protruding  from  anus .... 

Umbilical  region 

Movable        

1 

3 
3 
4 
25 
9 

i 

3 

i 

i 

7 
1 

1 

i 
1 

7 
12 
13 
18 

8 
28 
12 

2 

11 

13 
16 
21 
13 
61 
22 
1 
3 

Site  unknown           

1 

Total     

46 
10 

4 
2 

9 

3 

1 

100 
13 

162 

No  tumour  felt 

26 

Tumour  was  thus  made  out  during  life  in  eighty-six  per  cent  of  the 
cases;  and  in  the  great  majority  of  these  it  was  discovered  at  the  first 
careful  examination. 

It  will  be  noted  that  in  one-half  of  the  cases  the  tumour  was  either 
felt  in  the  rectum  or  protruded  from  the  anus,  and  that  in  over  two- 
thirds  it  had  advanced  as  far  as  the  descending  colon  or  beyond.  The 
tumour  may  reach  the  rectum  in  a  surprisingly  short  time,  even  when 
the  invagination  begins  at  the  ileo-caecal  valve.  In  one  of  my  own  cases 
it  was  felt  in  the  rectum  in  less  than  twelve  hours  from  the  onset.  The 
usual  description,  "  sausage-shaped,"  is  accurate  when  the  invagination 
is  large,  the  tumour  then  being  from  four  to  six  inches  long  and  about 
an  inch  and  a  half  in  diaipeter.     It  is  often  curved. 

During  manipulation,  or  during  an  attack  of  pain,  the  tumour  may 
become  more  prominent  and  may  be  distinctly  erectile.  To  the  touch 
the  rectal  tumour  closely  resembles  the  os  uteri,  the  central  opening  being 
the  apex  of  the  intussusception.  When  protruding  from  the  body,  the 
tumour  is  rarely  more  than  two  inches  long.  It  is  usually  of  a  deep 
purplish  colour,  and  may  be  gangrenous.  It  has  been  mistaken  for 
prolapsus  ani,  polypus,  and  even  haemorrhoids.  In  a  case  wliich  came 
subsequently  under  my  observation,  the  tumour  was  discovered  by  the 
mother  before  the  physician  had  suspected  the  condition. 

Condition  of  the  Bowels. — Bloody  stools  are  a  very  constant  symp- 
tom.   Of  186  cases  under  ten  years  in  which  this  condition  of  the  bowels 


INTUSSUSCEPTION.  413 

was  noted,  blood  in  the  stools  was  present  in  seventy-six  per  cent.  There 
are  very  often  two  or  three  thin,  diarrhceal  movements,  and  then  only 
blood  and  mucus  are  passed  with  no  trace  of  faces  and  with  no  fa3cal 
odour.  The  amount  of  blood  varies  from  a  quantity  sufficient  to  stain 
the  mucus,  to  an  ounce  of  semi-fluid  blood.  It  rarely  occurs  without 
some  mucus.  Such  discharges  frequently  follow  attacks  of  severe  colicky 
pain,  and  may  occur  several  times  in  an  hour.  They  may  continue,  or 
after  a  day  or  two  they  may  be  succeeded  by  absolute  stoppage.  Diar- 
rhoea throughout  the  attack  is  rare  in  children,  particularly  so  in  in- 
fants. It  belongs  generally  to  chronic  cases.  Constipation  is  complete 
in  most  of  the  acute  cases,  neither  gas  nor  faces  being  passed ;  a  fact 
which  the  discharge  of  blood  and  mucus  may  lead  one  to  overlook. 

Tenesmus  is  very  common  if  the  tumour  is  rectal.  Relaxation  of  the 
sphincter  is  met  with  in  a  considerable  proportion  of  the  cases  when  the 
tumour  is  in  the  sigmoid  flexure,  or  rectum. 

During  the  first  twenty-four  or  forty-eight  hours  the  abdominal  walls 
are  soft  and  relaxed,  and  may  even  be  retracted.  Usually  there  is  then 
little  resistance  to  abdominal  palpation.  After  the  second  or  third  day 
there  is  usually  tympanites;  but  this  does  not  necessarily  mean  that 
peritonitis  exists.  Localised  tenderness  is  a  symptom  of  some  impor- 
tance when  a  tumour  is  absent.  Scanty  urine  has  been  noted  in  a  few 
cases,  but  is  of  no  special  value  in  showing  the  seat  of  obstruction. 

In  the  acute  cases  the  general  symptoms  are  very  striking.  They  are 
the  ordinary  ones  of  severe  shock — marked  prostration,  pallor  with  an 
anxious  expression  of  the  face,  general  muscular  relaxation,  cold  extrem- 
ities, cold  perspiration,  and  often  a  subnormal  temperature.  Early  there 
is  marked  restlessness,  and  even  convulsions  may  occur.  Later  there  are 
apathy,  dulness,  and  semi-stupor.  The  temperature  during  the  first 
twenty-four  hours  is  usually  not  elevated,  and  is  frequently  subnormal. 
Toward  the  close  of  the  disease  it  rises  rapidly  to  103°,  104°  F.,  or  even 
higher,  quite  independently  of  peritonitis.  A  rapidly  rising  temperature 
is  always  a  bad  symptom,  and  usually  betokens  death  within  twenty- 
four  hours.  Wasting  is  seen  in  the  chronic  cases,  and  may  be  quite 
rapid. 

Course,  Duration,  and  Termination. — Of  198  cases  under  ten  years, 
155  were  classed  as  acute,  lasting  less  than  seven  days;  33  as  subacute, 
lasting  from  one  to  four  weeks ;  10  were  chronic,  lasting  over  four  weeks. 
Nearly  all  the  cases  occurring  in  infancy  are  acute. 

Spontaneous  reduction  is,  without  doubt,  possible  in  intussusception. 
Treves  and  others  are  of  the  opinion  that  this  happens  much  more  fre- 
quently than  is  generally  supposed,  and  that  many  cases  of  severe  colic 
are  really  cases  of  slight  intussusception.  There  are  seen  in  both  con- 
ditions the  tendency  to  vomit,  the  paroxysmal  pain,  the  constitutional 
depression^  and  often  the  sudden  cessation  of  the  symptoms,  especially 


414  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

under  the  influence  of  opium ;  but  to  make  a  positive  diagnosis  of  invagi- 
nation in  such  cases  is  impossible.  Intussusception  may  Im  cured  spon- 
taneously by  sloughing  of  the  invaginated  part,  the  continuity  of  the 
intestine  being  preserved  by  adhesions.  Such  a  result  is  rare  at  all  ages, 
and  is  almost  never  seen  in  infancy. 

The  most  frequent  cause  of  death  in  acute  cases  is  shock.  Peritonitis 
is  not  found  at  autopsy  or  operation  so  often  as  might  be  expected.  In 
fifty-eight  autopsies,  it  was  seen  but  twenty  times,  and  in  seven  of  these 
it  was  limited  to  the  intussusception.  In  but  seven  cases  was  there  per- 
foration. 

Diagnosis. — This  usually  presents  no  difficulty  in  acute  cases  provided 
the  physician  has  the  condition  in  mind.  The  great  majority  of  such 
cases  present  nearly  all  the  classical  symptoms,  viz.,  sudden  onset,  recur- 
ring colicky  pains,  frequent  vomiting,  bloody  and  mucous  stools  without 
faecal  matter,  general  prostration  or  collapse,  and  low  temperature.  The 
records  show  that  the  most  common  error  is  to  regard  the  case  for  the 
first  few  days  as  one  of  gastro-enteritis  or  ileo-colitis,  the  physician's 
attention  being  engrossed  by  the  vomiting  and  bloody  stools.  Given 
the  other  usual  s}Tnptoms,  the  presence  of  the  characteristic  tumour  is 
conclusive  evidence  of  intussusception.  Unless  the  patient  is  very  much 
relaxed,  a  satisfactory  examination  is  possible  only  under  full  anaesthesia. 
In  any  case  of  acute  intestinal  obstruction  in  infants,  intussusception 
should  first  be  considered.  I  once  saw,  in  a  young  infant,  strangulated 
hernia  produce  nearly  every  symptom  of  intussusception  except  the 
abdominal  tumour.  Chronic  cases  present  no  diagnostic  symptoms 
except  the  tumour.  In  both  acute  and  chronic  cases  the  rectal  exami- 
nation is  most  important  for  diagnosis,  and  often  settles  the  question 
at  once. 

Prognosis. — The  prognosis  of  intussusception  depends  upon  the  age 
of  the  patient,  upon  the  variety  of  the  disease — whether  acute,  subacute, 
or  chronic — and  upon  the  time  when  proper  treatment  is  begun. 

There  were  collected  by  Pilz  in  1870,  94  cases  under  one  year,  the 
mortality  being  84  per  cent.  Of  135  cases  of  the  same  age  reported 
between  1870  and  1891  the  mortality  was  59  per  cent.  Results  in  older 
children  were  somewhat  more  favourable.  Formerly  recovery  was  rare, 
except  in  cases  with  sloughing;  but  with  earlier  diagnosis  and  a  better 
understanding  of  the  proper  methods  of  treatment,  the  mortality  has 
been  very  much  reduced.  Combining  the  figures  of  Pilz  with  my  own, 
there  are  362  cases  with  231  deaths,  or  63.5  per  cent. 

Gibson  (New  York)  has  collected  reports  of  187  operations  for  intus- 
susception, with  a  general  mortality  of  51  per  cent;  in  126  cases,  in 
which  the  tumour  was  reducible,  it  was  but  36  per  cent;  in  61,  in  which 
it  was  irreducible  or  gangrenous,  it  was  80  per  cent.  The  table  following 
gives  the  mortality  in  relation  to  time  of  operation : 


APPENDICITIS.  415 


Time  or  Operation. 


Mortality. 
Per  cent. 


First      day 37 


Second 

Third 

Fourth 

Fifth 

Sixth 


39 
61 
67 
73 
75 


After  the  second  day  the  chances  of  success  are  greatly  reduced. 

Treatment. — The  diagnosis  of  acute  intussusception  once  made,  lapa- 
rotomy should  immediately  be  performed  without  an  hour's  unnecessary 
delay.  The  results  following  inflation  of  the  intestine  with  air  and 
injection  with  water  are  too  uncertain  to  be  depended  upon. 

Operation  should  be  looked  upon  as  a  measure  which,  if  employed 
reasonably  early,  offers  a  good  prospect  of  success.  All  statistics  show 
that  the  result  depends  more  upon  the  time  when  the  operation  is  done 
than  upon  any  other  single  factor.  With  earlier  diagnosis  and  more 
prompt  resort  to  operation,  the  mortality  from  acute  intussusception  has, 
during  the  past  fifteen  years,  been  steadily  falling.  In  chronic  cases, 
also,  laparotomy  offers  altogether  the  best  chance  of  success. 


CHAPTEK    IX. 
DISEASES  OF   THE  INTESTINES.— (Continued). 

APPENDICITIS. 

Appendicitis  is  met  with  at  all  ages,  and  is  not  especially  a  disease 
of  children.  When  it  attacks  those  over  ten  or  twelve  years  of  age  it 
does  not  differ  greatly  from  the  types  observed  in  adults.  All  that  will 
be  attempted  in  this  chapter  will  be  a  consideration  of  the  peculiarities 
of  the  disease  as  it  is  seen  in  children,  particularly  young  children.  For 
a  fuller  discussion  of  the  disease  as  a  whole  the  reader  is  referred  to 
works  on  general  medicine  and  surgery. 

Etiology. — Of  1,000  cases  of  appendicitis  personally  observed  by 
McCosh,  85  occurred  in  children  between  the  ages  of  ten  and  fifteen 
years;  51  between  the  ages  of  five  and  ten  years,  and  only  17  under  five 
years;  of  these  but  4  were  under  two  years.  Churchman's  figures  from 
the  Johns  Hopkins'  Hospital,  in  a  total  of  1,223  cases,  give  only  9  cases 
under  five  years,  and  50  between  five  and  ten  years.  In  infancy  and 
early  childhood  appendicitis  is,  therefore,  a  relatively  rare  disease.  The 
youngest  cases  that  have  come  under  my  observations  were  in  infants  of 
nine  and  fourteen  months  respectively.     Goyen's  case  was  in  an  infant 


416  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

only  six  weeks  old ;  Shaw's,  seven  weeks ;  Demme's,  seven  weeks ;  and 
Savage's,  nine  weeks  old.  The  predominance  of  the  male  sex  holds  true 
even  in  childhood.  Of  101  cases  under  fifteen  years,  72  were  males  and 
29  were  females. 

Regarding  the  exciting  cause  of  an  attack  hut  little  is  yet  definitely 
known.  In  only  a  very  small  proportion  of  the  cases  is  a  foreign 
body  discovered  in  the  appendix.  In  one  of  my  own  a  pin  was  found, 
and  a  number  of  similar  cases  are  on  record.  There  is,  however,  almost 
invariably  a  faecal  concretion  which  is  moulded  into  the  shape  of  a  for- 
eign body,  and  formerly  was  often  regarded  as  such.  This  probably  has 
some  relation  to  the  attack  by  causing  disturbances  of  circulation  and  in- 
creasing the  chances  of  infection.  Still  and  others  have  called  attention 
to  the  frequent  occurrence  of  pin  worms  in  the  appendices  of  young  chil- 
dren. There  is  abundant  reason  for  believing  that  these  may  at  times 
be  the  exciting  cause  of  an  attack.  The  bacteria  most  frequently  found 
in  abscesses  from  appendicitis  are  streptococci,  usually  associated  with 
colon  bacilli. 

Lesions. — All  the  common  varieties  of  acute  appendicitis,  the  catar- 
rhal, suppurative,  and  gangrenous,  are  met  with  in  children;  and,  much 
less  frequently,  the  chronic  form.  The  lesions  present  few  peculiarities 
in  early  life  except  that,  owing,  possibly,  to  the  relation  of  the  appendix 
to  the  omentum,  perforative  inflammations  are  less  likely  to  be  circum- 
scribed by  inflammatory  products  and  much  more  likely  to  result  in  a 
general  peritonitis  than  in  adults.  Whether  or  not  this  be  the  correct 
explanation,  it  is  certainly  true  that  general  peritonitis  is  a  much  more 
common  sequel  than  in  adults.  Another  point  of  some  importance  is 
the  fact  that  in  early  life  the  appendix  is  rather  more  frequently  found 
out  of  the  usual  position.  The  inflammation  excited  by  pin  worms  is 
usually  a  superficial  one;  perforation  and  abscess  formation  are  almost 
unknown  when  they  are  the  cause. 

Symptoms. — In  many  of  the  cases  the  familiar  symptoms  of  appen- 
dicitis— vomiting,  localised  pain  and  tenderness,  muscular  rigidity,  ab- 
dominal distention,  and  fever — are  all  present,  and  the  diagnosis  is  easy. 
But  in  perhaps  the  larger  number  the  disease  is  irregular  in  its  onset, 
insidious  in  its  course,  and  presents  at  times  great  difficulties  in  diagnosis. 
This  is  particularly  true  of  appendicitis  in  children  under  five  years. 
Vomiting  is  probably  the  most  constant  symptom;  it  is  seldom  absent, 
and  usually  persistent.  If  accompanied  by  pain  and  constipation,  ap- 
pendicitis should  at  once  be  thought  of.  Pain,  though  usually  present,  is 
often  indefinite;  it  is  generally  hard  to  localise  and  difficult  to  interpret. 
It  may  be  referred  now  to  one  and  now  to  another  part  of  the  abdomen. 
Often  the  only  evidence  of  pain  is  restlessness,  irritability,  and,  in  in- 
fants, frequent  crying.  Tenderness  is  even  more  difficult  to  elicit  than 
pain.    Young  children,  especially  if  nervous  and  sensitive,  shrink  from 


APPENDICITIS.  417 

any  touch,  and  the  results  of  abdominal  palpation  may  be  most  unreli- 
able. In  others  of  a  difPeTent  temperament  positive  information  may  be 
obtained.  In  any  child  under  three  years,  it  is  practically  impossible  to 
make  out  localised  tenderness.  The  same  is  true  of  muscular  rigidity. 
Only  with  the  greatest  amount  of  tact  and  by  diverting  the  patient's 
mind,  can  any  information  be  derived  from  this  part  of  the  examination. 
Tenderness  and  muscular  rigidity  are  sometimes  shown  by  the  child's 
disinclination  to  move  either  the  trunk  or  lower  extremities  and  by  evi- 
dences of  pain  when  he  is  moved  by  mother  or  nurse.  When  associated 
with  vomiting,  fever,  and  constipation,  such  syniptoms  are  always  sug- 
gestive. 

Constipation  is  usually  present,  but  by  no  means  so  regularly  as  in 
adults.  Diarrhoea  is  not  at  all  uncommon,  and,  when  associated  with 
vomiting,  tends  to  divert  attention  from  the  appendix  to  an  ordinary 
gastro-intestinal  attack.  Abdominal  distention,  when  present,  is  of  much 
importance,  taken  with  other  symptoms.  Fever  is  rather  more  apt  to 
be  high  than  in  adults.  But  there  are  many  exceptions,  and,  on  the 
whole,  the  temperature  is  a  very  untrustworthy  guide  either  to  diag- 
nosis or  prognosis.  The  leucocyte  count  is  of  much  assistance  in  diagno- 
sis, at  least  in  suppurative  forms  of  appendicitis.  A  leucocytosis  of  at 
least  10,000  to  20,000  is  usually  present,  with  a  polymorphonuclear  per- 
centage over  75.  Some  special  symptoms  may  be  seen  in  appendicitis 
which  are  quite  misleading.  I  have  on  several  occasions  seen  frequent 
micturition  and  other  marked  manifestations  of  vesical  irritation,  ow- 
ing to  the  position  of  the  appendix  behind  the  bladder.  The  rigidity 
of  the  thigh  flexors  seen  in  cases  of  appendicitis,  which  come  on  with 
subacute  symptoms,  may  give  rise  to  lameness  strongly  suggestive  of  hip 
disease;  cases  of  this  kind  are  not  infrequently  seen  at  the  Hospital  for 
Ruptured  and  Crippled. 

Course  of  the  Disease. — A  certain  number  of  cases  begin  with  definite 
symptoms — pain,  vomiting,  fever,  and  constipation — and  continue  with 
slowly  or  rapidly  advancing  symptoms  to  increasing  prostration,  con- 
tinued vomiting,  constipation,  rapid  pulse,  abdominal  distention,  and 
rigidity,  higher  temperature,  and  death  by  general  peritonitis  at  the 
end  of  five  or  seven  days'  illness.  Others,  with  a  similar  onset,  show  a 
gradual  abatement  of  all  acute  symptoms  after  a  few  days,  and  recovery 
at  the  end  of  ten  days  or  two  weeks,  followed,  perhaps,  by  another  at- 
tack after  a  few  months.  These  types  are  seen  in  children  as  in  adults. 
But  others  are  quite  common.  A  child  may  be  taken  ill,  sometimes 
abruptly,  sometimes  more  gradually,  with  vomiting,  which  is  repeated 
several  times  in  a  single  day,  afterward  only  occasionally.  There  is 
some  pain;  it  is  not  very  definite  and  not  localised.  The  prostration  is 
only  moderate,  the  temperature  not  over  100°  or  100.5°  F.  The  examina- 
tion shows  little.  Tenderness  can  not  be  definitely  made  out;  the  child 
28 


418  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

is  irritable,  fretful,  wishes  to  be  left  alone,  and  resists  all  efforts  at  ab- 
dominal palpation.  The  bowels  are  constipated,  or  they  may  be  at  first 
loose  and  afterward  constipated.  The  child  does  not  seem  very  sick. 
The  attack  is  probably  regarded  as  an  ordinary  one  of  acute  indigestion. 
But  things  do  not  improve  as  they  ought.  The  pulse  becomes  more 
rapid,  the  prostration  greater,  and  the  child  begins  to  look  seriously  ill, 
though  the  temperature  has  not  risen.  The  abdominal  distention  is  now 
considerable  and  tenderness  undoubted.  An  operation  is  decided  on,  and 
there  is  found  a  gangrenous  appendix  and  a  diffuse  general  peritonitis. 
Sometimes  the  grave  symptoms  develop  with  great  rapidity  in  the  course 
of  a  few  hours,  when  previous  sjonptoms  had  all  been  mild;  sometimes 
so  insidiously  that  the  transition  is  almost  imperceptible. 

Prognosis. — The  prognosis  in  young  children  is  not  good;  of  132 
collected  cases  in  infants  and  very  young  children  the  mortality  was  38i, 
per  cent.  But  in  those  over  seven  years  old  the  outlook  is  rather  better 
than  in  adults.  The  results  depend  much  upon  early  diagnosis  and 
proper  treatment.  General  peritonitis,  it  is  generally  agreed,  occurs 
much  oftener  in  children  than  in  adults ;  it  is  the  cause  of  death  in  about 
80  per  cent  of  the  cases.  Of  43  fatal  cases,  nearly  all  of  them  from  gen- 
eral peritonitis,  only  6  died  during  the  first  three  days,  19  from  the 
fourth  to  the  seventh  day,  13  in  the  second  week,  and  5  in  the  third 
week.  If  general  peritonitis  occurs,  the  chances  of  recovery  after  opera- 
tion are,  however,  better  with  children  than  with  adults. 

Diagnosis. — The  diagnostic  symptoms  of  appendicitis  are  a  sudden 
onset  with  vomiting,  sharp  pain  in  the  abdomen,  and  persistent  acute 
localised  tenderness  in  the  right  iliac  fossa.  Rigidity  of  any  or  all  of 
the  abdominal  muscles  is  also  significant.  Constipation  is  more  fre- 
quent than  diarrhoea,  though  the  latter  is  not  rare.  There  is  almost 
invariably  some  elevation  of  temperature,  but  not  often  high  fever. 

Appendicitis  may  be  confounded  with  colic,  indigestion,  and  in  in- 
fants with  intussusception;  in  older  children  with  abscesses  due  to  pso- 
itis. Colic  is  distinguished  by  the  absence  of  localised  tenderness  and 
fever,  by  its  short  duration,  and  by  the  fact  that  the  pain  is  generally 
less  intense.  Severe  colic  with  fever  in  children  over  three  years  old 
should,  however,  always  be  regarded  with  suspicion.  From  acute  indi- 
gestion the  diagnosis  of  appendicitis  is  difficult  at  the  onset,  and  it  may 
be  impossible  for  twenty-four  hours.  However,  the  pain  of  indigestion 
is  rarely  so  severe,  while  the  fever  is  usually  higher.  It  should  be  re- 
membered that  the  pain  in  appendicitis  is  not  always  localised,  nor  is  the 
tumour  always  in  the  right  iliac  fossa.  The  presence  of  pain,  vomiting, 
and  localised  tenderness,  and  the  greater  severity  of  the  constitutional 
symptoms,  indicate  appendicitis.  I  have  several  times  known  the 
pleurisy  accompanying  pneumonia  at  the  right  base  to  be  mistaken  for 
appendicitis.    With  this  there  may  be  vomiting,  severe  localised  pain,  and 


INTESTINAL   WORMS.  419 

sometimes  also  localised  tenderness.  Cyclic  vomiting  is  distinguislied  by 
the  history  of  previous  attacks,  the  greater  frequency  witli  which  the 
vomiting  occurs,  its  abrupt  cessation  after  twenty-four  to  forty-eight 
hours,  the  sunken  abdomen,  and  the  absence  of  pain,  tenderness,  and 
rigidity.  The  presence  of  early  acetonuria  is  also  cliaracteristic.  Intus- 
susception, with  its  pain,  colic,  and  vomiting,  may  suggest  a])])eiidicitis, 
but  is  very  rare,  except  in  infants.  Fever  is  absent  early  in  tlie  disease, 
and  a  tumour  is  usually  present.  Acute  or  subacute  supjmration  in  the 
right  iliac  fossa  is  almost  invariably  due  to  appendicitis. 

The  leucocyte  count  may  be  of  consideral)le  assistance  in  differentiat- 
ing appendicitis  from  colic,  cyclic  vomiting,  ileo-colitis,  and  intussus- 
ception. It  should,  however,  be  remembered  that  in  some  of  the  gravest 
cases  the  leucocytosis  may  be  slight  or  there  may  be  none  at  all.  On 
the  whole,  while  the  presence  of  marked  leucocytosis — i.  e.,  aljove  20,000 
— may  be  of  considerable  assistance  in  the  diagnosis,  no  inference  can 
be  drawn  from  a  normal  count  or  a  slight  leucocytosis  if  the  child  is 
greatly  prostrated.  Whenever,  in  children  over  two  years  old,  there  are 
symptoms  pointing  to  acute  peritonitis,  no  matter  what  their  combina- 
tion or  variety,  appendicitis  should  always  be  suspected. 

Treatment. — Absolute  rest  in  bed  can  not  be  too  strongly  insisted 
upon  whenever  appendicitis  is  suspected,  no  matter  how  mild  the  attack 
may  appear.  As  a  local  application,  the  ice-bag  is  to  be  preferred. 
Opium  should  not  be  given.  It  does  harm  by  obscuring  important 
symptoms  and  increasing  constipation.  The  colon  should  be  kept  empty 
by  the  daily  use  of  enemata.  After  a  thorough  clearing  of  the  bowels 
in  the  beginning,  preferably  by  a  saline,  cathartics  are  to  be  avoided. 

Appendicitis  is  a  surgical  disease,  and  surgical  advice  should  be 
sought  early.  In  deciding  as  to  the  time  of  operative  interference,  it 
should  be  remembered  that  the  natural  course  of  the  disease  in  children 
is  much  less  likely  to  be  favourable  than  in  older  patients;  that  the 
dangers  of  general  peritonitis  are  much  greater ;  that  the  progress  of  the 
disease  is  much  less  regular;  that  grave  conditions  are  not  revealed  at 
once  by  grave  symptoms;  that  the  disease  is  an  insidious  one,  and  that 
to  foretell  the  outcome  even  in  the  mildest  cases  is  impossible.  Taking 
all  these  things  into  account,  I  believe  that  immediate  operation,  once 
the  diagnosis  is  made,  is  the  course  to  be  recommended  in  all  cases  of 
acute  appendicitis  in  children.  The  younger  the  child  the  greater  the 
urgency  for  operation. 

INTESTINAL  WORMS. 

Judging  by  published  reports,  intestinal  worms  are  much  more  com- 
mon in  Europe  than  in  this  country.  In  10,000  patients  treated  for 
medical  diseases  in  my  dispensary  service,  there  was  positive  evidence  of 
worms  in  but  79  cases.    Of  these,  9  had  tapeworms,  40  roundworms,  27 


420  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

threadworms,  and  3  both  round  and  threadworms.  In  private  practice 
among  the  better  classes,  worms  are  certainly  rare. 

Cestodes — Tapeworms. — Cestodes  are  usually  introduced  into  the 
body  by  the  ingestion  of  some  form  of  food  containing  larvfe  (cysticerci). 
The  larva  of  the  tcenia  solium  is  most  frequently  found  in  pork ;  that  of 
the  tcenia  mediocaneUata  in  beef;  that  of  the  bothriocephalus  latus  in 
fish;  that  of  the  tcsnia  cucumerina  inhabits  dog  or  cat  lice,  being  intro- 
duced into  the  intestinal  tract  accidentally  by  the  hands.  Several  vari- 
eties of  taenia  are  found  in  the  human  intestine. 

T^NiA  Saginata  or  Mediocanellata — Beef  Tapeworm. — Infec- 
tion results  from  eating  raw  or  partially  cooked  beef  containing  cys- 
ticerci. The  worm  is  from  twelve  to  twenty  feet  in  length,  and  has  a 
square  pigmented  head  without  hooks  but  provided  with  four  suckers. 
The  full-sized  segments  are  from  one-half  to  three-fourths  of  an  inch 
long  and  about  half  as  wide, 

T^NiA  Solium — Pork  Tapeworm. — This  is  a  rare  form  in  chil- 
dren, and  comes  from  eating  raw  or  partially  cooked  pork  or  sausage. 
It  is  from  six  to  ten  feet  in  length,  the  segments  being  nearly  square. 
The  head  is  about  the  size  of  a  mustard  seed  and  is  pigmented.  It  also 
is  provided  with  four  suckers  and  a  proboscis,  surrounding  which  is  a 
circle  of  about  twenty-six  hooklets. 

TAENIA  Cucumerina  or  Elliptica. — The  larvse  of  this  form  develop 
in  a  louse  found  on  the  skin  of  dogs  and  cats.  Children  who  play  with 
infected  animals  are  the  ones  affected,  the  parasite  being  conveyed  to 
the  mouth  usually  by  means  of  the  hands;  it  may  thus  be  found  even 
in  young  infants.  This  form  of  tsenia  is  much  smaller  than  either  of 
'  the  preceding  varieties,  the  full  length  being  only  from  six  to  twelve 
inches. 

Bothriocephalus  Latus. — This  is  a  rare  form  except  in  the  sea 
countries  of  northern  Europe  and  Switzerland,  where  it  is  said  to  be 
very  common.  The  larvas  are  harboured  by  certain  fish,  through  which 
they  are  introduced  into  the  body.  The  full-grown  worm  is  from  twenty- 
five  to  thirty  feet  in  length. 

T^NiA  Nana. — The  taenia  nana,  or  dwarf  tapeworm,  is  the  smallest 
of  all  the  cestodes.  It  is  a  narrow  worm  of  one-half  to  three-fourths  of 
an  inch  in  length,  and  is  composed  of  one  hundred  to  two  hundred 
segments.  It  has  a  slender  neck  and  globular  head  which  contains  four 
suckers  and  twenty  or  thirty  hooklets.  The  habitat  of  the  nana  is  the 
upper  part  of  the  ileum  where  it  is  often  found  in  immense  numbers. 
A  single  stool  may  contain  several  hundred  worms.  The  ova  have  two 
definite  membranes  within  the  inner  one  of  which  three  pairs  of  hook- 
lets are  found.  The  cysticercus  stage  of  this  parasite  is  not  known. 
It  is  probable  that  infection  occurs  from  swallowing  the  ova  them- 
selves.    As  a  similar  parasite  inhabits  the  intestinal  tract  of  rats  and 


INTESTINAL  WORMS.  421 

mice  it  is  possible  that  these  animals  play  a  part  in  transmission. 
From  the  observations  of  Schloss  it  seems  probable  that  in  the  vicin- 
ity of  New  York  this  is  the  most  frequent  intestinal  parasite  of 
childhood. 

Symptoms. — The  only  positive  evidence  of  tapeworm  is  the  discharge 
of  the  worms  or  separated  segments,  either  singly  or  in  groups.  Occa- 
sionally worms  pass  into  the  stomach  and  are  vomited.  Various  abdomi- 
nal symptoms  may  be  associated  with  worms,  l)ut  most  of  these  are  very 
indefinite  in  character  and  are  more  often  due  to  other  causes.  The 
most  frequent  symptoms  are  bad  breath,  various  annoying  sensations, 
colicky  attacks,  inordinate  or  capricious  appetite,  and  diarrhoea.  Usu- 
ally, if  the  patient  is  in  good  health,  no  constitutional  symptoms  are 
seen.  Sometimes,  particularly  with  the  bothriocephalus  latus,  there  is  a 
very  grave  degree  of  anaemia.  The  increase  in  the  number  of  eosinophile 
cells  in  the  blood  is  of  considerable  diagnostic  value.  They  generally 
form  from  four  to  ten  per  cent  of  the  leucocytes,  while  in  normal  blood 
the  usual  number  is  less  than  two  per  cent.  Many  cases  are  on  rec- 
ord, some  of  them  in  children,  in  which  the  symptoms  of  pernicious 
anaemia  have  been  present  and  have  disappeared  after  the  expulsion  of 
the  tapeworm.  Nervous  symptoms  are  not  so  often  seen  as  with  round- 
worms, and  will  be  discussed  in  connection  with  them. 

Treatment. — Prophylaxis  requires  the  cooking  of  meat  to  a  suf- 
ficient degree  to  destroy  the  cysticerci.  There  is  especial  danger  in 
eating  raw  pork  or  sausage;  that  from  rare  beef  is  much  less.  The  list 
of  drugs  used  for  the  expulsion  of  the  worm  is  a  long  one;  probably 
the  most  efficient  is  the  oleoresin  of  male  fern ;  it  is,  however,  difficult  to 
administer  and  it  is  very  likely  to  provoke  vomiting.  It  may  be  given 
in  capsules  containing  TTLx  to  TTI.xx,  or  in  an  emulsion  made  up  with 
simple  elixir  and  acacia,  in  which  Tl\v  to  n|,x  are  contained  in  one 
drachm.  For  a  child  of  four  years  at  least  one  drachm  of  the  male  fern 
should  be  given  in  the  course  of  six  to  eight  hours.  The  vermifuge 
should  be  preceded  by  several  hours'  fasting,  and  the  bowels  previously 
opened  by  a  laxative.  The  following  plan  of  administration  has  been 
found  satisfactory:  A  light  supper  of  milk,  and  in  the  morning  a  saline 
laxative  on  rising,  but  no  breakfast;  after  the  saline  has  acted  freely 
the  remedy  is  to  be  given,  and  following  the  last  dose,  half  an  ounce  of 
castor  oil  or  some  other  active  purge.  The  effect  of  the  cathartic  is 
aided  by  a  large  injection  of  warm  soap  and  water.  Only  milk  should 
be  given  that  day.  The  fragments  passed  should  be  carefully  examined 
to  see  if  the  head  has  been  expelled,  as  the  worm  is  very  likely  to  be 
broken  at  the  neck.  If  this  occurs  it  will  grow  again,  and  in  about 
three  months  segments  will  appear  in  the  stools.  Other  drugs  useful 
for  taenia  are  pumpkin  seeds  Which  are  given  in  powdered  form,  infusion 
of  pomegranate  root,  turpentine,  and  chloroform. 


422 


DISEASES  OF  THE   DIGESTIVE   SYSTEM. 


Nematodes. — Three  varieties  are  found  in  the  intestinal  canal,  the 
ascaris  lumhricoides,  the  oxyuris  vermicularis,  and  the  uncinaria  Amer- 
icana. 

AscARis  LuMBRicoiDEs — ROUNDWORM. — This  worm  is  usually  found 
in  the  small  intestine.  It  is  much  more  frequently  met  with  in  children 
than  is  the  tapeworm.  It  is  exceedingly  rare  in  infancy,  hut  is  usually 
seen  between  the  third  and  tenth  years.  In  over  one  thousand  autopsies 
upon  infants  I  have  only  once  found  a  roundworm  in  the  intestine. 

The  roundworm  resembles  the  ordinary  earthworm;  it  is  from  five 
to  ten  inches  long,  the  female  being  longer  than  the  male.     It  is  of  a 

light  gray  colour  with  a  slightly  pinkish  tint, 
cylindrical,  and  tapering  toward  the  extrem- 
ities (Fig.  67).  The  eggs  are  oval  in  form, 
about  ^^  inch  in  diameter,  and  numbered  by 
millions.  These  worms  rarely  exist  singly; 
usually  from  two  to  ten  are  present,  but  there 
may  be  hundreds.  When  very  numerous  they 
coil  up  and  form  large  masses,  which  may 
cause  intestinal  obstruction. 

The  migration  of  these  worms  is  curious, 
and  in  some  instances  truly  remarkable.  They 
frequently  enter  the  stomach  and  are  vomited. 
Occasionally  one  may  appear  in  the  nose. 
They  have  been  known  to  pass  through  the 
Eustachian  tube  into  the  middle  ear  and  to 
appear  in  the  external  meatus.  Entering  the 
larynx  they  have  produced  fatal  asphyxia.  It 
is  not  very  rare  for  them  to  enter  the  common 
bile  duct  and  produce  jaundice.  They  may  even  enter  in  great  numbers 
the  smaller  bile  ducts  and  produce  hepatic  abscesses.  They  have  been  found 
in  the  pancreatic  duct,  in  the  vermiform  appendix,  and  in  the  splenic 
vein.  It  has  long  been  known  that  they  would  perforate  an  intestine 
which  was  the  seat  of  ulceration,  but  well  authenticated  cases  have  been 
reported  in  which  they  have  perforated  an  intestine  previously  healthy, 
setting  up  a  fatal  peritonitis.  In  Archambault's  case  they  perforated  the 
stomach.  In  cases  of  a  persistent  Meckel's  diverticulum,  worms  have 
been  discharged  from  an  umbilical  fistula.  They  have  been  found  in 
umbilical  abscesses.  Considering,  however,  the  frequency  of  round- 
worms, migrations  are  rare. 

Symptoms. — The  symptoms  of  roundworms  are  of  the  most  in- 
definite kind ;  often  there  are  none  until  the  worm  is  discovered  in  the 
stools.  It  is  then  fair  to  assume  that  other  worms  are  also  present.  The 
most  frequent  abdominal  symptoms  are  colic,  tympanites,  and  other 
symptoms  of  indigestion,  loss  of  appetite,  restless,  disturbed  sleep,  grind- 


FiG.  67. — Ascaris  Lumbri- 
coiDES.  a,  entire  worm; 
b,  head;  c,  eggs.  (Jaksch.) 


INTESTINAL  WORMS.  423 

ing  of  the  teeth  at  night,  and  picking  the  nose.  These  symptoms  are 
much  more  frequently  due  to  other  causes  than  to  worms,  hut  when  all 
are  present  the  existence  of  worms  should  V)e  suspected. 

A  great  variety  of  nervous  symptoms  may  be  associated  with  intes- 
tinal worms.  They  are  more  often  seen  with  lumbricoids  than  with 
either  of  the  other  varieties.  The  SMuptoms  may  be  of  tlie  most  puzzling 
character,  and  may  simulate  very  closely  those  of  serious  organic  dis- 
ease. There  may  be  prolonged  low  fever,  chills,  headache,  vertigo,  hal- 
lucinations, hysterical  seizures,  epileptiform  attacks,  convulsions,  tetany, 
transient  paralyses  such  as  strabismus,  and  even  hemiplegia  and  aphasia. 
All  these  have  been  observed  in  connection  with  intestinal  worms,  and 
from  the  fact  that  the  symptoms  disappeared  completely  after  the  worms 
were  expelled  there  seems  to  be  but  little  doubt  that  they  were  the  cause 
of  the  symptoms.  As  in  the  case  of  the  abdominal  symptoms,  however, 
intestinal  worms  are  only  one  of  the  causes  of  such  nervous  disturbances, 
and  certainly,  not  the  most  frequent;  but  the  possibility  that  nervous 
disturbances  may  depend  upon  worms  should  not  be  overlooked.  The 
blood  generally  shows  eosinophilia,  as  in  patients  with  tapeworm. 

The  only  positive  evidence  of  the  existence  of  roundworms  is  the  dis- 
charge of  a  worm  from  the  body,  or  the  discovery  of  the  ova  in  the  stools. 
A  microscopic  examination  of  the  stools  is  a  valuable  means  of  diagnosis, 
and  one  that  is  too  infrequently  employed.  When  worms  are  present  the 
ova  may  be  found  in  great  numbers.  Their  continued  presence,  after  the 
discharge  of  one  worm,  indicates  that  other  worms  remain. 

Treatment. — Altogether  the  most  efficient  agent  for  the  removal  of 
the  worms  is  santonin.  The  same  plan  of  administration  may  be  fol- 
lowed as  in  the  case  of  the  tapeworm,  viz.,  to  give  the  drug  on  an  empty 
stomach,  preceded  by  a  laxative.  Santonin  is  best  given  in  powdered 
form  mixed  with  sugar.  For  a  child  of  five  years  as  much  as  three  grains 
are  usually  required.  This  amount  should  be  given  in  three  doses  at 
intervals  of  four  hours,  soon  followed  by  a  purge  of  calomel  or  castor  oil. 
Or  one  or  two  grains  of  santonin  may  be  given  with  half  the  amount 
of  calomel  every  other  night  for  three  or  four  nights.  The  great  dif- 
ficulty with  santonin  is  its  tendency  to  provoke  vomiting.  Occasionally 
in  susceptible  children,  even  with  ordinary  doses,  toxic  symptoms  may 
develop,  such  as  yellow  vision,  dark  red  or  yellow  urine,  and  nervous 
excitement  or  delirium. 

OxYCRis  Vermiculakis — PiNWORM — THREADWORM. — The  oxyuris 
(Fig.  68)  resembles  a  short  piece  of  white  thread.  The  female  is 
about  one-third  of  an  inch  long,  the  male  about  one-half  that  length, 
but  is  less  frequently  seen.  The  worm  tapers  toward  the  tail.  The  ova 
are  of  slightly  irregular  size,  and  are  considerably  smaller  than  those  of 
the  roundworm. 

The  oxyuris  inhabits  the  rectum,  the  caecum,  and,  according  to  Still, 


424 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


i 


very  frequently  the  appendix.  These  worms  may  be  found  also  in  the 
lower  small  intestine,  in  the  stomach,  and  even  in  the  mouth.  If  present 
in  the  rectum  tliey  are  usually  discovered  by  separating  the  folds  of  the 
anus.     The  number  of  worms  is  usually  large.    The  irritation  to  which 

they  give  rise  causes  a  great  pro- 
duction of  mucus,  and  frequently 
leads  to  a  chronic  catarrli  of  the 
colon  of  considerable  severity.  The 
worms  are  imbedded  in  the  nm- 
cus ;  often  they  form  with  it  small 
balls.  According  to  Leuckart,  they 
are  incapable  of  multiplying  in 
situ.  Doubt  has  recently  been 
thrown  upon  this  view  by  the  ob- 
servations of  Still.  From  the  im- 
mature character  and  the  large 
numbers  of  the  worms  found  in 
the  appendix  (111  in  one  case), 
this  writer  believes  that  the  ap- 
pendix may  be  a  breeding  place. 
The  ova  as  well  as  the  worms  are 
passed  in  enormous  numbers  with 
the  stools.  They  attach  themselves 
to  the  folds  of  the  skin,  the  hairs  about  the  anus,  and  even  to  the  genitals. 
The  patient  may,  through  lack  of  cleanliness  of  the  parts,  continually 
re-infect  himself.  After  discharge  from  the  body,  the  ova  may  be 
carried  by  flies  and  deposited  upon  fruits,  vegetables,  or  in  drinking 
water. 

Symptoms. — The  principal  local  symptom  caused  by  the  oxyuris  is 
itching  of  the  anus  or  the  genitals.  This  is  caused  by  the  migration  of 
the  worms  from  the  bowel,  and  usually  comes  on  at  about  the  same  hour 
at  night,  generally  soon  after  the  patient  has  retired.  It  is  sometimes  so 
intense  as  to  be  almost  intolerable.  It  leads  to  frequent  micturition,  to 
incontinence  of  urine,  in  the  male  to  balanitis,  and  in  the  female  to 
vaginitis  or  vulvitis,  and  in  both,  but  especially  in  the  latter,  it  may  be 
the  cause  of  masturbation.  Owing  to  the  catarrhal  colitis  which  is  ex- 
cited, there  is  discharged  from  time  to  time  a  large  quantity  of  mucus. 
Severe  colicky  pains  are  often  associated.  The  irritation  may  lead  to 
prolapsus  ani.  Nervous  symptoms  are  not  so  frequently  associated 
as  with  the  other  varieties  of  worms,  although  I  have  seen  at  least 
one  case  of  chorea  in  which  they  were  almost  certainly  the  cause.  They 
have  been  known  to  excite  convulsions.  The  general  health  is  some- 
times undermined  and  there  may  be  marked  and  progressive  loss  in 
weight. 


Fig.  68. — Pinworms.  «,  head;  b,  female;  c, 
male;  e,  female  and  male,  natural  size; 
d,  ova.     (Jaksch.) 


INTESTINAL   WORMS.  425 

Treatment. — This  is  usually  spoken  of  as  a  very  simple  matter,  and 
no  doubt  in  recent  cases,  or  where  the  number  of  worms  is  small,  this  is 
true;  but  where  the  number  is  large,  and  considerable  catarrhal  inflam- 
mation of  the  colon  is  present,  it  is  often  a  matter  of  the  greatest  dif- 
ficulty to  rid  the  bowel  of  these  parasites.  Cases  frequently  resist  treat- 
ment by  injection  for  months,  even  though  thoroughly  used.  The  reason 
for  this  is,  that  only  the  lower  colon  is  reached  by  injections  while  the 
worms  may  be  chiefly  in  the  caecum  and  even  in  the  appendix  and  small 
intestine.  While,  therefore,  injections  are  important  and  indeed  invalu- 
able, they  can  not  be  relied  upon  exclusively.  Tlic  most  scrupulous  atten- 
tion to  cleanliness  is  an  absolute  necessity  as  the  first  step  in  the  treatment 
of  all  cases.  It  is  well  to  bathe  the  parts  about  the  anus  after  each  stool, 
and  even  two  or  three  times  a  day,  witli  a  bichloride  solution,  1  to  10,000. 
Itching  is  best  controlled  by  the  application  of  mercurial  ointment  to  the 
folds  of  the  anus  at  bedtime,  this  effectually  preventing  the  escape  of  the 
worms  from  the  bowel.  The  local  application  of  cold  will  sometimes 
have  the  same  effect.  The  most  efficient  of  the  injections  is  probably 
the  bichloride.  The  colon  should  first  be  thoroughly  cleansed  by  an 
injection  of  lukewarm  water  containing  one  teaspoonful  of  borax  to  the 
pint,  in  order  to  remove  the  mucus.  When  this  has  been  discharged,  half 
a  pint  of  the  bichloride  solution  of  the  strength  mentioned  should  be 
injected  high  into  the  bowel  through  a  catheter,  and  retained  as  long 
as  possible.  This  should  be  repeated  every  second  or  third  night.  On 
other  nights  a  simple  saline  injection  may  be  employed.  The  infusion  of 
quassia,  asafcetida,  aloes,  and  garlic  are  also  useful.  Solutions  of  car- 
bolic acid  should  never  be  employed. 

When  the  worms  are  high  in  the  colon,  drugs  by  the  mouth  must 
be  combined  with  injections.  Probably  the  most  efficient  remedy  is 
santonin,  which  may  be  used  as  for  roundworms.  The  expulsion  of  the 
worms  is  aided  by  saline  cathartics;  simple  bitters,  such  as  gentian  and 
quassia,  are  also  of  some  value.  I  have  known  one  case,  which  resisted 
for  over  two  years  everything  which  had  been  tried,  to  be  cured  in 
two  or  three  weeks  by  injections  of  a  decoction  of  garlic,  in  connection 
with  which  garlic  was  given  in  liberal  quantities  by  the  mouth. 

Uncinaria  Americana  or  Hookworm. — This  belongs  to  the  class 
of  nematodes.  The  males  are  one-fourth  to  one-half  inch  in  length  and 
the  females  slightly  longer.  The  parasite  resembles  the  ankylostomum 
duodenale  of  Europe.  Infection  usually  takes  place  through  the  skin 
of  the  bare  feet,  more  rarely  that  of  the  hands.  It  is.  possible,  however, 
to  contract  the  disease  by  eating  dirty  fruit  or  vegetables  contaminated 
by  the  developing  larvae;  but  infection  does  not  occur  from  swallowing 
the  ova  or  young  larvae.  After  entering  the  skin  the  larvae  find  their  way 
into  the  circulation  and  thus  reach  the  lungs.  From  the  lungs  they  may 
migrate  or  be  coughed  up  into  the  mouth  and  then  swallowed.     They 


426  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

are  not  acted  upon  by  the  gastro-intestinal  secretions,  and  in  the  upper 
part  of  the  small  intestine  they  develop  into  mature  worms.  These  may 
exist  in  the  small  intestine  for  years. 

The  symptoms  in  the  milder  cases  are  minor  digestive  disturbances, 
general  malnutrition  with  moderate  anaemia  and  arrested  growth.  In 
the  more  severe  cases  the  anaemia  is  very  marked,  the  haemoglobin  often 
falling  to  thirty  per  cent  or  below.  The  leucocytes  are  normal  in  num- 
ber or  slightly  increased;  but  the  percentage  of  eosinophiles  is  above  the 
normal.  Usually  the  proportion  reaches  five  or  ten  per  cent;  it  may 
however  be  twenty-five  per  cent  or  even  higher.  (Edema  of  the  face  is 
common  and  there  may  be  general  dropsy  without  albuminuria.  Af- 
fected children  besides  being  very  backward  in  physical  development,  are 
dull,  inattentive  and  entirely  wanting  in  physical  or  mental  energy. 
The  appetite  is  sometimes  absent;  but  more  characteristic  is  the  crav- 
ing, not  only  for  every  kind  of  food,  but  for  such  articles  as  clay,  dirt, 
chalk,  etc.  Death  may  be  due  to  a  progressive  failure  of  nutrition  or  to 
intercurrent  disease. 

Prophylaxis  in  the  individual  consists  chiefly  in  the  protection  of  the 
feet  of  persons  living  in  an  infected  district,  by  wearing  shoes.  The 
chief  remedy  for  the  hookworm  is  thymol.  Its  administration  should  be 
preceded  by  one  or  more  full  doses  of  the  sulphate  of  magnesia  or  soda 
given  upon  a  fasting  stomach.  The  quantity  of  thymol  given  to  a  child 
of  five  years  should  be  six  or  eight  grains  in  divided  doses  in  the  course 
of  three  or  four  hours.  It  may  be  administered  either  in  capsule  or  in 
suspension.  Two  hours  after  the  last  dose,  the  salts  should  be  repeated; 
but  no  food  should  be  given  until  the  cathartic  has  acted  freely.  Castor 
oil  should  not  be  used.  A  repetition  of  the  treatment  is  often  necessary 
before  a  cure  is  accomplished. 


CHAPTER    X. 
DISEASES  OF  THE  RECTUM. 

PROLAPSUS  ANI. 

Under  this  term  are  included  two  conditions.  In  the  first,  or  partial 
prolapse,  there  is  simply  an  eversion  of  the  mucous  membrane  which 
protrudes  beyond  the  sphincter.  In  the  second,  or  complete  prolapse, 
there  is  invagination  of  the  rectal  wall  for  a  variable  distance,  usually 
two  or  three  inches. 

Etiology. — Prolapse  is  most  common  in  children  during  the  sec- 
ond and  third  years.  Its  frequency  in  early  life  is  partly  due  to  the  lack 
of  support  furnished  by  the  levator-ani  muscles.     It  also  occurs  very 


PROLAPSUS  ANI. 


427 


readily  when  the  ischio-rectal  fat  is  scanty;  it  is  therefore  often  seen  in 
children  suffering  from  marasmus.  Tlie  exciting  cause  may  be  anything 
which  provokes  severe  and  prolonged  straining.  This  may  be  either  the 
tenesmus  accompanying  inflammation  of  the  rectal  mucous  membrane 
or  chronic  constipation.  It  may  come  from  phimosis  or  stricture  of  the 
urethra,  and  it  is  a  very  frequent  symptom  of  stone  in  the  bladder. 

Symptoms. — Prolapse  usually  occurs  during  the  act  of  defecation.  It 
is  generally  easily  reduced,  but  shows  a  great  disposition  to  return  with 
every  stool.  In  obstinate  cases  the  bowel  comes  down  at  other  times. 
The  appearance  of  the  tumour  varies  with  its  size.  In  the  slighter  form 
there  is  simply  a  ring  composed  of  a  fold  of  mucous  membrane  sur- 
rounding the  anus.  In  the  more  severe  form  there  is  a  flattened,  corru- 
gated tumour,  usually  about  the  size  of  a  small  tomato  (Fig.  69).     The 


Fig.  69. — Prolapsus  Ani. 


mucous  membrane  covering  the  tumour  is  of  a  deep  purplish-red  colour, 
and  bleeds  readily.  It  may  be  the  seat  of  catarrhal  or  membranous  in- 
flammation. The  diagnosis  in  most  cases  is  easy,  although  the  tumour 
has  been  confounded  with  polypus  and  intussusception. 

Treatment. — In  most  cases  reduction  is  easily  accomplished  by  laying 
the  child  upon  its  face  across  the  lap,  and  making  gentle  pressure  upon 
the  tumour  with  oiled  fingers.  The  application  of  cold,  either  by  means 
of  ice  or  cold  cloths,  is  of  assistance  in  cases  which  are  not  at  once  re- 
duced by  pressure.  After  reduction,  in  the  milder  cases  the  child  should 
be  kept  upon  its  back  for  at  least  an  hour.  When  the  tumour  tends  to 
come  down  with  every  stool,  special  attention  should  be  given  at  this 
time.  If  an  infant,  the  bowels  should  always  move  while  the  child  lies 
upon  his  back,  and  during  defecation  the  buttocks  should  be  pressed  to- 
gether by  a  nurse.    Older  children  should  use  an  inclined  seat  placed  at 


428  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

an  angle  of  about  forty-five  degrees,  but  should  never  sit  upon  a  low 
chair  or  assume  any  position  in  which  straining  is  easy.  After  defecation 
the  patient  should  lie  down  for  at  least  half  an  hour.  Where  there  is 
constipation,  the  bowels  should  be  kept  free  by  means  of  laxatives.  If 
there  is  a  diarrhoea,  tenesmus  may  be  overcome  by  frequent  sponging 
with  ice  water,  or  by  the  use  of  small  injections  of  ice  water  and  tannic 
acid,  in  the  proportion  of  twenty  grains  to  the  ounce.  In  more  severe 
cases  it  may  be  controlled  by  the  use  of  suppositories  of  opium.  When 
the  bowel  tends  to  come  down  frequently,  this  may  be  prevented  by  the 
use  of  an  adhesive  strap  two  or  three  inches  wide,  placed  tightly  across 
the  buttocks.  This  is  better  in  the  milder  cases  than  a  T-bandage.  The 
great  majority  of  the  cases  are  cured  by  these  means  in  the  course  of  a 
few  weeks. 

In  the  most  severe  cases  the  bowel  not  only  protrudes  during  defeca- 
tion, but  also  in  the  interval,  and  it  may  be  down  for  days  at  a  time. 
Such  cases  are  rarely  seen  except  in  infants  who  have  very  flabby  muscles, 
and  but  little  adipose  tissue  at  the  floor  of  the  pelvis.  Eeduction  is 
sometimes  difficult  in  cases  when  the  prolapse  has  lasted  a  long  time.  It 
is  often  facilitated  by  painting  the  protruding  part  with  a  two-per-cent 
solution  of  cocaine,  and  then  dilating  the  sphincter  by  passing  the  finger 
into  the  central  opening  of  the  tumour.  After  reduction,  suppositories 
containing  from  one-fourth  to  one  grain  of  cocaine  may  be  inserted. 
They  are  more  efficient  than  those  containing  opium  or  belladonna.  A 
firm  pad  should  be  applied  over  the  anus,  held  in  position  by  a  T-bandage. 
For  several  days  at  a  time  a  short  rubber  tube  may  be  kept  in  the  rec- 
tum, held  in  place  by  adhesive  plaster.  The  bowels  should  be  kept  freely 
open.  Where  all  other  measures  fail,  the  protruding  part  may  be 
touched  with  the  Paquelin  cautery,  linear  markings  being  made  at  in- 
tervals of  an  inch.    Amputation  or  excision  is  not  required  in  children. 

FISSURE  OF  THE  ANUS. 

This  is  not  a  very  uncommon  condition  in  children.  The  most  fre- 
quent cause  is  the  passage  of  a  large,  hard,  faecal  mass.  Sometimes  it 
results  from  traumatism  inflicted  with  the  nozzle  of  a  syringe  while 
giving  an  enema.  It  may  be  produced  by  the  scratching  excited  by  pin- 
worms.  In  the  beginning  there  is  a  simple  tear  at  the  margin  of  the 
anus-  The  laceration  which  is  produced  usually  heals  promptly;  but  if 
the  cause  is  repeated,  healing  is  prevented,  and  there  is  finally  produced 
a  linear  ulcer,  or  a  true  fissure,  which  may  last  for  some  time  and  be  a 
source  of  great  annoyance. 

A  fresh  fissure  has  the  appearance  of  any  other  tear  at  a  muco-cuta- 
neous  orifice.  One  of  longer  standing  has  a  gray  base,  slightly  indurated 
edges,  often  discharges  a  small  amount  of  pus,  and  bleeds  a  drop  or  two 


PROCTITIS.  429 

with  nearly  every  movement  of  the  bowels.  The  most  constant  symptom 
is  pain,  whch  usually  occurs  with  the  act  of  defecation,  and  continues  for 
some  time  afterward.  It  is  most  severe  when  the  fissure  is  just  at  the 
margin  of  the  sphincter,  and  leads  the  child  to  resist  every  inclination  to 
have  the  bowels  move,  so  that  it  becomes  a  cause  of  chronic  constipation, 
which  condition  again  greatly  aggravates  the  fissure.  The  pain  is  often 
referred  to  other  parts  in  the  neighbourhood. 

The  treatment  is  simple  and  usually  efficient.  It  consists  in  clean- 
liness, overcoming  the  constipation,  and  touching  the  fissure  with  nitrate 
of  silver,  preferably  with  the  solid  stick.  If  the  case  is  not  speedily  re- 
lieved by  such  measures,  the  sphincter  should  be  stretched  as  in  adult 
patients. 

PROCTITIS. 

Proctitis,  or  inflammation  of  the  rectum,  usually  occurs  with  inflam- 
mation of  the  rest  of  the  large  intestine,  but  it  may  occur  alone.  It  is 
to  the  cases  in  which  only  the  rectum  is  involved  that  the  term  is  gen- 
erally applied. 

The  causes  are  for  the  most  part  local.  A  frequent  one  in  infants 
is  the  use  of  irritating  injections  or  suppositories,  either  for  the  relief  of 
constipation  or  as  a  means  of  administering  certain  drugs.  I  have  seen 
one  obstinate  case  in  an  infant  a  year  old,  following  the  prolonged  use  of 
glycerin  suppositories.  It  is  sometimes  caused  by  traumatism,  especially 
by  the  careless  giving  of  an  enema.  It  accompanies  pinworms.  In 
certain  cases  it  may  result  from  direct  infection  through  the  anus.  This 
may  be  from  a  gonococcus  inflammation  extending  from  the  vagina  or 
urethra,  or  from  an  infection  due  to  other  bacteria,  particularly  in  cases 
of  measles,  scarlet  fever,  and  diphtheria;  or,  finally,  it  may  be  due  to 
syphilis.  The  varieties  of  inflammation  are  the  same  as  in  the  rest  of  the 
intestine.    Proctitis  may  thus  be  catarrhal,  membranous,  or  ulcerative. 

Catarrhal  Proctitis. — The  pathological  conditions  are  the  same  as  in 
ordinary  catarrhal  inflammation  of  the  intestinal  mucous  membrane.  By 
the  introduction  of  a  speculum,  or  by  simply  everting  the  mucous  mem- 
brane, it  is  seen  to  be  reddened,  swollen,  and  bleeds  easily.  There  is  a 
copious  secretion  of  mucus.  In  cases  of  long  standing  there  may  be 
superficial  ulceration  appearing  as  a  white  or  yellowish-white  surface, 
usually  just  inside  the  sphincter. 

The  symptoms  are  chiefly  local,  although  a  condition  of  general  irrita- 
bility may  result  from  the  local  condition.  There  is  heightened  reflex 
action,  so  that  the  stool  often  comes  with  a  squirt.  There  is  pain  with 
defecation,  and  mucus  is  discharged,  usually  as  a  clear,  jelly-like  mass, 
and  sometimes  in  the  form  of  a  cast,  but  not  generally  mixed  with  the 
stool.  There  are  usually  traces  of  blood,  sometimes  quite  large  haemor- 
rhages.    In  the  most  acute  cases,  tenesmus  is  present  both  during  and 


430  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

after  the  stool.  There  may  be  prolapsus  ani.  The  skin  in  the  vicinity  is 
irritated  by  the  discharges,  most  frequently  so  in  infants.  If  the  cause 
is  pinworms,  there  may  be  intense  itching.  The  duration  of  the  disease 
is  indefinite,  depending  upon  the  cause.  It  may  be  a  few  days  or  many 
months.  The  inflammation  may  extend  from  the  rectum  to  neighbouring 
parts,  leading  to  ischio-rectal  abscess. 

Membranous  Proctitis. — It  has  been  customary  to  describe  this  as  a 
complication  of  diphtheria,  usually  occurring  with  diphtheria  of  the  ex- 
ternal genitals.  As  very  few  of  these  cases  have  been  studied  bacteriolog- 
ically,  it  is  impossible  to  say  what  proportion  of  them,  if  any,  are  to  be 
regarded  as  true  diphtheria.  It  is  probable  that  the  great  majority  are 
due  to  infection  by  streptococci.  When  the  infection  is  from  the  intes- 
tine above,  the  rectum  is  never  affected  alone.  When  it  is  from  below, 
this  may  be  the  case.  The  lesions  are  the  same  as  in  membranous  in- 
flammation occurring  higher  in  the  colon.  The  symptoms  resemble  those 
of  the  catarrhal  variety,  with  the  addition  that  the  stools  contain  pieces 
of  pseudo-membrane.  This  can  be  made  out  only  by  repeatedly  washing 
the  discharges  with  water.  If  accompanied  by  prolapse,  the  pseudo- 
membrane  may  be  seen.  Membranous  proctitis  may  be  complicated  by 
a  membranous  inflammation  of  the  genitals  or  the  perinaeum.  Although 
it  is  usually  acute,  it  may  last  for  weeks. 

Ulcerative  Proctitis. — Ulcers  of  the  rectum  may  be  the  result  of  a 
catarrhal  inflammation;  these,  however,  are  usually  superficial,  affecting 
the  mucous  membrane  only,  and  in  most  cases  heal  rapidly.  Sometimes 
they  extend  more  deeply  into  the  submucous  or  even  the  muscular  coat. 
They  are  then  chronic,  often  very  obstinate,  and  may  last  indefinitely. 
Follicular  ulcers  of  the  rectum  are  nearly  always  associated  with  the 
same  condition  in  the  sigmoid  flexure.  These  are  always  multiple  and 
usually  small,  rarely  being  more  than  a  quarter  of  an  inch  in  diameter. 
Sometimes  the  small  ones  coalesce,  producing  much  larger  ulcers.  Mem- 
branous proctitis  is  rarely  followed  by  ulceration,  although  this  is  a 
possible  result  where  sloughing  has  occurred.  Single  ulcers  may  be  of 
tuberculous  origin.  Steffen  reports  two  cases  of  tuberculous  ulcer  of  the 
rectum  in  children  of  seven  months  and  three  years  respectively.  I  have, 
in  a  young  infant,  seen  one  such  ulcer,  which  was  fully  three-fourths  of 
an  inch  in  diameter,  and  was  not  associated  with  other  tuberculous  dis- 
ease of  the  large  intestine.  Syphilitic  ulcers  are  extremely  rare  in 
children. 

The  symptoms  of  ulcer  of  the  rectum  are  mainly  two — pain  and  haem- 
orrhage. The  pain  is  of  variable  intensity,  and  may  be  referred  to  the 
coccyx,  or  to  any  of  the  neighbouring  parts.  The  amount  of  bleeding 
may  be  small,  the  blood  coming  in  clots,  or  it  may  be  fluid  and  in  so 
large  a  quantity  as  to  produce  general  symptoms.  It  usually  accom- 
panies every  stool.    In  addition  the  stool  contains  more  or  less  pus,  par- 


ISCHIO-RECTAL  ABSCESS.  431 

ticularly  in  chronic  cases.  When  the  ulcer  is  low  down,  tenesmus  is 
present  and  may  be  a  prominent  symptom.  A  positive  diagnosis  of  ulcer 
can  be  made  only  by  examination  with  a  speculum. 

Treatment. — In  cases  of  acute  catarrhal  proctitis  injections  of  some 
bland  fluid  should  be  employed,  such  as  a  starch-water,  limewater,  a  mix- 
ture of  oil  and  limewater,  or  a  warm  one-per-cent  saline  solution.  The 
local  cause,  if  one  exists,  should  be  removed.  The  disordered  diges- 
tion, when  present,  is  to  be  treated  according  to  its  special  symptoms. 
In  the  most  acute  cases  the  patient  should  be  kept  in  bed.  When  the 
tenesmus  is  severe,  suppositories  of  opium  may  be  used.  In  the  more 
chronic  cases  saline  injections  should  be  given,  and  followed  by  a  mild 
astringent  like  tannic  acid,  ten  grains  to  the  ounce,  or  a  one-per-cent 
solution  of  hamamelis.  Cases  associated  with  pinworms  are  especially 
obstinate.  Here  the  treatment  is  first  to  be  directed  to  the  worms,  and 
afterward  to  the  proctitis. 

In  the  membranous  cases  the  same  measures  are  to  be  employed,  and 
in  addition  the  injection  of  a  warm  boric-acid  solution  two  or  three 
times  a  day. 

Cases  of  ulcer  require  the  most  careful  treatment.  In  many  there  is 
but  little  tendency  to  spontaneous  recovery.  An  examination  with  the 
speculum  should  be  insisted  upon  in  all  cases  of  chronic  proctitis,  to 
make  sure  of  the  diagnosis.  Eest  in  bed  is  essential  to  a  rapid  improve- 
ment. The  patient  should  be  put  upon  a  bland  diet,  especially  of  milk, 
and  the  bowels  kept  freely  open  by  the  use  of  laxatives,  and  injections 
twice  a  day  of  a  saturated  boric-acid  solution.  Locally  there  should  be 
applied  a  solution  of  nitrate  of  silver,  one  grain  to  the  ounce,  the  bowel 
having  previously  been  washed  with  tepid  water.  If  a  stronger  solution 
than  this  is  used,  it  should  be  neutralised  after  half  a  minute  by  the 
injection  of  a  salt  solution. 

ISCHIO-RECTAL  ABSCESS. 

This  is  not  a  very  rare  condition  even  in  infancy.  Infection  from  the 
rectum,  usually  through  the  lymph  channels,  seems  to  be  the  most  com- 
mon cause,  although  sometimes  the  abscess  may  be  traced  directly  to  trau- 
matism. In  a  single  year  I  have  seen  six  such  cases.  All  but  two  were 
small,  circumscribed  abscesses,  and  quite  superficial,  apparently  starting 
as  an  acute  inflammation  of  the  lymph  glands  of  the  region.  They  are 
analogous  to  a  similar  process  in  the  lymph  glands  of  the  neck,  seen  in 
infancy.  These  cases  healed  promptly  after  incision.  In  other  instances 
there  is  seen  a  disposition  to  burrow,  as  in  adults.  Only  once  have  I  met 
with  diffuse  suppuration  in  the  ischio-rectal  region,  terminating  in 
sloughing  and  death,  and  this  was  in  an  infant  only  three  months  old. 

Essentially  the  same  varieties  of  inflammation  are  seen  in  early  life  as 


432  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

in  adults.     Most  of  these  cases  recover  promptly  after  simple  incision 
and  cleanliness,  fistula  being  a  rare  sequel. 

RECTAL  POLYPUS. 

Polypi  are  rarely  seen  in  children,  but,  when  present,  may  be  the 
cause  of  rather  obscure  symptoms.  The  most  important  one  is  haemor- 
rhage. This  at  first  occurs  at  intervals  of  days  or  weeks.  The  amount 
of  blood  lost  is  from  a  drachm  to  an  ounce  or  more.  Later,  the  haemor- 
rhages become  more  frequent  and  may  be  almost  continuous,  although 
rarely  profuse  enough  to  produce  serious  symptoms.  The  diagnosis  of 
polypus  is  made  only  after  a  local  examination.  Sometimes  the  tumoura 
are  within  the  reach  of  the  finger;  in  other  cases  a  proctoscope  must  be 
employed.  Spontaneous  cure  often  takes  place  by  the  sloughing  of  the 
tumour,  after  which  the  bleeding  soon  ceases.  In  other  cases  operation 
is  necessary. 

HiEMORRHOIDS. 

These,  fortunately,  are  not  often  seen  in  children,  although  they  occur 
in  those  as  young  as  three  or  four  years,  and  in  some  cases  may  even  be 
congenital.  The  principal  cause  is  chronic  constipation,  rarely  diarrhoea. 
The  tumours  are  generally  small  and  external,  the  chief  symptom  com- 
plained of  being  pain  on  defecation.  Bleeding  sometimes  accompanies 
the  pain,  but  the  haemorrhages  are  usually  small.  The  treatment  is  to  be 
directed  toward  the  underlying  cause.  In  most  of  the  cases  this  suffices 
to  cure  the  condition.  I  have  rarely  seen  in  a  young  child  a  case  requir- 
ing operation,  although  neglect  may  make  this  procedure  necessary. 

INCONTINENCE  OF  F^CES. 

Inability  to  control  the  fa?cal  evacuations  is  seen  in  certain  cases  of 
paraplegia  due  to  myelitis,  in  injury  of  the  lumbar  portion  of  the  spinal 
cord,  and  in  spina  bifida.  It  is  also  seen  in  acute  disease,  as  in  the  coma 
of  meningitis,  and  occasionally  in  the  typhoid  condition  and  in  extreme 
adynamia,  from  any  cause.  It  is  quite  common  in  severe  attacks  of 
chorea.  In  all  these  conditions  incontinence  of  faeces  is  a  symptom  giv- 
ing rise  to  much  annoyance  and  needing  careful  attention.  Uncleanli- 
ness  with  reference  to  excreta,  seen  in  idiocy,  can  hardly  be  classed  as 
incontinence. 

Besides  these  familiar  forms,  the  condition  is  sometimes  seen  from 
causes  somewhat  resembling  those  of  incontinence  of  urine.  The  tone 
of  the  sphincter  becomes  so  feeble  that  it  does  not  resist  even  the  slight- 
est impulse  to  evacuate  the  rectum.  The  discharge  may  take  place  with 
but  little  warning,  and  may  occur  either  by  day  or  night.  In  some  cases 
a  local  cause  exists,  such  as  stretching  of  the  sphincter  by  an  old  rectal 


DISEASES  OF  THE   LIVER. 


433 


prolapse.  It  has  followed  overdistention  of  the  rectum  from  prolonged 
chronic  constipation.  Ostheimer  reports  a  case  in  which  a  vesical  cal- 
culus was  present.  It  is  sometimes  seen  after  severe  acute  illness,  as  a 
result  of  a  loss  of  general  muscular  tone.  In  certain  children  it  has  been 
known  to  persist  from  infancy  until  the  age  of  ten  or  twelve  years.  It 
may  come  on  as  a  somewhat  acute  condition  in  highly  nervous  patients 
with  poor  general  nutrition.  The  causes  are  chiefly  of  local  and  nervous 
origin.  The  treatment  is  rather  unsatisfactory,  except  in  recent  cases 
and  in  those  due  to  local  causes  which  can  be  removed.  If  constipation 
exists  the  rectum  should  be  emptied  daily,  preferably  by  an  enema. 
The  remedies  which  have  proven  most  successful  are  strychnia,  ergot, 
and  belladonna,  but  they  must  be  given  in  full  doses,  sometimes  advan- 
tageously by  suppository  as  well  as  by  mouth.  The  general  health  should 
receive  careful  attention. 


CHAPTER    XI. 


DISEASES  OF  THE  LIVER. 


Aside  from  the  different  forms  of  degeneration  which  are  seen  in  the 
various  infectious  diseases,  the  liver  is  not  often  the  seat  of  serious  dis- 
ease in  infancy  and  early  childhood.  In  later  childhood  nearly  all  the 
forms  seen  in  adult  life  are  occasionally  met  with,  although  even  then 
they  are  quite  rare. 

Size  and  Position. — The  weight  of  the  liver  in  the  newly-born  child, 
from  one  hundred  and  seven  observations  of  Birch-Hirschfeld,  is  4,5 
ounces  (127  grammes),  or  about  4.2  per  cent  of  the  body  weight.  The 
following  table  gives  the  results  of  one  hundred  and  seventy-four  ob- 
servations upon  the  liver  in  infancy  in  the  autopsy  room  of  the  New 
York  Infant  Asylum : 


Average. 

Per  cent  of 

Ounces. 

Grammes. 

body  weight. 

3  months 

6.3 

7.5 

11.0 

14.0 

16.0 

180 
212 
311 
397 
453 

3.1 

6        "       

3.0 

12        "       

3.40 

2  years 

3.37 

3      "     

3.26 

In  adults,  according  to  Frerichs,  the  weight  of  the  liver  is  about  2 . 5 
per  cent  of  the  weight  of  the  body. 

The  upper  border  of  the  liver  is  best  made  out  by  percussion.  In  the 
child,  the  upper  limit  of  the  liver  dulness  in  the  mammary  line  is  found 
29 


434  DISEASES  OF  THE   DIGESTI\T  SYSTEM. 

in  the  fifth  intercostal  space;  in  the  axillary  line,  in  the  seventh  space; 
posteriorly,  in  the  ninth  space.  The  lower  border  is  best  determined  by 
palpation.  This,  as  a  rule,  in  the  mammary  line  is  found  about  one-half 
an  inch  below  the  free  border  of  the  ribs.  According  to  Steffen,  the  left 
lobe  is  relatively  larger  in  the  child  than  in  the  adult.  The  liver  may  be 
displaced  downward  by  contraction  of  the  chest,  as  in  rickets,  or  by  an 
accumulation  of  fluid  in  the  pleural  cavity.  It  is  frequently  found  lower 
than  normal  in  conditions  of  great  emaciation,  owing  to  relaxation  of  the 
abdominal  walls  and  its  ligamentous  supports.  Upward  displacement  is 
much  less  frequent,  and  depends  usually  upon  ascites  or  abdominal 
tumours. 

Malformations  and  Malpositions. — Congenital  malformations  relate 
chiefly  to  the  bile  ducts.  These  have  been  considered  in  the  chapter  de- 
voted to  Icterus  in  the  Newly  Born. 

The  liver  may  be  found  upon  the  left  side  in  cases  of  general  trans- 
position of  the  viscera.  In  diaphragmatic  hernia  it  has  been  found  in 
the  thoracic  cavity. 

CHRONIC  FAMILY  JAUNDICE. 

This  disease  is  usually  hereditary,  but  it  occasionally  exists  in  sev- 
eral brothers  and  sisters,  the  parents  being  unaffected.  Similar  cases  may 
be  seen  without  a  family  association.  There  are  records  of  many  fami- 
lies in  which  jaundice  has  existed  through  three  or  four  generations. 
It  is  transmitted  alike  through  the  male  and  female  descendants,  and  not 
all  of  the  children  in  a  family  are  affected.  The  descendants  of  unaf- 
fected members  escape.  The  jaundice  may  be  noticed  shortly  after 
birth,  or  it  may  develop  at  any  time  during  childhood,  sometimes  not 
until  later.  This  is  the  most  striking  feature  of  the  disease.  The  dis- 
colouration may  be  very  slight  and  noticeable  only  in  the  sclerotics,  or 
the  skin  may  be  icteric.  The  colour  is  never  very  intense.  It  varies 
somewhat  in  degree  and  is  increased  after  intercurrent  gastro-intestinal 
attacks,  which  are  rather  frequent.  When  once  developed,  the  icterus 
never  entirely  disappears. 

This  jaundice  is  not  obstructive;  the  stools  are  usually  darker  than 
normal  and  the  urine  contains  urobilin  in  excess,  but  no  bile.  There 
is  an  increased  production  of  biliary  pigment.  The  liver  is  normal  or 
slightly  enlarged.  The  spleen  is  regularly,  and  often  excessively,  en- 
larged, and  even  in  youth  there  may  be  attacks,  of  biliary  colic  and  of 
perisplenitis.  Anaemia  of  a  moderate  grade  is  the  rule.  Both  the  red 
cells  and  haemoglobin  are  reduced,  and  a  few  nucleated  red  cells  may  be 
found.  Very  characteristic  of  the  disease  is  the  increased  fragility  of 
the  red  cells  to  haemolytic  agents,  especially  to  hypotonic  salt  solutions. 

The  growth  and  development  of  children  go  on  uninfluenced  by  the 


CATARRHAL  JAUNDICE.  435 

condition,  and  many  affected  persons  have  lived  to  an  advanced  age. 
There  are  no  characteristic  post-mortem  findings,  and  the  disease  is  un- 
influenced by  treatment.^ 

CATARRHAL  JAUNDICE. 

This  is  due  to  a  catarrhal  inflammation  of  the  common  bile  duct 
with  which  there  is  usually  associated  a  similar  inflammation  of  the 
duodenum  and  sometimes  of  the  stomach  also.  The  term  gastro- 
duodenitis  is  sometimes  used  synonymously  with  catarrhal  jaundice. 
The  jaundice  in  these  cases  is  due  to  obstruction  which  is  caused  by 
swelling  of  the  mucous  membrane  of  the  bile  duct.  Catarrhal  jaundice 
is  rare  in  infancy.  I  have  never  seen  it  in  a  child  under  two  years  old. 
In  children  from  three  to  six  years  it  is  not  uncommon,  and  curiously 
occurs  much  more  frequently  in  the  fall  months.  This  suggests  an 
infectious  origin.     For  the  most  part  its  causes  are  obscure. 

It  occasionally  complicates  malarial  fever.  I  have  seen  it  several 
times  with  influenza,  and  it  may  occur  with  any  of  the  infectious  dis- 
eases.   Eehn  has  described  a  form  which  occurred  epidemically. 

The  symptoms  of  the  disease  are  quite  uniform.  When  primary,  the 
onset  is  like  an  ordinary  attack  of  indigestion,  with  vomiting,  pain, 
slight  fever,  and  a  moderate  amount  of  prostration.  The  vomiting  in 
some  of  the  cases  is  repeated  for  several  days.  The  pain  may  be  quite 
severe,  and  localised  in  the  region  of  the  duodenum.  It  may  be  asso- 
ciated with  tenderness  in  this  region.  The  bowels  are  usually  consti- 
pated. After  three  or  four  days,  icterus,  which  is  the  only  diagnostic 
symptom,  appears.  It  is  first  seen  in  the  conjunctiva,  afterward  in  the 
skin,  varying  in  degree  according  to  the  severity  of  the  attack,  but  in 
most  cases  not  being  very  intense.  It  is  accompanied  by  the  regular 
symptoms  of  obstructive  jaundice.  The  stools  are  gray,  sometimes  white ; 
there  is  a  marked  amount  of  intestinal  flatulence.  The  urine  is  very 
dark,  of  a  yellowish-green  or  bronze  hue,  and  stains  the  clothing.  There 
is  complete  anorexia ;  the  tongue  is  thickly  coated  with  a  white  fur. 
Headache,  dulness,  and  languor  are  present,  and  the  patient  feels  gen- 
erally wretched.  The  slow  pulse  and  the  itching  skin  are  uncommon 
symptoms  in  children.  The  liver  is  usually  found,  upon  examination, 
slightly  enlarged,  and  sometimes  tender  on  pressure.  The  duration  of 
the  disease  is  about  two  weeks,  the  general  symptoms  disappearing  be- 
fore the  icterus.    Eecurrences  and  prolonged  attacks  are  occasionally  seen. 

The  diagnosis  rarely  presents  any  difficulty,  and  the  prognosis  is 
invariably  good. 

Treatment.— In  the  diet,  fats  and  starches  should  be  reduced  to  a 
low  point  or  be  entirely  prohibited.     Patients  usually  do  much  better 

1  Tileston  and  Griffin,  American  Journal  of  the  Medical  Sciences,  June,  1910. 


436  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

upon  a  diet  of  rare  meat,  fruit,  and  of  skimmed  milk,  or  buttermilk.  If 
there  is  very  much  vomiting,  the  milk  should  be  largely  diluted  with 
lime-water.  The  amount  of  food  given  should  be  small,  but  water  should 
be  allowed  freely,  particularly  the  mineral  waters.  The  bowels  should  be 
opened  every  other  day  by  calomel,  followed  by  a  saline  purgative.  In 
most  of  the  cases  no  other  treatment  is  necessary.  When  the  pain  is 
severe  it  may  be  relieved  by  counter-irj-itation  by  mustard,  turpentine, 
or  even  cantharides.  The  gastric  symptoms  should  be  managed  as  are 
those  of  ordinary  acute  gastritis.  The  restricted  diet  should  in  all  cases 
be  continued  for  at  least  a  week  after  the  jaundice  has  disappeared. 

FUNCTIONAL  DISORDERS  OF  THE  LIVER. 

Functional  disorders  of  the  liver  are  undoubtedly  exceedingly  com- 
mon in  childhood.  They  are  as  yet  but  little  understood,  and  it  is 
almost  impossible  to  separate  them  from  the  other  symptoms  of  intes- 
tinal indigestion  with  which  they  are  associated.  These  are  described  in 
the  chapter  upon  Chronic  Intestinal  Indigestion.  Some  of  these  symp- 
toms depend  upon  a  diminution  in  the  quantity,  or  the  impoverished 
quality  of  the  biliary  secretion.  There  are  gray  or  white  stools,  flatu- 
lence, and  other  evidences  of  increased  intestinal  putrefaction.  These 
probably  depend  upon  imperfect  absorption  in  consequence  of  the  ab- 
sence of  bile.  The  other  functional  disorders  of  the  liver  relate  to 
its  effect  upon  the  transformation  of  nitrogenous  substances.  The 
nature  of  this  change,  and  the  symptoms  which  result  from  this  dis- 
turbance are  as  yet  but  imperfectly  understood.  It  is  quite  probable  that 
many  of  the  nervous  functional  disorders  of  children — for  example, 
attacks  of  migraine  or  of  cyclic  vomiting — may  depend  upon  such  a  cause. 

NEW  GROWTHS. 

New  growths  of  the  liver  are  rare  in  children  and  are  usually  sec- 
ondary to  deposits  elsewhere,  most  frequently  in  the  kidney.  They  are 
generally  sarcomatous.  Primary  sarcoma  of  the  liver  has,  however,  been 
observed,  and  at  so  early  an  age  as  to  make  it  practically  certain  that 
the  condition  was  a  congenital  one.  A  single  example  of  primary  adeno- 
sarcoma  of  the  liver  has  fallen  under  my  observation.  This  was  in  an 
infant  only  seven  months  old.  In  a  report  of  this  case  I  collected  from  the 
literature  ten  cases  of  sarcoma  of  various  types  in  infants  under  one 
year.*  In  most  of  the  cases  there  is  simply  a  slowly  increasing  abdominal 
tumour  and  progressive  asthenia. 

^Archives  of  Pcediatrics,  April,  1905. 


ABSCESS  OF  THE   LIVER— SUPPURATIVE   HEPATITIS.         437 

ACUTE  YELLOW  ATROPHY. 

This  form  of  hepatic  disease  is  very  rare  in  children.  Greves  has 
reported  a  well-marked  case  in  an  infant  of  twenty  months,  and  has 
collected  seventeen  other  cases  under  ten  years  of  age ;  the  youngest  was 
in  an  infant  three  months  old.  The  symptoms  and  course  of  the  disease 
are  essentially  the  same  as  in  adults.  A  condition  closely  allied  to  this 
is  occasionally  seen  as  a  result  of  the  administration  of  chloroform. 

CONGESTION  OF  THE  LIVER. 

Congestion  of  the  liver  occurs  from  the  same  causes  in  children  as 
in  adults.  Acute  congestion  is  not  often  seen.  Chronic  congestion  is 
more  common,  and  is  usually  secondary  to  general  venous  obstruction  de- 
pendent upon  congenital  or  acquired  heart  disease,  atelectasis,  or  other 
pulmonary  conditions,  particularly  chronic  pleurisy,  chronic  interstitial 
pneumonia,  and  emphysema.  Chronic  congestion  of  the  liver  causes  no 
characteristic  symptoms  except  a  moderate  enlargement  of  the  organ 
with  some  pain  and  tenderness.  The  treatment  is  that  of  the  primary 
disease. 

ABSCESS  OF  THE  LIVER— SUPPURATIVE  HEPATITIS. 

In  1890  Musser  found  but  thirty-four  recorded  cases  of  abscess  of 
the  liver  in  children  under  thirteen  years.  Since  that  time  a  few  addi- 
tional cases  have  been  reported.  In  the  above  collection,  there  have 
not  been  included  cases  of  suppurative  hepatitis  occurring  in  the  newly 
born. 

As  in  adults,  abscess  of  the  liver  may  result  from  traumatism,  or  it 
may  be  secondary  to  suppurative  pylephlebitis,  which  depends  upon  a 
focus  of  infection  in  the  umbilical  vein,  or  in  some  part  of  the  abdomen 
from  which  the  branches  of  the  portal  vein  arise.  Pylephlebitis  may  fol- 
low appendicitis  (Bernard's  case),  it  may  follow  typhoid  fever  directly 
(Asch's  case),  or  be  due  to  suppuration  of  the  mesenteric  glands  or  peri- 
tonitis following  typhoid.  In  seven  of  the  cases  collected  by  Musser  the 
disease  was  due  to  migration  of  roundworms  from  the  intestine  into 
the  hepatic  ducts.  Menger  (Texas)  has  reported  one  case  following 
dysentery,  the  only  one,  I  think,  on  record  in  this  country.  Very  rarely 
great  numbers  of  minute  abscesses  are  found  as  a  result  of  suppurative 
thrombosis  of  the  jugular  bulb  following  middle  ear  disease.  In  quite 
a  number  of  cases  no  adequate  cause  can  be  found. 

In  the  cases  occurring  in  pygemia  and  in  those  associated  with  pyle- 
phlebitis there  are  usually  several  abscesses ;  in  traumatic  cases  generally 
but  one.  If  untreated,  the  majority  of  cases  prove  fatal  either  from  ex- 
haustion or  from  rupture  into  the  pleura  or  peritonseum.  In  Asch's 
case  spontaneous  cure  took  place  by  rupture  into  the  intestine. 


438  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Symptoms. — Occasionally  abscess  of  tlie  liver  is  latent,  but  in  most 
of  the  cases  the  symptoms  are  marked  and  sufficiently  characteristic  to 
make  the  diagnosis  a  matter  of  no  great  difficulty.  The  most  constant 
general  symptoms  are  chills,  which  may  be  single,  but  are  usually  re- 
peated; fever,  which  is  commonly  of  the  hectic  variety  and  followed  by 
sweating;  prostration,  vomiting,  diarrhoea,  and  cachexia.  Jaundice  is 
present  in  less  than  half  the  cases,  and  is  rarely  intense.  The  liver  is 
almost  invariably  sufficiently  enlarged  to  be  easily  made  out  by  palpation 
or  by  percussion;  the  enlargement  in  most  cases  is  chiefly  downward. 
Pain  is  quite  constant,  and  frequently  intense,  but  not  always  in  the 
region  of  the  liver.  It  may  be  in  the  epigastrium,  at  the  umbilicus,  in 
the  lower  part  of  the  abdomen,  and  occasionally  in  the  right  shoulder. 
Tenderness  over  the  liver  is  usually  present.  A  positive  diagnosis  of 
hepatic  abscess  is  to  be  made  only  by  aspiration  and  the  withdrawal  of 
a  fluid  having  the  characteristics  of  "  liver  pus."  Pulmonary  symptoms 
usually  exist  with  an  abscess  occupying  the  convexity  of  the  right  lobe. 
There  may  be  cough  and  dyspnoea  from  pressure,  or  pleurisy  from  ex- 
tension of  the  inflammation  through  the  diaphragm,  or  from  rupture 
into  the  pleural  cavity.  The  usual  duration  of  abscess  of  the  liver  after 
the  beginning  of  the  symptoms  is  from  one  to  two  months.  The  prog- 
nosis will  depend  upon  the  cause  of  the  disease.  The  pysemic  cases  are 
usually  fatal.  In  Musser's  collection,  the  proportion  of  recoveries  was 
about  thirty  per  cent.  At  the  present  time,  with  improved  methods  of 
treatment  and  earlier  diagnosis,  the  outlook  is  somewhat  better  than  this. 

Treatment. — This  is  purely  surgical.  Without  operation  the  chances 
of  recovery  are  very  slight.  A  small  number  of  cases  have  been  cured 
by  aspiration,  but  in  the  vast  majority  only  incision  and  drainage  are  to 
be  depended  upon,  and,  if  the  abscess  is  accessible,  should  be  resorted  to 
as  soon  as  the  diagnosis  is  established. 

CIRRHOSIS. 

Cirrhosis  of  the  liver  is  exceedingly  rare  in  early  life,  although  quite 
a  number  of  cases  are  now  on  record  between  the  ages  of  seven  and  four- 
teen years.  Sixty-five  have  been  collected  by  Howard  and  fifty-three  by 
Laure  and  Honorat.  Nearly  all  the  cases  in  these  collections  were  be- 
tween nine  and  fifteen  years  old.  Cirrhosis  in  infancy  is  usually  of 
syphilitic  origin.  Two-thirds  of  those  in  Howard's  collection  were  males. 
The  etiology  in  most  of  the  cases  is  obscure;  in  over  half  of  those  re- 
ported no  cause  could  be  discovered.  Fifteen  per  cent  of  Howard's 
cases  were  traced  to  alcoholism,  eleven  per  cent  to  syphilis,  and  eleven 
per  cent  to  tuberculosis.  Laure  and  Honorat  believe  tliat  the  eruptive 
fevers  sometimes  play  an  important  part  as  an  etiological  factor,  and  that 
at  other  times  the  cause  is  possibly  malaria. 


AMYLOID   DEGENERATION.  439 

The  anatomical  features  of  cirrhosis  in  early  life  are  essentially  the 
same  as  in  adults.  The  liver  is  sometimes  enlarged,  l)ut  usually  it  is 
smaller  than  normal.  The  connective  tissue  may  be  distributed  around 
the  lobules,  along  the  bile  ducts,  in  irregular  patches,  or  in  striations 
through  the  organ.  Associated  with  this  there  is  atrophy  and  fatty 
degeneration  of  the  liver  cells.  In  some  of  the-  cases  reported  there  has 
been  also  a  similar  increase  in  the  connective  tissue  of  the  spleen  and 
kidneys. 

Symptoms. — These  are  very  much  the  same  as  in  adult  life.  In  the 
beginning  there  are  the  indefinite  disturbances  referable  to  the  digestive 
organs,  and  the  liver  may  be  slightly  enlarged;  later  there  is  ascites, 
enlargement  of  the  spleen,  and  dilatation  of  the  abdominal  veins.  Ascites 
is  a  pretty  constant  symptom,  and  is  generally  marked.  Slight  icterus 
is  often  present,  but  a  marked  amount  is  rare.  There  may  be  haemor- 
rhages from  the  stomach,  from  the  nose,  or  from  other  organs ;  in  a  few 
cases  there  is  flight  fever.  The  late  symptoms  are,  a  small  liver,  marked 
ascites  with  the  consequent  embarrassment  of  respiration,  cachexia,  and 
sometimes  general  dropsy.  Diarrhoea  is  a  much  more  constant  symptom 
than  in  adults.  Death  usually  takes  place  from  exhaustion.  The  course 
of  cirrhosis  in  children  is  commonly  more  rapid  than  in  adults,  and  the 
progress  is  steadily  downward. 

Treatment. — Medicinal  treatment  is  of  avail  only  in  cases  which  are 
syphilitic.  These  should  be  put  upon  anti-syphilitic  remedies  in  full 
doses.  The  treatment  in  other  respects  is  symptomatic  and  palliative. 
As  largely  as  possible  patients  should  be  kept  upon  a  milk  diet.  The 
ascites  may  require  paracentesis  as  in  adults. 

AMYLOID  DEGENERATION  {Waxy  or  Lardaceous  Liver). 

From  the  experiments  of  Krawkow,  Davidsohn,  and  others  there 
seems  now  little  doubt  that  amyloid  degeneration  can  be  produced  by  the 
prolonged  action  of  the  staphylococcus  aureus,  and  probably  by  other 
organisms.  Amyloid  degeneration  of  the  liver  is  associated  with  similar 
changes  in  the  spleen  and  kidneys,  and  sometimes  in  the  villi  of  the  small 
intestine,  and  is  usually  seen  in  children  after  long-continued  suppura- 
tion in  chronic  bone  or  joint  disease,  empyema,  tuberculosis,  or  syphilis. 

The  liver  is  generally  very  much  enlarged ;  in  extreme  cases  a  weight 
of  six  or  seven  pounds  may  be  reached.  It  is  of  a  glistening,  waxy  ap- 
pearance, very  firm  and  hard.  With  a  solution  of  iodine,  a  mahogany- 
brown  reaction  is  obtained.  The  amyloid  substance  is  deposited  between 
the  capillaries  and  the  hepatic  cells,  leading  to  occlusion  of  the  vessels 
and  atrophy  of  the  cells  from  pressure. 

Amyloid  liver  per  se  produces  few  symptoms.  Ascites  is  rarely  pres- 
ent except  in  cases  in  which  the  liver  is  very  large,  and  jaundice  does  not 


440  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

occur.  In  addition  to  the  symptoms  of  the  original  disease  in  the 
course  of  which  the  amyloid  degeneration  occurs,  there  is  the  peculiar 
waxy  cachexia  which  is  seen  in  no  other  condition,  but  resembles  some- 
what that  belonging  to  malignant  disease.  The  face  has  the  appearance 
of  alabaster,  and  the  skin  has  a  singular  translucency.  The  liver  may  be 
so  large  as  to  form  a  tumour,  sometimes  nearly  filling  the  abdominal 
cavity.  Not  infrequently  it  extends  to  the  umbilicus,  and  even  to  the 
crest  of  the  ilium.  The  surface  is  smooth  and  hard,  and  the  edges  usually 
rounded.  There  is  no  localised  pain  or  tenderness.  The  spleen  is  in- 
variably enlarged.  As  a  result  of  the  associated  amyloid  degeneration  of 
the  kidney,  there  may  be  anasarca  and  albuminuria.  Dropsy  may  occur 
from  pressure  of  the  large  liver  upon  the  vena  cava,  apart  from  the  con- 
dition of  the  kidney. 

Amyloid  changes  usually  take  place  slowly,  the  whole  course  of  the 
disease  being  marked  by  years,  the  patient  dying  from  slow  asthenia, 
from  nephritis,  or  from  some  acute  intercurrent  disease.  As  a  rule,  cases 
go  on  steadily  from  bad  to  worse;  but  sometimes,  after  the  disease  has 
reached  a  certain  point,  the  condition  remains  stationary  for  a  long  time. 

The  prognosis  is  always  bad,  although  in  a  few  cases  improvement, 
and  even  cure,  are  stated  to  have  occurred  after  the  excision  of  the  dis- 
eased joints  upon  which  the  amyloid  degeneration  depended.  When  due 
to  syphilis,  the  usual  anti-syphilitic  remedies  should  be  given. 

FATTY  LIVER. 

Fatty  infiltration  of  the  liver  is  generally  a  secondary  condition  in 
early  life,  and  causes  no  sjnnptoms  by  which  it  can  be  positively  recog- 
nised. Considerable  discussion  has  of  late  arisen  regarding  its  frequency 
in  infants.  From  our  records  at  the  Babies'  Hospital,  Dr.  Martha  Woll- 
stein  has  tabulated  345  consecutive  autopsies  in  which  the  condition  of 
the  liver  was  carefully  noted.  The  liver  was  fatty  in  201,  or  58  per  cent. 
Of  these  autopsies,  63  were  cases  of  tuberculosis,  in  43  of  which,  or  68 
per  cent,  the  liver  was  fatty. 

The  general  nutrition  of  the  345  infants  was  as  follows : 

Wasted 188:  liver  fatty,  104,  or  55  per  cent — very  fatty  in  17. 

Fairly  nourished 80:     "        "       52,  "  65    "      "  "        "      "    9. 

Well  nourished 77:     "        "       45,   "  59   "      "  "        "      "  20. 

These  figures  coincide  very  closely  with  the  observations  of  Free- 
man at  the  New  York  Foundling  Hospital,  and  indicate  that  fatty  liver 
is  not,  as  has  been  so  often  asserted,  much  more  frequent  in  wasted 
infants  than  in  others.  The  cause  of  this  change  in  the  liver  is  as  yet 
but  little  understood. 

The  liver  is  moderately  enlarged,  smooth,  with  rounded  edges,  of  a 
yellowish-red  or  a  lemon-yellow  colour,  and  can  be  indented  with  the 


BILIARY  CALCULI.  441 

finger.  A  warm  knife  becomes  coated  with  oil  after  cutting.  Microscop- 
ically there  is  seen  an  accumulation  of  fat  in  the  liver  cells,  usually 
irregularly  distributed,  but  chiefly  in  the  periphery  of  the  lobule.  Jaun- 
dice, ascites,  and  the  other  peculiar  symptoms  of  hepatic  disease  are 
absent.  The  liver  is  moderately  increased  in  size  and  its  functions  may 
be  interfered  with,  but  not  in  such  a  way  as  to  be  recognised  by  the 
symptoms.    The  treatment  is  that  of  the  original  disease. 

HYDATIDS. 

Echinococcus  disease  of  the  liver,  while  rare  among  adults  in  this 
country,  is  almgst  imknown  in  children.  I  have  been  able  to  find  but 
two  recorded  cases  in  America.  From  twenty-two  European  cases  col- 
lected by  Pontou,  it  appears  that  unilocular  cysts  are  especially  frequent 
in  young  subjects.  If  the  upper  surface  is  afEected,  pulmonary  symp- 
toms, cough  and  dyspnoea,  are  usually  present;  if  the  under  surface 
of  the  organ,  there  is  pressure  upon  the  portal  vein,  the  vena  cava,  bile 
ducts,  stomach,  and  intestines.  This  pressure  may  cause  icterus,  dilata- 
tion of  the  superficial  abdominal  veins,  and  sometimes  ascites.  The  local 
signs  are  enlargement  of  the  liver  with  a  tumour,  which  is  easily  recog- 
nised in  children  because  of  the  thin  abdominal  walls.  The  hydatid 
fremitus  is  usually  obtained.  By  aspiration  a  clear  fluid  is  withdrawn, 
showing  under  the  microscope  the  presence  of  the  booklets,  which  estab- 
lishes the  diagnosis.  Occasionally  cure  may  take  place  by  spontaneous 
rupture  or  suppuration  of  the  cyst,  but  in  most  cases,  when  left  to  itself, 
the  disease  proves  fatal.  The  treatment  is  surgical,  and  consists  in 
aspiration  or  in  incision,  and  the  evacuation  of  the  cyst. 

BILIARY  CALCULI. 

Up  to  the  age  of  puberty  calculi  are  extremely  rare.  Of  twenty  cases 
collected  by  Still,  eleven  occurred  in  newly-born  infants  or  else  gave 
symptoms  during  the  first  month  of  life.  The  prominent  symptom  was 
intense  and  persistent  Jaundice.  Nearly  all  died  within  the  first  month, 
the  autopsy  usually  showing  multiple  calculi  in  the  common  duct. 

The  cases  in  older  children  do  not  differ  from  those  in  adults. 


CHAPTEE    XII. 

DISEASES  OF  THE  PERITONEUM. 

Inflammation  of  the  peritonaeum  is  not  very  frequent  in  childhood, 
because  at  this  time  most  of  the  causes  which  are  operative  in  later  life 
either  do  not  exist  at  all  or  are  infrequent. 


442  DISEASES  OF  THE   DIGESTIVE  SYSTEM 

nitis. 


We  shall  consider  separately  acute,  chronic,  and  tuberculous  perito- 
is. 


ACUTE  PERITONITIS. 

Acute  peritonitis  may  occur  at  any  period  of  infancy  or  childhood. 
It  may  even  exist  in  intra-uterine  life.  In  the  newly  born,  peritonitis  is 
not  infrequent.  After  this  time  it  is  exceedingly  rare  during  infancy, 
only  four  cases,  including  all  varieties,  being  met  with  in  726  consecutive 
autopsies  in  the  New  York  Infant  Asylum.  After  the  fifth  year  the 
disease  is  relatively  much  more  common.  Of  the  187  cases  above  re- 
ferred to,  25  per  cent  occurred  in  the  newly  born,  21  per  cent  between 
one  and  five  years,  and  54  per  cent  between  the  fifth  and  the  sixteenth 
years. 

Etiology. — In  the  newly  born,  peritonitis  is  seen  as  one  of  the  most 
frequent  lesions  of  acute  pyogenic  infection.  It  is  usually  due  to  direct 
infection  through  the  umbilical  vessels.  In  infancy  and  childhood, 
peritonitis  occurs  both  as  a  primary  and  secondary  inflammation.  The 
primary  form  is  rare.  It  may  be  due  to  traumatism,  such  as  falls  or 
blows,  or  to  surgical  operations  upon  the  abdomen;  it  has  occurred  after 
an  injection  for  the  cure  of  a  congenital  hydrocele.  In  a  very  small 
number  of  cases  the  inflammation  seems  to  have  been  excited  by  cold 
or  exposure,  and  it  may  follow  severe  burns.  Cases  of  acute  serous  or 
suppurative  peritonitis  are  occasionally  seen  which  are  apparently  pri- 
mary. I  have  met  with  two  such  in  young  children  which  were  due  to 
the  streptococcus. 

The  secondary  form  is  more  common.  The  most  frequent  of  all 
causes  is  appendicitis,  which  should  always  be  suspected  in  acute  perito- 
nitis occurring  without  definite  cause.  Extension  of  inflammation  from 
the  viscera  to  the  peritonaeum  is  very  much  less  frequent  in  cliildren  than 
in  adults.  I  have  seen  it  but  once  in  autopsies  in  acute  intestinal  dis- 
eases. It  is  also  rare  in  typhoid  fever,  being  noted  but  twice  among  my 
collected  cases.  It  is  occasionally  due  to  abscess  of  the  liver,  ulcer  of 
the  stomach,  acute  intestinal  obstruction  from  internal  strangulation, 
intussusception,  volvulus,  or  congenital  atresia.  It  may  extend  from  in- 
flammation of  the  pleura.  This  may  be  in  the  form  of  an  empyema  which 
burrows  through  the  diaphragm,  or,  without  burrowing,  the  infection 
may  take  place  through  the  lymph  channels;  or  it  may  be  secondary 
to  a  general  pneumococcus  septicaemia.  Peritonitis  is  infrequently  due 
to  infection  through  the  female  genital  tract,  especially  in  gonococcus 
vulvo-vaginitis  in  older  girls.  Extension  of  inflammation  from  the 
male  genital  organs  is  very  rare.  In  one  case  at  the  New  York  Infant 
Asylum,  fatal  peritonitis  in  an  infant  started  from  a  suppurative  in- 
flammation of  the  tunica  vaginalis  of  unknown  origin,  the  infec- 
tion   extending    into    the    peritonaeum    through    the    inguinal    canal. 


ACUTE   PERITONITIS.  443 

Any  abscess  in  the  neighbourhood  may  rupture  into  the  peritonaeum 
and  excite  peritonitis.  Those  most  frequent  in  chiklren  are  con- 
nected with  Pott's  disease,  perinephritis,  and  cellulitis  of  the  abdominal 
wall. 

Of  the  acute  infectious  diseases,  peritonitis  is  most  frequently  seen 
with  pneumonia,  and  very  rarely  with  scarlet  fever.  When  secondary  to 
])neumonia,  there  is  usually  extreme  pleurisy  and  sometimes  also  peri- 
carditis and  meningitis;  in  other  words  a  general  pneumococcus  infection 
is  present. 

The  bacteria  most  frequentl}'  associated  with  acute  peritonitis  in  chil- 
dren are:  the  streptococcus,  especially  in  the  newly  born;  the  pneumo- 
coccus in  cases  complicating  pneumonia  or  empyema ;  and  the  6.  coli 
communis,  associated  with  other  pyogenic  bacteria,  in  those  following 
intestinal  perforation. 

Lesions. — In  the  fibrinous  form  there  are  changes  similar  to  those 
occurring  in  inflammation  of  the  pleura  and  the  other  serous  membranes. 
The  peritonaeum  is  injected  and  fibrin  is  thrown  out  in  considerable 
quantity,  usually  accompanied  by  a  small  amount  of  serum.  The  process 
is  usually  a  localised  one.  The  peritonaeum  lining  the  abdominal  wall, 
as  well  as  that  covering  the  adjacent  coils  of  intestine  and  the  solid 
viscera,  is  covered  by  patches  of  yellowish-gray  fibrin,  causing  adhesions 
between  the  various  viscera  and  often  matting  the  intestines  together. 
In  recent  eases  these  adhesions  are  soft,  and  easily  broken  down;  in  old 
cases  they  are  quite  firm,  and  they  may  result  in  the  formation  of  con- 
nective-tissue bands  which  are  the  source  of  subsequent  trouble.  In 
other  cases  the  serum  is  more  abundant,  usually  clear,  but  it  may  be 
turbid  or  even  bloody. 

In  the  purulent  form  the  products  are  serum,  fibrin,  and  pus.  When 
peritonitis  results  from  perforation  it  is,  as  a  rule,  purulent  from  the 
outset,  and  the  pus  is  foul  and  stinking.  The  amount  of  pus  is  pro- 
portionally larger  than  in  adult  cases.  When  the  disease  proves  fatal 
in  a  few  days  there  is  found  an  extensive  exudation  of  fibrin,  with  the 
formation  of  small  pockets  containing  pus,  among  the  coils  of  intestine. 
Occasionally  there  may  be  larger  collections  of  pus  in  the  peritoneal 
cavity.  In  cases  which  have  lasted  a  longer  time — generally  those  of 
localised  inflammation — the  process  results  in  the  formation  of  a  peri- 
toneal abscess.  This  consists  in  a  collection  of  pus  in  some  part  of  the 
peritoneal  cavity,  the  situation  depending  upon  the  cause,  but  it  is 
usually  in  one  iliac  fossa  or  in  the  pelvis.  The  abscess  is  shut  off  from 
the  rest  of  the  peritoneal  cavity  by  a  thick  wall  of  fibrin.  If  left  alone, 
such  abscesses  may  open  into  the  rectum,  vagina,  bladder,  pelvis  of  the 
kidney,  or  externally,  usually  at  the  umbilicus.  After  the  discharge  of 
pus  the  cavity  may  contract  and  fill  up  by  granulations,  and  the  patient 
recover. 


444  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Inflammations  of  the  other  serous  membranes,  especially  the  pleura, 
are  often  associated  with  peritonitis. 

Symptoms. — The  symptoms  of  acute  peritonitis  in  older  children,  as 
in  adults,  are  usually  well  marked  and  sufficiently  characteristic  to  enable 
one  to  recognise  the  disease  easily ;  but  not  so  in  the  case  of  infants.  In 
them  the  symptoms  are  often  obscure,  and  the  disease  may  be  found  at 
autopsy  when  not  suspected  during  life.  The  onset  is  nearly  always 
abrupt,  with  fever  and  vomiting.  As  a  rule,  the  temperature  is  high — 
from  103°  to  105°  F.  Vomiting  may  occur  only  at  the  onset,  but  it 
often  continues;  the  vomited  matters  are  usually  green.  Older  children 
complain  of  pain,  which  may  be  localised  or  general;  and  in  younger 
ones  this  is  indicated  by  crying  and  fretfulness.  The  abdomen  very  soon 
becomes  swollen  and  tympanitic,  this  being  one  of  the  most  constant 
features  of  the  disease.  The  distention  is  generally  uniform,  but  it  may 
be  irregular.  There  is  tenderness  on  pressure,  and  usually  marked  rigid- 
ity of  the  abdominal  walls.  The  pain  causes  the  child  to  assume  a  fixed 
position  and  he  cries  if  moved  or  disturbed.  The  posture  is  generally 
dorsal,  with  the  thighs  flexed.  The  bowels  are  in  most  cases  constipated, 
but  diarrhoea  is  by  no  means  rare.  The  abdominal  distention  causes 
dyspnoea  and  thoracic  breathing.  There  may  be  retention  of  urine  or 
frequent  micturition. 

The  general  symptoms,  almost  from  the  beginning,  are  those  of  a 
serious  disease.  The  pulse  is  small,  rapid,  and  compressible.  The 
prostration  is  great,  from  the  very  outset.  The  face  is  pinched,  the 
mouth  is  drawn,  and  the  features  indicate  pain.  In  severe  cases  there 
may  be  hiccough,  cold  extremities,  clammy  perspiration,  and  collapse. 
The  mind  is  usually  clear.  In  infants  there  may  be  convulsions.  A 
polymorphonuclear  leucocytosis  is  almost  invariably  present,  but  is  want- 
ing in  some  cases  of  the  gravest  type. 

In  the  most  severe  forms  of  general  peritonitis  the  course  is  short 
and  intense,  and  the  disease  goes  on  rapidly  from  bad  to  worse  until 
death  occurs.  In  infants  this  is  often  on  the  third  or  fourth  day.  The 
very  severe  forms  of  general  peritonitis  in  older  children  run  the  same 
rapid  course.  In  other  cases  the  course  is  slower,  lasting  a  week  or  ten 
days.  If  the  patient  lives  longer  than  this  the  case  is  more  hopeful, 
because  the  process  is  more  apt  to  be  localised.  The  development  of 
peritoneal  abscess  is  indicated  by  the  continuance  of  the  temperature, 
which  may  assume  a  hectic  type,  and  be  accompanied  by  chills  and 
sweating.    There  are  the  local  signs  of  an  abdominal  tumour. 

Frognosis. — Acute  general  peritonitis,  whatever  its  cause,  is  a  very 
serious  disease  in  childhood.  Of  eighty  cases  of  all  varieties  under 
sixteen  years  of  age,  sixty-nine  per  cent  died.  In  the  newly  born  and 
in  infancy  the  disease  is  almost  invariably  fatal.  In  older  children  the 
outlook  is  not  quite  so  hopeless,  and  depends  upon  the  exciting  cause. 


CHRONIC   PERITONITIS.  445 

Treatment. — The  medical  treatment  of  acute  general  peritonitis  in 
children  is  extremely  unsatisfactory,  as  the  disease  is  almost  always  fatal 
unless  it  can  be  relieved  surgically.  Opium  is  indicated  only  for  the  re- 
lief of  the  single  symptom,  pain.  It  has,  however,  serious  disadvantages 
in  that  it  may  mask  important  symptoms.  Other  medical  treatment  is 
symptomatic  only  and  is  to  be  employed  in  conjunction  with  surgical 
measures. 

As  a  local  application  cold  is  usually  to  be  preferred.  It  may  be 
applied  either  by  an  ice-bag  or  by  a  Leiter's  coil.  If  children  rebel 
against  the  use  of  cold,  heat  may  be  substituted.  Turpentine  stupes  may 
aid  in  relieving  tympanites. 

Feeding  is  always  a  diJBficult  matter  on  account  of  the  strong  tend- 
ency to  vomit;  this  is  due  to  regurgitation  from  the  intestine  into 
the  stomach,  which  in  some  cases  is  almost  continuous.  In  such  con- 
ditions I  have  found  great  benefit  from  washing  the  stomach  shortly 
before  feeding,  repeating  this  several  times  each  day.  In  this  way  vomit- 
ing may  often  be  controlled  and  the  stomach  made  ready  for  food.  The 
diet  should  be  peptonised  milk,  broth,  or  kumyss. 

In  every  case  of  acute  peritonitis,  an  immediate  exploratory  operation 
should  be  done  if  the  child's  general  condition  will  permit.  Appendicitis 
is  often  found  to  be  the  cause  when  least  expected;  and  even  when  the 
peritonitis  is  due  to  some  other  cause  operation  gives  the  only  chance 
for  recovery.  Operation  is  also  indicated  in  localised  inflammations  with 
the  formation  of  peritoneal  abscesses. 

CHRONIC  (NON-TUBERCULOUS)  PERITONITIS. 

Peritonitis  may  occur  in  foetal  life  with  the  production  of  extensive 
adhesions,  which  may  interfere  with  the  development  of  the  intestine  and 
result  in  various  malformations.  These  cases  have  been  ascribed  by 
Silbermann  to  syphilis. 

Chronic  peritonitis  may  follow  the  acute  form,  in  which  there  are 
left  adhesions  which  slowly  increase  owing  to  the  production  of  new 
connective  tissue.  Such  cases  are  sometimes  chronic  from  the  be- 
ginning. 

The  peritoneal  abscesses  which  follow  the  suppurative  form  may 
run  a  chronic  course.  Chronic  localised  peritonitis  may  occur  in  connec- 
tion with  disease  of  any  of  the  organs  covered  by  the  peritonaeum. 

Chronic  Peritonitis  with  Ascites. — In  most  cases  this  is  chronic  from 
the  outset  and  independent  of  the  causes  above  mentioned.  By  far  the 
most  frequent  form  of  inflammation  is  that  due  to  tuberculosis,  and  by 
some  writers  the  opinion  is  still  held  that  chronic  peritonitis  with  ascites 
is  always  tuberculous.  After  the  observations  reported  by  Henoch,  Vier- 
ordt,  Fiedler,  and  others,  there  seems  to  be  no  longer  any  room  for  doubt- 


446  DISEASES  OF  THE   DIGESTIVE   SYSTEM. 

ing  the  existence  of  a  chronic  non-tuberculous  form  of  peritonitis  with 
ascites,  although  it  must  be  considered  a  rare  disease.  In  its  pathological 
and  clinical  aspects  it  is  to  be  compared  to  subacute  or  chronic  pleurisy 
with  effusion. 

Etiology. — Nearly  all  the  cases  thus  far  reported  have  occurred 
in  children  over  six  years  old.  The  causes  are  for  the  most  part  ob- 
scure. It  may  be  associated  with  disease  of  the  intestines  or  the  solid 
viscera  of  the  abdomen,  especially  with  new  growths  of  the  kidney, 
liver,  etc. 

Lesions. — The  post-mortem  observations  thus  far  have  been  few.  In 
the  reported  cases  there  has  been  found  a  large  amount  of  greenish 
serum  in  the  general  peritoneal  cavity,  with  a  very  moderate  amount  of 
fibrin  and  with  adhesions,  which  are  sometimes  few  and  sometimes  very 
numerous.    Chronic  pleurisy  may  be  associated. 

Symptoms. — The  early  symptoms  are  of  a  very  indefinite  character, 
but  often  nothing  whatever  is  noticed  until  the  swelling  of  the  abdomen 
begins.  The  enlargement  comes  on  rather  gradually  in  the  course  of  a 
few  weeks.  Pain  is  slight,  or  wanting  altogether.  There  may  be  some 
abdominal  tenderness.  The  abdomen  is  usually  distended  with  fluid,  the 
umbilicus  protruding,  and  the  superficial  veins  prominent.  The  enlarge- 
ment is  generally  regular  and  symmetrical,  and  the  wave  of  fluctuation 
is  readily  obtained.  The  general  symptoms  are  very  few.  In  some 
cases  there  is  a  slight  evening  rise  of  temperature  of  one  or  two  de- 
grees. There  may  be  general  weakness,  loss  of  appetite,  and  moderate 
anaemia. 

The  usual  course  of  the  disease  is  for  the  fluid  to  remain  for  a 
time  and  then  undergo  slow  absorption.  In  some  instances  there  is  no 
tendency  to  absorption  of  the  fluid,  the  general  health  is  gradually  un- 
dermined, and  the  patients  die  from  exhaustion  or  from  some  inter- 
current disease.  The  diagnosis  rests  upon  the  presence  of  ascites,  devel- 
oping gradually  without  any  signs  or  symptoms  of  disease  in  the  heart, 
liver,  or  other  organs.  The  points  which  distinguish  it  from  tuberculous 
peritonitis  are  considered  under  that  disease.  The  prognosis  must  be 
guarded  on  account  of  the  difficulty  in  making  a  positive  diagnosis  from 
the  tuberculous  form. 

Treatment. — It  is  important  that  the  patient  should  be  kept  at  rest, 
preferably  confined  to  bed.  The  best  results  are  obtained  by  the  adop- 
tion of  a  general  tonic  plan  of  treatment.  When  there  is  no  tend- 
ency to  absorption  after  a  thorough  trial  of  the  above  measures,  and 
especially  when  the  patient's  general  health  begins  to  suffer,  the  fluid 
should  be  removed  by  paracentesis.  If  it  continues  to  accumulate  after 
repeated  tapping,  laparotomy  may  be  performed,  for  in  some  cases 
this  has  the  same  beneficial  effect  as  in  tuberculous  peritonitis, 


TUBERCULOUS  PERITONITIS.  447 


TUBERCULOUS  PERITONITIS. 


The  peritonaeum  is  quite  frequentl}^  the  seat  of  tuberculous  inflam- 
mation in  early  life.  It  occurs  especially  between  the  ages  of  one  and 
five  years,  but  is  infrequent  during  the  first  year.  Of  100  cases  observed 
by  Still,  the  largest  number  were  seen  in  the  second  year  of  life.  In 
255  autopsies  upon  tuberculous  patients,  most  of  them  under  three  years 
old,  of  which  I  have  records,  the  peritonaeum  was  involved  in  8 . 6  per  cent ; 
but  in  a  majority  of  these  the  peritonitis  was  not  the  most  important 
lesion  nor  the  cause  of  death.  Tuberculous  peritonitis  is  apparently 
much  more  frequent  in  Europe  than  in  this  country.  Thus,  Still  states 
that  this  was  the  cause  of  death  in  16.8  per  cent  of  his  tuberculous 
patients  under  twelve  years  of  age,  and  in  13  per  cent  of  the  deaths 
from  tuberculosis  under  two  years.  In  105  autopsies,  for  the  most  part 
upon  older  tuberculous  children,  Ashby  found  the  peritonaeum  involved 
in  36  per  cent.  In  883  collected  autopsies  upon  tuberculous  children  of 
all  ages,  Biedert  found  the  peritonaeum  involved  in  18.3  per  cent. 
These  figures  do  not  represent  the  number  of  cases  of  tuberculous  peri- 
tonitis, as  in  many  of  them  only  a  few  miliary  tubercles  were  present. 

It  is  possible  for  peritonitis  to  occur  as  the  primary  lesion  of  tuber- 
culosis, the  bacilli  entering  by  way  of  the  intestine,  causing  no  lesion  of 
the  mucous  membrane,  but  in  the  great  majority  of  cases  it  is  secondary 
to  tuberculosis  of  the  intestine,  the  mesenteric  glands,  the  pleura,  or 
to  that  of  more  .distant  parts,  such  as  the  lungs,  the  bronchial  glands, 
etc.  In  a  small  number  of  cases  there  is  a  history  of  some  local  excit- 
ing cause,  such  as  a  fall  or  blow  upon  the  abdomen.  The  bovine  type  of  the 
tubercle  bacillus  is  more  frequently  found  in  tuberculous  peritonitis  than 
in  any  other  form  of  tuberculosis,  possibly  excepting  cervical  adenitis, 
which  fact  is  strongly  suggestive  of  milk  as  the  source  of  infection. 

Tuberculous  peritonitis  is  usually  associated  with  other  abdominal 
lesions — tuberculosis  of  the  mesenteric  glands,  intestinal  ulceration,  etc. 
It  is  very  rarely  acute,  but  usually  occurs  as  a  subacute  or  chronic  disease. 

The  peritonaeum  may  be  involved  as  one  of  the  lesions  in  acute  or 
subacute  general  miliary  tuberculosis.  This  is  the  most  common  form 
seen  in  infants.  The  lesions  consist  in  a  deposit  of  miliary  tubercles, 
which  are  generally  rather  sparsely  scattered  over  the  peritonaeum.  The 
evidences  of  inflammation  are  very  slight,  or  they  may  be  absent  alto- 
gether. These  cases  do  not  come  under  observation  as  cases  of  peri- 
tonitis, as  there  are  no  abdominal  symptoms. 

The  principal  anatomical  and  clinical  varieties  of  tuberculous 
peritonitis  are  the  ascitic  and  the  flbrous  forms. 

The  Ascitic  Form. — This  is  much  less  frequent  than  the  fibrous  form. 
The  peritonaeum  is  thickly  sown  with  miliary  tubercles,  both  discrete 


448  DISEASES  OF  THE  DIGESTI\'E  SYSTEM. 

and  in  conglomerate  masses.  They  are  found  in  the  omentum  and  the 
mesentery,  upon  the  surface  of  the  intestines  and  tlie  solid  viscera. 
The  peritonaeum  shows  in  varying  degrees  the  changes  of  acute  or  sub- 
acute inflammation.  There  is  congestion,  with  tlie  production  of  a  mod- 
erate amount  of  fibrin  and  a  large  amount  of  serum.  In  the  most  acute 
cases  the  fluid  is  in  the  general  peritoneal  cavity.  In  those  of  longer 
duration  it  may  be  sacculated.  The  fluid  is  usually  abundant,  but  not 
excessive.  It  is  most  commonly  an  olive-coloured  serum,  but  it  may  be 
sero-purulent,  or  even  bloody.  There  are  commonly  otlier  lesions  of 
tuberculosis  in  the  body,  but  they  are  usually  less  marked  than  those 
of  the  peritonaeum. 

Clinically,  ascitic  cases  usually  present  the  symptoms  of  a  low  grade 
of  peritonaeal  inflammation.  The  onset  is  gradual,  with  indefinite  gen- 
eral symptoms.  There  is  usually  some  fever — 100°  to  101 . 5°  F.  There 
is  general  weakness,  prostration,  and  some  loss  of  flesh,  but  not  rapid 
emaciation.  Vomiting  is  not  prominent,  and  pain  and  tenderness  are 
often  absent.  There  may  be  nothing  distinctive  until  distention  of  the 
abdomen  is  seen.  This  at  first  is  due  to  intestinal  gas,  but  later  to  fluid, 
which  may  accumulate  in  sufficient  quantity  to  fill  the  general  peritoneal 
cavity.  The  bowels  may  be  constipated  or  there  may  be  diarrhoea.  In 
other  cases  there  may  be  only  a  slowly  developing  ascites  without  any 
inflammatory  signs,  and  the  abdominal  enlargement  is  practically  the 
only  symptom. 

The  ascitic  form  of  tuberculous  peritonitis  may  result  fatally,  death 
occurring  from  general  tuberculosis  or  by  slow  exhaustion  from  the  local 
disease;  the  duration  under  these  conditions  is  usually  from  two  to  four 
months.  At  other  times  the  fluid  may  gradually  undergo  absorption 
and  recovery  take  place,  or  after  absorption  the  fibrous  form  of  inflam- 
mation may  develop. 

The  Fibrous  Form. — This  is  generally  slower  in  its  development  and 
more  chronic  in  its  course  than  the  ascitic  form.  There  is  a  tuberculous 
inflammation,  the  products  of  which  have  undergone  transformation  into 
fibrous  tissue.  The  most  important  feature  of  these  cases  is  the  pro- 
duction of  extensive  organised  adhesions  between  the  solid  viscera  and 
the  intestines,  between  the  intestinal  coils,  and  between  the  intestines 
and  the  abdominal  walls.  The  intestines  may  be  compressed  against  the 
spine  by  bands. 

These  adhesions  and  their  mechanical  consequences  are  sometimes 
almost  the  only  lesions  present.  In  other  cases  there  may  be  an  ac- 
cumulation of  fluid,  which  may  be  sacculated  or  in  the  general  peritoneal 
cavity.  This  may  be  serous,  sero-purulent,  or  purulent.  The  omentum 
may  be  greatly  thickened.  There  are  often  present  in  the  fibrous  exu- 
date covering  the  intestines,  in  the  omentum,  and  in  the  mesentery,  tu- 
berculous deposits  consisting  of  caseous  nodules  or  larger  caseous  masses. 


TUBERCULOUS  PERITONITIS.  449 

which  are  frequently  softened  at  the  centre.  Tuberculous  deposits  are 
found  upon  the  peritoneal  surface  of  the  intestine,  and  infiltrate  the 
intestinal  walls,  often  leading  to  perforation,  and  sometimes  to  fistulous 
communications  between  adherent  intestinal  coils.  There  may  also  be 
tuberculous  infiltration  of  the  abdominal  walls,  accompanied  by  cellu- 
litis, resulting  in  abscesses,  which  may  open  externally,  usually  in  the 
neighbourhood  of  the  umbilicus. 

Clinically,  these  cases  are  distinguished  by  their  slow,  irregular  course. 
They  are  the  most  chronic  of  all  the  forms.  The  onset  is  generally  in- 
sidious, and  fever  is  commonly  absent.  There  is  rarely  vomiting.  The 
bowels  may  be  constipated  or  loose.  For  a  long  time  the  general  health 
may  remain  good.  The  only  characteristic  symptom  is  the  enlargement 
of  the  abdomen.  In  the  early  part  of  the  disease  this  is  chiefly  from  the 
tympanites,  but  later  there  may  be  some  accumulation  of  fluid.  It  is 
rare  that  the  inflammation  remains  entirely  fibrinous.  Ascites  usually 
develops  very,  slowly,  but  may  be  abundant.  The  adhesions  of  the  in- 
testines may  give  rise  to  irregularities  in  the  outline  of  the  abdomen. 
Ascites  may  be  present  for  a  time  and  then  disappear  spontaneously, 
and  the  general  health  may  so  improve  that  the  patient  is  considered  quite 
well.  There  may  even  be  a  permanent  cure.  In  other  cases,  after 
symptoms  have  been  absent  for  some  time,  relapses  occur,  and  more 
fluid  is  poured  out.  In  addition  to  these  symptoms,  others  are  present 
depending  upon  the  mechanical  effects  of  pressure  from  the  contracting 
adhesions.  There  may  be  more  or  less  constriction  of  the  intestine, 
pressure  upon  the  vena  cava,  the  renal  or  portal  veins,  the  thoracic  duct 
or  its  branches,  or  upon  the  stomach.  These  conditions  may  give  rise 
to  dyspeptic  symptoms,  emaciation,  oedema  of  the  lower  extremities,  and 
albuminuria.  In  some  cases  tuberculous  peritonitis  is  entirely  latent, 
and  it  is  discovered  at  autopsy  when  there  have  been  either  no  abdominal 
symptoms  during  life,  or  only  colicky  pains  of  an  indefinite  character. 
The  course  of  this  form  of  peritonitis  is  slow  and  irregular;  it  generally 
lasts  for  from  six  to  twelve  months,  although  with  intermissions  and 
exacerbations  it  may  extend  over  several  years. 

If  softening  and  breaking  down  of  inflammatory  products  take  place, 
well-marked  constitutional  symptoms  are  usually  present.  These  are 
partly  from  the  peritonitis  and  partly  from  general  tuberculosis.  Fever 
is  regularly  present,  the  temperature  usually  ranging  from  99°  to  103° 
F.  Sometimes  it  assumes  a  distinctly  hectic  type.  There  is  progressive 
emaciation,  anaemia,  prostration,  and  sweating.  Diarrhoea  is  frequent, 
and  the  intestinal  discharges  may  at  times  be  bloody.  The  abdomen  is 
large,  but  not  so  much  distended  as  in  some  of  the  other  forms;  the 
superficial  veins  are  often  prominent.  Ascites  often  can  not  be  made 
out  by  percussion,  although  fluid  can  often  be  found  by  puncture.  Areas 
of  dulness  and  tympanitic  resonance  are  irregularly  distributed.  Nodu- 
30 


450  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

lar  rtiasses  of  various  sizes  and  irregular  shapes  may  be  felt  anywhere  in 
the  abdomen,  but  they  are  more  frequently  in  the  region  of  the  umbilicus 
and  in  the  right  iliac  fossa  than  elsewhere.  The  epigastric  region  may 
be  occupied  by  a  smooth,  hard  tumour — the  thickened  omentum — which 
may  resemble  the  liver.  There  may  be  the  signs  of  phlegmonous  inflam- 
mation of  the  abdominal  wall  in  the  neighbourhood  of  the  umbilicus, 
and  even  an  abscess,  which,  after  opening,  may  leave  a  fistulous  com- 
munication with  the  peritonaeum.  There  are  usually  some  signs  of  dis- 
ease in  the  lungs,  and  the  pulmonary  symptoms  may  mask  those  of  the 
abdomen.  The  course  of  the  disease,  when  softening  and  breaking  down 
have  taken  place,  is  steadily  progressive,  the  usual  duration  being  from 
three  to  six  months.  Death  results  from  the  pulmonary  disease,  from 
tuberculous  meningitis,  from  exhaustion,  and  occasionally  it  is  due  to 
accidents  associated  with  perforation. 

Diagnosis. — The  essential  symptoms  of  tuberculous  peritonitis  are  an 
enlarged  abdomen,  often  with  evidence  of  fluid,  wasting,  colicky  pain, 
irregularity  of  the  bowels,  nodular  masses  in  the  abdomen,  and  usually 
slight  but  continuous  fever.  In  young  children  chronic  ascites  with 
fever  usually  means  tuberculous  peritonitis.  Pouting  of  the  navel,  with 
induration  and  redness  about  it,  is  suggestive,  and  any  chronic  abscess 
in  the  neighbourhood  of  the  umbilicus  is  suspicious.  If  the  abdominal 
eflPusion  is  sacculated  instead  of  diffuse,  the  probabilities  of  peritonitis 
are  much  increased.  If  there  are  added  physical  signs  pointing  to  dis- 
ease of  the  lungs  or  the  evidence  of  tuberculosis  elsewhere,  or  a  positive 
tuberculin  reaction,  cutaneous  or  otherwise,  the  diagnosis  is  almost  cer- 
tain. Cirrliosis  of  the  liver  is  practically  unknown  in  infancy  and  early 
childhood.  If  ascites  is  absent,  tuberculosis  of  the  peritonaeum  may  be 
suspected  if  there  are  irregular  nodules  or  masses  in  various  parts  of  the 
abdomen,  with  tenderness,  emaciation,  colicky  pains,  and,  in  the  later 
stages,  fever.  But  fever  may  be  absent  for  a  long  time,  even  though  local 
symptoms  are  marked.  The  epigastric  tumour  due  to  omental  thickening 
may  be  mistaken  for  the  liver;  but  it  generally  extends  quite  across  the 
abdomen,  and  the  upper  as  well  as  lower  border  can  often  be  felt. 
Faecal  masses  may  resemble  tuberculous  deposits,  but  are  removed  by 
cathartics  and  enemata. 

The  examination  of  the  fluid  drawn  by  aspiration  is  not  of  much  as- 
sistance in  diagnosis.  Bacilli  are  very  difficult  to  demonstrate;  only  by 
animal  innoculations  can  the  tuberculous  nature  of  the  fluid  usually  be 
proven. 

Prognosis. — Tuberculous  peritonitis  is  always  a  serious  disease,  but 
by  no  means  a  hopeless  one;  rather  more  than  half  of  all  cases  recover. 
The  younger  the  child  the  worse  the  outlook.  It  is  especially  bad  during 
the  first  year.  Many  cases  occurring  in  the  second  year  and  later  re- 
cover spontaneously  and  entirely.    The  most  hopeful  ones  are  those  with 


TUBERCULOUS   PERITONITIS.  451 

ascites.  But  even  in  the  fibrous  form  some  apparently  complete  recov- 
eries take  place,  the  adhesions  disappearing  by  absorption  to  a  degree 
truly  remarkable.  The  most  unfavourable  cases  are  those  in  which 
there  is  strong  evidence  of  the  breaking  down  of  tuberculous  deposits, 
with  continuous  fever  and  wasting. 

Treatment. — The  general  treatment  of  tuberculous  peritonitis  is  sim- 
ilar to  that  of  tuberculosis  in  other  parts  of  the  body.  The  essentials  are, 
rest,  which  should  be  invariably  in  the  recumbent  position,  a  climate 
mild  enough  to  permit  the  patient  to  remain  out  of  doors  the  greater 
part  of  the  time,  and  very  careful  attention  to  feeding,  with  the  purpose 
of  improving  the  general  nutrition.  Under  this  treatment  a  very  con- 
siderable number  of  patients  recover,  especially  those  who  are  over  a 
year  old.  Such  a  termination  is  more  likely  if  the  diagnosis  has  been 
made  early  and  if  the  disease  is  limited  to  the  peritonaaum.  Drugs  play 
but  a  small  part  in  the  treatment  of  these  cases,  but  it  is  the  general 
opinion  that  creosote  is  of  some  value.  The  carbonate  may  be  used,  or 
the  creosote  itself  may  be  given  in  "  pearls  "  or  in  emulsion.  English 
authorities  still  attach  considerable  importance  to  the  use  of  iodoform, 
which  may  be  used,  though  somewhat  cautiously,  by  inunctions  (twenty 
grains  to  one  ounce  of  olive  oil),  or  it  may  be  given  by  mouth  in  pill 
form,  in  doses  of  one-third  to  one-half  grain  three  times  a  day.  A 
faithful  trial  of  these  measures  should  be  made  before  resorting  to 
operation.  The  use  of  tuberculin  as  a  therapeutic  measure  in  these 
cases  has  not  yet  been  tested  sufficiently  to  enable  one  to  speak  with  any 
positiveness  of  results;  it  demands  further  trial. 

In  cases  not  -progressing  favourably  under  medical  treatment,  the 
question  of  operation  should  be  considered.  The  most  favourable  cases 
for  operation  are  those  of  the  ascitic  variety.  It  may  be  useful  also  with 
localised  or  general  suppuration  and  for  the  relief  of  intestinal  obstruc- 
tion occurring  in  the  course  of  the  disease.  In  the  fibrous  form  less  is 
to  be  expected  from  it.  Operation  may  be  done  for  the  relief  of  recur- 
ring colicky  pains  due  presumably'  to  constriction  by  bands.  Exploratory 
laparotomy  is  indicated  in  all  cases  of  doubtful  diagnosis.  The  exist- 
ence of  other  foci  of  tuberculosis  does  not  contraindicate  operation  ex- 
cept when  these  are  chiefly  intestinal,  or  when  there  is  advanced  general 
tuberculosis. 

Aldibert  has  collected  statistics  of  53  operations,  with  7  deaths  and 
45  recoveries.  Nine  patients  were  reported  well  one  year  after  opera- 
tion. It  is  possible  that  among  these  cases  some  of  simple  inflammation 
were  included;  of  18  cases,  however,  in  which  the  diagnosis  of  tubercu- 
losis was  established  by  the  microscope  or  inoculation  experiments,  all 
recovered,  and  6  were  well  one  year  after  operation.  Why  it  is  that 
simply  opening  the  abdomen  and  draining  or  washing  out  the  peritoneal 
cavity  should  have  such  an  influence  in  arresting  the  disease,  which,  in  a 


452  DISEASES.  OF  THE  DIGESTIVE  SYSTEM. 

certain  proportion  of  instances,  is  certainly  the  case,  lias  not  yet  been 
satisfactorily  explained.  In  deciding  the  question  of  operation,  its  un- 
favourable results  should  also  be  borne  in  mind.  A  not  uncommon 
consequence  is  injury  to  the  intestine  from  the  breaking  up  of  adhesions, 
which  may  result  in  fascal  fistulae.  For  the  surgical  aspect  of  the  treat- 
ment the  reader  should  consult  works  upon  surgery. 

ASCITES. 

Ascites  consists  in  an  accumulation  of  fluid,  usually  clear  serum,  in 
the  general  peritoneal  cavity.  It  is  a  symptom  of  the  various  forms  of 
peritonitis,  especially  the  chronic  varieties  described  in  the  preceding 
pages.  It  may  be  due  also  to  portal  obstruction  from  cirrhosis  of  the 
liver,  or  pressure  upon  the  portal  vein  by  peritoneal  adhesions  or  large 
lymphatic  glands.  It  is  occasionally  seen  in  all  forms  of  abdominal 
tumours.  Ascites  may  occur  in  general  dropsy  from  cardiac  disease, 
chronic  pleurisy,  or  interstitial  pneumonia,  or  from  any  condition  caus- 
ing pressure  upon  the  vena  cava.  It  is  also  seen  in  the  general  dropsy 
of  renal  disease.  A  moderate  amount  of  ascites  is  often  met  with  in 
extreme  anaemia  or  leukaemia. 

Small  accumulations  of  fluid  in  the  peritoneal  cavity  are  difficult  of 
detection.  Large  amounts  are  generally  easily  made  out.  There  is  a 
uniform  smooth  distention  of  the  abdomen  and  dilatation  of  the  super- 
ficial veins,  especially  about  the  umbilicus.  On  palpation,  the  wave  of 
fluctuation  can  be  obtained  by  placing  one  hand  against  the  abdomen 
upon  one  side  and  giving  the  opposite  side  a  sliarp  tap.  A  similar  wave 
may  be  felt  when  there  is  tympanitic  distention.  The  two  are,  however, 
readily  distinguished  by  having  an  assistant  make  pressure  with  the 
edge  of  the  hand  along  the  linea  alba  while  the  test  is  being  made ;  this 
obstructs  the  wave  transmitted  through  the  abdominal  wall,  but  does 
not  affect  that  through  the  fluid.  On  percussion  in  the  sitting  posture, 
there  is  dulness  below  and  resonance  above.  When  the  patient  is  re- 
cumbent, there  is  resonance  in  the  median  line  and  dulness  or  flatness 
in  the  lateral  portion  of  the  abdomen. 

The  prognosis  and  treatment  of  ascites  will  depend  upon  its  cause. 

Chylous  Ascites. — This  term  is  applied  to  certain  cases  in  which  the 
abdominal  fluid  contains  fat.  The  colour  may  be  milky-white  or  light 
brown,  and  the  fluid,  after  standing,  may  have  at  its  surface  a  thick, 
creamy  layer.  The  amount  of  fat  present  has  been  as  high  as  five  per 
cent.  This  condition  is  rare  in  childhood.  The  exact  pathology  is  as 
yet  not  well  understood.  In  the  cases  which  have  thus  far  come  to 
autopsy  there  has  usually  been  found  chronic  peritonitis,  sometimes 
simple,  sometimes  tuberculous.  The  lymph  vessels  in  some  of  the  cases 
have  been  empty,  and  often  no  obstruction  of  the  lymph  circulation 


SUBPHREMC  ABSCESS.  453 

could  be  discovered.  Tlie  fat  is  believed  b}  some  to  be  derived  from 
fatty  degeneration  of  the  products  of  chronic  inflammation,  but  this 
seems  hardly  sufficient  to  explain  the  large  amount  of  fat  sometimes 
found.  In  some  of  the  cases  it  has  been  due  to  a  wound  of  the  thoracic 
duct.  The  amount  of  fluid  is  frequently  very  large.  The  prognosis  is 
usually  bad,  although  Pounds  has  reported  a  ease  in  a  girl  of  ten  years, 
where  recovery  followed  laparotomy.    Tul)erculous  peritonitis  was  present. 

SUBPHRENIC  ABSCESS. 

In  the  group  of  cases  of  localised  peritonitis  or  peritoneal  abscess, 
must  be  included  subphrenic  abscess.  This  is  a  rare  condition  in  child- 
hood, and  consists  in  an  accumulation  of  pus  just  beneath  the  diaphragm 
and  above  the  liver.  Its  cause  may  be  either  in  the  thorax  or  in  the  ab- 
domen. It  may  complicate  acute  pneumonia,  usually  of  the  right  lower 
lobe,  by  a  direct  extension  of  infection  through  the  lymph  channels. 
Sometimes  it  has  been  associated  with  phthisical  cavities.  In  the  abdo- 
men it  may  be  associated  with  disease  of  the  liver.  The  accumulation  of 
pus  is  sometimes  very  great,  so  that  the  diaphragm  is  crowded  high  into 
the  thorax. 

The  symptoms  and  physical  signs  closely  resemble  those  of  empyema, 
and  most  of  the  cases  have  been  operated  upon  with  the  belief  that  the 
surgeon  was  dealing  with  empyema.  Meltzer  has  reported  a  case  in  a 
child  of  two  years  which  followed  pneumonia  of  the  right  base.  At  the 
operation  only  a' few  drops  of  pus  were  found  in  the  pleural  cavity;  but 
there  was  discovered  a  pinhole  opening  in  the  diaphragm,  from  which  the 
pus  had  escaped  from  a  large  subphrenic  abscess.  This  was  evacuated, 
and  the  patient  recovered  perfectly.  Subphrenic  abscesses  may  contain 
air;  they  are  then  likely  to  be  mistaken  for  pneumothorax.  These  ab- 
scesses require  incision  and  drainage  like  other  forms  of  peritoneal 
abscess. 


SECTION   IV. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

CHAPTER    I. 

NASAL    CAVITIES. 

ACUTE  RHINO-PHARYNGITIS. 
{Acute  Nasal  Catarrh-Cory za.) 

Although  the  symptoms  of  acute  nasal  catarrh  are  chiefly  nasal,  the 
principal  seat  of  the  pathological  process  is  the  rhino-pharynx. 

Etiology. — Certain  children  are  predisposed  to  attacks  of  acute  nasal 
catarrh.  This  predisposition,  as  it  sometimes  extends  to  entire  fam- 
ilies, may  be  inherited;  but  more  frequently  it  is  acquired,  and  usually 
by  the  following  mode  of  life :  It  is  seen  in  children  who  get  very  little 
fresh  air,  because  they  are  kept  indoors  unless  the  weather  is  perfect; 
who  live  in  houses  always  overheated;  whose  sleeping  rooms  are  kept 
carefully  closed  at  night  for  fear  they  may  take  cold;  who  are  for  the 
same  reason  so  overloaded  with  clothing  that  they  can  not  engage  in 
any  active  play  without  being  thrown  into  a  profuse  perspiration.  These 
conditions  after  a  time  result  in  a  great  sensitiveness  of  all  the  mucous 
membranes,  but  especially  those  of  the  nose  and  pharynx,  which  is  much 
increased  by  residence  in  a  damp,  changeable  climate.  Young  infants 
and  those  who  are  rachitic,  are  frequent  sufferers  from  acute  nasal 
catarrh.  Attacks  are  often  brought  on  by  insufficient  covering  for  the 
head,  by  wetting  the  feet,  by  cold  and  exposure,  especially  to  street  dust 
a;nd  the  raw  winds  of  winter  and  spring,  accompanied  by  the  damp- 
ness which  occurs  with  melting  snow.  In  susceptible  children  the  ex- 
citing cause  is  often  a  very  trivial  one.  A  draught  of  cold  air  for  a 
few  minutes  may  be  sufficient  to  excite  sneezing  and  a  nasal  discharge. 
Atmospheric  conditions  are  probably  not  the  only  cause  of  acute  nasal 
catarrh.  Micro-organisms  certainly  play  an  important  part,  particularly 
the  staphylococcus  aureus,  pneumococcus,  streptococcus,  and  the  b.  in- 
fluenzae, their  importance  being  in  the  order  named.  Although  pyogenic 
germs  are  always  present  in  the  nose,  they  do  not  excite  an  attack  of 
acute  catarrh  without  the  vascular  changes  which  are  produced  by  other 
causes.  Acute  catarrh  ma}'  be  sporadic  or  epidemic;  certain  forms  are 
454 


ACUTE  RHINO-PHARYXGITIS.  455 

contagious,  being  communicated  by  c-liildren  using  the  same  handker- 
chief, occupying  the  same  bed  or  simply  by  close  contact. 

Acute  nasal  catarrh  may  be  a  symptom  of  measles,  nasal  diphtheria, 
or  influenza,  and  it  may  accompany  erysipelas  of  the  face. 

Symptoms. — In  the  mild  form  the  changes  in  the  mucous  membrane 
of  the  nose  are  not  great,  and  are  usually  secondary  to  those  of  the  rhino- 
phar3Tix,  being  in  a  large  measure  due  to  the  discharge.  There  is 
redness  and  slight  swelling.  The  nasal  passages  may  be  for  the  time 
quite  occluded  by  the  discharge,  which  is  usually  profuse,  at  first  sero- 
mucous,  and  later  muco-purulent.  The  symptoms  may  be  very  transient, 
sometimes  passing  away  in  a  few  hours,  in  which  cases  there  is  only  a 
vasomotor  disturbance;  or  they  may  continue  and  develop  into  a  true 
inflammation.  The  discharge  may  excoriate  the  nostrils  and  the  upper 
lip.  At  the  onset  there  is  usually  sneezing,  and  in  infants  often  a  slight 
fever.  In  older  children  there  is  no  rise  of  temperature  except  in  the 
most  severe  cases.  The  obstruction  to  nasal  respiration  causes  mouth- 
breathing,  and  the  dr}Tiess  and  discomfort  which  result  from  it  produce 
disturbed  sleep,  snuffling  and  difficulty  in  nursing,  this  being  in  severe 
cases  almost  impossible.  The  inflammation  may  extend  to  the  lachrymal 
duct,  involving  the  eyes  in  a  mild  conjunctivitis.  The  process  often 
extends  to  the  larynx  and  bronchi,  with  hoarseness  and  cough.  There 
may  be  closure  of  the  Eustachian  tubes,  causing  deafness  and  otalgia. 
The  chief  complication  for  which  the  physician  should  watch  is  otitis. 

The  severe  form  in  infants  is  often  attended  by  marked  constitutional 
symptoms ;  the  temperature  may  be  as  high  as  104°  or  105°  F.  and  some- 
times fluctuates  widely.  The  discharge  soon  becomes  muco-purulent  and 
is  very  profuse,  pouring  from  the  anterior  nares  and  filling  the  pharjmx. 
The  cultures  in  this  form  most  frequently  show  the  pneumococcus  and 
the  staphylococcus  aureus.  Severe  symptoms  often  continue  for  a  week 
or  more,  the  child  being  really  seriously  ill.  Complications  are  almost 
always  present.  In  most  cases  there  is  cervical  adenitis  and  otitis.  If  the 
child  is  a  delicate  one  broncho-pneumonia  is  apt  to  develop.  Eetro- 
pharyngeal  abscess  is  not  infrequently  seen. 

Diagnosis. — It  is  important  to  distinguish  between  a  simple  acute 
catarrh  and  one  due  to  measles,  influenza,  nasal  diphtheria,  or  hereditary 
syphilis.  Measles  and  influenza  usually  cause  more  fever  and  general 
constitutional  disturbance  than  does  simple  catarrh.  Nasal  diphtheria 
may  be  present  when  there  is  only  a  profuse  discharge  tinged  with  blood. 
When  such  a  discharge  persists  for  two  or  three  weeks  this  is  always  to 
be  suspected,  even  though  the  constitutional  symptoms  may  be  very 
slight.  The  only  positive  means  of  excluding  diphtheria  is  by  cultures. 
A  persistent  acute  nasal  catarrh  in  a  young  infant  should  always  suggest 
syphilis,  and  the  patient  should  be  carefully  watched  for  the  development 
of  other  symptoms. 


456  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Treatment. — A  young  child  suffering  from  acute  coryza  should  be 
kept  indoors  in  a  room  with  an  even  temperature  of  about  70°  F.,  the 
bowels  freely  opened,  and  the  amount  of  food  somewliat  reduced.  The 
only  drug  which  seems  to  have  much  influence  upon  the  secretion  is 
belladonna.  A  good  combination  is  that  known  as  the  "  rhinitis  "  tablet 
(camphor,  gr.  ^;  quinine,  gr.  ^;  fluid  extract  of  belladonna,  Tr\.  ^)  ;  on^ 
half  a  tablet  may  be  given  every  hour  to  a  child  of  five  years. 

Useful  local  applications  are  liquid  albolene,  oleo-stearate  of  zinc,  or 
alkaline  sprays,  such  as  Seller's  solution,  to  clear  away  the  secretions. 
If  the  nasal  obstruction  causes  great  interference  with  respiration  or 
nursing,  adrenalin  diluted  with  a  saline  solution  may  be  used  with  a 
medicine  dropper. 

The  upper  lip  and  nostrils  should  be  protected  by  vaseline  or  some 
simple  ointment.  Under  no  circumstances  should  irritating  or  astringent 
injections  be  given.  In  older  children  inhalations  of  spirits  of  camphor 
may  be  used  with  some  advantage. 

The  severe  cases  require  more  active  treatment.  For  most  of  them 
nasal  irrigation  with  a  warm  saline  solution  is  to  be  advised.  This 
should  be  done  as  in  diphtheria.  After  cleansing  the  rhino-pharynx  a 
few  drops  of  a  five-per-cent  solution  of  argyrol  may  be  dropped  into  the 
nostrils  two  or  three  times  daily. 

Prophylaxis  consists  in  solving  the  perplexing  question,  so  often 
put  to  the  physician,  of  how  to  prevent  children  from  "taking  cold." 
This  is  a  matter  of  the  utmost  importance,  and  follows  what  has  been 
previously  said  under  the  head  of  Etiology.  No  amount  of  cod-liver  oil 
and  iron  will  remove  this  tendency  to  catarrh  so  long  as  bad  hygienic 
conditions  continue.  Sleeping  rooms  should  be  large  and  well  ventilated, 
and  a  window  should  be  kept  open  at  night,  except  in  very  severe  weather 
or  during  acute  attacks.  The  temperature  of  the  house  during  the  day 
should  be  from  65°  to  68°  F.,  but  never  above  this.  Children  should  be 
accustomed  to  go  out  of  doors  unless  the  weather  is  especially  bad.  So 
firmly  rooted  in  the  minds  of  the  laity  is  the  idea  that  acute  catarrhs 
come  from  cold,  that  the  habit  of  coddling  delicate  children  is  always 
likely  to  be  carried  to  an  extreme. 

With  every  delicate  and  "  catarrhal "  child  one  should  begin  in  the 
summer  by  having  him  live  in  the  open  air  as  much  as  possible,  sleep- 
ing in  a  room  with  free  ventilation,  with  moderate  covering,  and  con- 
tinuing the  same  practice  into  the  fall  and  early  winter.  If  begun 
gradually  in  this  way  there  is  little  difficulty  in  continuing  throughout 
the  winter. 

The  next  point  to  be  insisted  on  is  cold  sponging  immediately  upon 
rising  in  the  morning,  especially  about  the  chest,  throat,  and  spine.  Th^ 
use  of  chest  protectors,  cotton  pads,  and  extremely  thick  clothing  should 
be  prohibited.     Flannel  underclothing  should  be  worn  upon  the  chest 


CHRONIC   NASAL  CATARRH.  457 

throughout  the  year,  and  upon  the  legs  also  in  winter ;  the  very  lightest 
in  summer,  and  only  a  medium  weight  in  winter. 

Frequently  repeated  attacks  point  to  the  presence  of  adenoid  vegeta- 
tions in  the  pharynx,  and  no  measures  are  of  much  avail  until  these  are 
removed. 

CHRONIC  NASAL  CATARRH. 

This  term  is  rather  loosely  used  to  designate  a  chronic  nasal  dis- 
charge. Such  a  discharge  is  frequent  both  in  infancy  and  childhood. 
It  is  a  condition  much  neglected  by  the  general  practitioner.  Patients 
are  too  often  subjected  to  routine  constitutional  treatment  by  cod-liver 
oil  and  preparations  of  iodine,  with  the  idea  that  such  cases  are  "  scrofu- 
lous," while  local  treatment  is  either  neglected  altogether,  or  consists 
only  of  the  use  of  the  nasal  douche  or  syringing  with  a  saline  solution. 
Sometimes,  when  suggested  by  parents,  local  treatment  is  opposed  by  the 
physician  in  the  case  of  young  children,  and  a  great  amount  of  harm 
follows.  Permanent  damage  to  the  organs  of  hearing,  smell,  speech,  and 
respiration  may  result  from  neglecting  or  ignoring  chronic  nasal  catarrh 
in  childhood. 

Chronic  nasal  catarrh  is  not  to  be  regarded  as  a  disease,  but  only  as 
a  symptom  which  may  be  due  to  any  one  of  a  variety  of  pathological 
conditions,  each  of  which  requires  very  different  treatment,  viz.,  adenoid 
growths  of  the  pharynx,  foreign  bodies  in  the  nose,  polypi,  deviation 
of  the  septum  or  any  other  congenital  deformity  of  the  nasal  passages, 
the  various  forms  of  chronic  rhinitis,  and  syphilis,  which  causes  a  form 
of  rhinitis  peculiar  to  itself. 

Adenoid  Growths  of  the  Pharynx. — These  are  more  fully  discussed 
elsewhere.  They  are  by  far  the  most  frequent  cause  of  chronic  nasal 
discharge  in  infants  and  young  children,  and  should  be  the  first  sus- 
pected. Every  general  practitioner  can  easily  familiarise  himself  with 
the  method  of  digital  exploration  of  the  rhino-pharynx,  by  which  means 
these  growths  can  in  most  cases  be  easily  recognised.  The  nasal  dis- 
charge accompanying  adenoid  growths  is  due  to  a  chronic  rhino-pharyn- 
gitis. Treatment  is  without  avail  unless  the  growths  are  removed.  After 
this  is  done  the  nasal  discharge  usually  disappears  quite  promptly. 

Foreign  Bodies  in  the  Nose. — This  condition  should  be  suspected 
whenever  there  is  an  abundant  muco-purulent  discharge  limited  to  one 
nostril.  Foreign  bodies  in  the  nose  are  quite  frequent  in  young  children. 
Peas,  beans,  beads,  or  shoe  buttons  are  most  frequently  lodged  there. 
The  efforts  at  removal  on  the  part  of  the  child,  or  even  of  the  mother, 
generally  result  in  pushing  the  body  farther  into  the  nose.  It  first  sets 
up  a  mechanical  irritation,  accompanied  by  pain,  swelling,  sneezing,  and 
sometimes  haemorrhage.  This  is  followed  by  a  catarrhal  inflammation, 
which  in  the  course  of  a  few  days  becomes  purulent,  and  may  last  in- 


468  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

definitely.  The  discharge  is  generally  quite  abundant.  The  symptoms 
point  to  an  obstruction  of  one  nostril,  and  an  examination  with  the  probe 
readily  detects  the  presence  of  the  foreign  body. 

In  recent  cases  the  removal  of  the  foreign  body  may  sometimes  be 
accomplished  by  compressing  the  empty  nostril  and  having  the  child 
blow  his  nose  strongly.  Often  the  sneezing  which  the  foreign  body  ex- 
cites is  sufficient  to  remove  it.  Before  any  attempt  is  made  to  seize  the 
body  with  forceps  cocaine  should  be  used,  not  only  for  the  purpose  of 
preventing  pain,  but  in  order  to  contract  the  mucous  membrane  so  as  to 
allow  better  manipulation.  In  many  cases  chloroform  is  necessary.  In 
most  circumstances  ordinary  foreign  bodies  can  with  proper  forceps  be 
extracted  without  difficulty.  ISTo  subsequent  treatment  is  required,  except 
the  use  of  some  mild  antiseptic  to  keep  the  nose  clean  for  a  few  days, 
as  the  inflammation  quickly  subsides  after  the  removal  of  the  cause. 

Nasal  Polypi. — These  are  among  the  infrequent  causes  of  chronic 
nasal  discharge  in  childhood.  They  are  especially  rare  before  the  seventh 
year,  but  both  mucous  and  fibrous  polypi  are  seen.  The  symptoms  are 
those  of  a  chronic  nasal  catarrh  with  partial  or  complete  obstruction  of 
one  or  both  sides.  Polypi  increase  in  size  with  the  occurrence  of  every 
acute  coryza,  and  are  always  especially  troublesome  in  damp  weather. 
They  may  be  accompanied  by  reflex  symptoms,  such  as  cough,  sneezing, 
and  even  by  attacks  of  asthma.  There  may  be  headache,  and  sometimes 
disturbances  of  smell,  taste,  and  hearing.  The  symptoms  are  of  much 
longer  duration  than  in  the  case  of  obstruction  from  a  foreign  body,  the 
discharge  is  not  so  abundant,  and  is  not  purulent.  The  diagnosis  is 
made  only  by  examining  the  nose  with  the  mirror  and  nasal  speculum. 

Polypi  may  be  removed  with  the  forceps,  but  this  is  best  accomplished 
by  the  use  of  the  wire  snare.  When  they  have  been  present  for  a  long 
time  the  accompanying  chronic  rhinitis  may  require  subsequent  treat- 
ment 

Deviation  of  the  nasal  septum,  and  other  congenital  deformities 
which  cause  narrowing  of  the  nasal  respiratory  tract,  are  conditions 
which  belong  to  the  specialist. 

CHRONIC  RHINITIS. 

Simple  Chronic  Rhinitis. — Simple  chronic  rhinitis  existing  alone  is- 
of  rare  occurrence  in  young  children.  In  the  cases  so  classed  the  symp- 
toms are  usually  due  to  rhino-pharyngitis,  which  almost  invariably  de- 
pends upon  an  adenoid  growth.  The  growth  may  be  a  small  one,  so 
that  the  symptoms  of  obstruction  are  slight  or  absent.  A  frequent  com- 
plication is  chronic  enlargement  of  the  cervical  lymph  glands. 

The  only  constant  symptom  is  an  excessive  nasal  discharge  which  is 
usually  mucous  but  which  may  be  muco-purulent.     It  is  easily  removed 


CHRONICA   RHINITIS.  459 

by  blowing  the  nose,  if  the  child  is  old  enough  to  be  taught  to  do  this. 
Children  too  young  to  clear  the  nose  in  this  way,  suffer  from  almost  con- 
stant discomfort.  The  amount  of  discharge  dejjends  upon  the  severity  of 
the  case.  It  frequently  causes  irritation  of  the  upper  lip,  which  may  be 
the  seat  of  eczema  or  impetigo,  especially  in  infants.  The  lip  may  be 
swollen  and  prominent.  The  condition  of  the  external  parts  is  aggra- 
vated by  the  constant  disposition  to  pick  the  nose,  which  may  be  over- 
come by  the  application  of  a  short  anterior  splint  to  each  elbow. 

Epistaxis  sometimes  occurs.  Tlie  duration  of  the  disease  is  indefi- 
nite ;  it  may  last  for  montlis  or  even  for  years,  the  symptoms  in  summer 
being  insignificant,  but  returning  every  cold  season.  It  may  terminate 
in  recovery,  or,  in  children  with  flabby  tissues  and  delicate  constitution, 
it  may  be  followed  in  later  childhood  by  hypertrophic  rhinitis. 

Treatment. — Prophjdaxis  is  very  important.  The  main  purpose 
should  be  to  prevent  attacks  of  acute  nasal  catarrh  by  the  measures  men- 
tioned in  the  discussion  of  that  disease.  The  general  treatment  should 
not  be  routine,  but  based  upon  the  indications  of  each  case.  General 
tonic  treatment  is  required  in  most  cases. 

Local  treatment  consists  first  in  cleanliness,  and,  secondly,  in  the  use 
of  astringents  in  the  form  of  powder  or  solution.  In  infants,  if  the  dis- 
charge is  abundant,  the  only  efficient  method  of  getting  rid  of  it  is  by 
nasal  syringing.  This  is  attended  by  some  risk  of  forcing  materials  into 
the  middle  ear;  but  if  carefully  done,  the  danger  seems  to  me  to  be  less 
than  that  of  allowing  the  discharge  to  remain.  All  solutions  are  to  be 
made  with  sterile  water  and  used  warm,  either  with  a  nasal  douche 
or  syringe.  Very  little  force  should  be  employed,  and  it  may  be  well  to 
have  a  syringe  the  nozzle  of  which  does  not  completely  fill  the  nostril. 
Either  Dobell's  or  Seller's  solution  may  be  employed,  diluted  with  an 
equal  amount  of  water.  Ordinarily,  the  nose  should  be  cleansed  thor- 
oughly twice  a  day,  more  frequently  in  very  severe  cases.  Harm  is  often 
done  by  the  overzealous  use  of  local  treatment  in  these  conditions. 

Syphilitic  Rhinitis. — Ehinitis  is  seen  both  in  early  and  late  hered- 
itary syphilis.  Coryza,  or  snuffles,  is  one  of  its  earliest  and  most  con- 
stant symptoms.  It  usually  begins  between  the  third  and  sixth  weeks 
of  life,  rarely  after  the  third  month.  The  pathological  condition  is  a 
subacute  catarrhal  rhinitis,  sometimes  with  the  formation  of  superficial 
ulcers  or  mucous  patches.  The  disease  is  usually  attended  by  a  profuse 
nasal  discharge  of  sero-mucus  or  muco-pus,  occasionally  tinged  with 
blood.  It  may  continue  from  a  few  weeks  to  two  or  three  months.  It 
usually  requires  only  constitutional  treatment,  and  protection  of  the 
nostrils  and  lips  by  the  use  of  the  ointment  of  the  yellow  oxide  of  mer- 
cury diluted  with  four  parts  of  vaseline.  When  the  discharge,  is  very 
abundant,  any  one  of  the  cleansing  solutions  previously  mentioned  may 
be  used  as  a  spray. 


460  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  rhinitis  of  late  hereditary  syphilis  is  a  very  different  patholog- 
ical condition.  There  are  here  gummatous  deposits  which  break  down, 
and  form  ulcers  of  the  mucous  membrane  and  deeper  tissues.  There  is 
also  periostitis,  with  extension  of  the  disease  to  the  cartilages  and  bones 
of  the  nasal  fossae,  particularly  of  the  septum.  There  may  be  perforation 
of  the  triangular  cartilage,  necrosis  of  the  vomer  or  nasal  bones,  perfora- 
tion of  the  hard  or  soft  palate,  and  at  times  extensive  ulceration  of  the 
alae  nasi  and  the  face.  Cicatrisation  may  follow,  causing  stenosis  of  the 
nostril.  These  lesions  in  the  nose  are  generally  accompanied  by  deep 
ulceration  of  the  pharynx  and  soft  palate.  They  usually  occur  in  chil- 
dren who  have  presented  the  early  symptoms  of  hereditary  syphilis,  but 
are  occasionally  seen  when  no  such  history  can  be  obtained.  Such  was 
the  case  in  a  patient  recently  under  observation  in  the  Babies'  Hospital, 
who  had  perforation  of  the  nasal  septum  and  of  the  floor  of  the  nasal 
fossae,  causing  a  free  communication  with  the  mouth.  These  are  cases 
of  true  ozaena.  The  odour  from  the  discharge  is  at  times  almost  intoler- 
able. When  neglected,  these  cases  go  on  from  bad  to  worse,  and  may 
continue  for  years,  producing  unsightly  deformities. 

The  constitutional  treatment  is  that  of  hereditary  syphilis  in  general 
and  is  discussed  in  the  chapter  upon  that  disease. 

Locally  there  may  be  used  a  spray  of  one  of  the  cleansing  solutions 
already  mentioned,  or  black  wash,  or  a  solution  of  bichloride  of  mercury, 
1  to  10,000.  Although  improvement  may  take  place  quite  promptly,  the 
results  of  treatment  in  the  late  cases  are  often  unsatisfactory,  as  the 
disease  has  usually  progressed  so  far  before  treatment  is  begun  that 
some  deformity  of  the  nose  results,  usually  a  sinking  in  of  the  bridge 
and  flattening  of  the  alae,  giving  rise  to  the  so-called  "  saddle-back  " 
deformity. 

EPISTAXIS. 

The  haemorrhage  may  come  from  any  part  of  the  nasal  fossae,  but  it 
is  generally  from  the  anterior  nares,  and  most  frequently  from  the  vessels 
of  the  septum.  Epistaxis  is  a  rare  symptom  in  the  haemorrhages  of  the 
newly  born,  and  when  present  indicates  syphilis.  It  is  infrequent 
throughout  infancy,  but  in  childhood  it  is  quite  common,  occurring  in 
boys  more  frequently  than  in  girls.  In  the  latter  it  is  especially  common 
about  the  time  of  puberty.  Children  who  are  kept  much  indoors  in 
overheated  apartments,  and  who  have  susceptible  mucous  membranes  and 
flabby  tissues,  are  particularly  prone  to  it.  The  exciting  cause  may  be  a 
local  one,  like  a  fall  or  blow;  it  may  be  due  to  picking  the  nose,  or  to 
any  kind  of  mechanical  irritation;  it  may  be  associated  with  nasal  ca- 
tarrh; and  it  is  often  caused  by  a  small  ulcer  upon  the  septum.  An 
attack  may  be  brought  on  by  mental  or  physical  excitement.  It  occurs 
as  an  occasional,  often  an  early  symptom,  in  typhoid  or  malarial  fever. 


EPISTAXIS.  461 

in  measles,  or  during  severe  paroxysms  of  pertussis.  It  is  seen  in  the 
hsemorrhagic  form  of  all  the  eruptive  fevers,  in  certain  cases  of  diph- 
theria, in  haemophilia  and  scorbutus,  in  grave  anaemia,  leukaemia,  and  in 
diseases  of  the  heart  and  blood-vessels. 

Symptoms. — Epistaxis  is  frequently  preceded  by  a  sense  of  fulness  or 
pain  in  the  head,  which  is  relieved  by  the  bleeding.  The  blood  is  usually 
from  one  nostril,  and  comes  slowly  by  drops.  The  amount  lost  is  gen- 
erally small,  but  it  may  be  large  enough,  when  repeated,  to  produce  a 
serious  grade  of  anaemia  even  in  strong  children,  and  the  haemorrhage 
may  prove  fatal.  Epistaxis  may  be  overlooked  if  the  blood  finds  its  way 
into  the  pharynx  and  is  swallowed.  In  most  of  the  cases  the  haemor- 
rhage ceases  spontaneously  in  from  ten  to  twenty  minutes,  recurring  at 
longer  or  shorter  intervals,  according  to  the  nature  of  the  cause.  Haem- 
orrhage from  adenoid  growths  of  the  pharynx  may  closely  resemble  that 
from  the  nose,  but  otherwise  there  can  rarely  be  any  difficulty  in  recog- 
nising epistaxis. 

Prognosis.-^-This  depends  upon  the  cause.  In  the  great  majority  of 
the  so-called  idiopathic  cases  epistaxis  is  not  serious.  Occurring  early  in 
the  course  of  the  infectious  diseases,  it  does  not  ordinarily  affect  the  prog- 
nosis unless  it  is  very  severe.  When  it  occurs  late,  however,  it  is  always 
a  bad  sign,  and  particularly  so  in  diphtheria.  It  may  be  serious  in  any 
of  the  hsemorrhagic  diseases  or  in  diseases  of  the  blood,  where  it  is  not 
infrequently  a  cause  of  death. 

Treatment. — To  remove  the  predisposition,  a  child  should  receive 
general  tonic  treatment,  especially  plenty  of  outdoor  exercise,  and  every 
means  should  be  taken,  by  the  use  of  cold  baths,  friction,  and  proper  food, 
to  tone  up  the  vascular  system. 

An  efficient  means  of  arresting  the  haemorrhage  is  compression  of  the 
nose  between  the  thumb  and  finger.  This  may  be  combined  with  the 
application  of  ice  over  the  nose,  and  sometimes  small  pieces  of  ice  may 
be  introduced  into  the  nostrils.  The  application  of  cold  to  the  back  of 
the  neck  or  its  use  in  the  mouth  may  be  of  service  by  exciting  reflex 
contraction  of  the  capillary  vessels.  All  tight  clothing  or  bands  about 
the  neck  should  be  loosened,  and  the  patient  kept  quiet  in  the  sitting 
posture.  After  the  haemorrhage  has  ceased  the  child  should  not  blow 
his  nose  for  some  time.  Adrenalin  is  one  of  the  most  efficient  local  means 
of  checking  the  bleeding.  Another  valuable  remedy  is  the  peroxide  of 
hydrogen,  used  full  strength.  If  bleeding  continues  in  spite  of  all  the 
above  measures,  the  anterior  nares  should  be  plugged  with  styptic  cotton, 
and  if  this  does  not  control  it,  the  posterior  nares  should  be  plugged. 
Usually  very  little  effect  is  seen  from  drugs  given  internally,  although 
in  frequently  recurring  haemorrhages  where  no  local  cause  can  be  dis- 
covered, calcium  lactate  should  be  tried ;  at  least  thirty  of  forty  grains  a 
day  should  be  given  to  a  child  of  five  years. 


462  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

In  severe  cases  of  nasal  haemorrhage  recurring  at  short  intervals  with- 
out any  apparent  cause,  ulcer  of  the  septum  should  be  suspected,  and, 
if  present,  should  be  touched  with  chromic  acid. 


CHAPTER    II. 

DISEASES  OF  THE  LARYNX. 

The  characteristic  feature  of  laryngeal  disease  in  infants  and  young 
children  is  the  association  of  muscular  spasm  with  all  forms  of  inflam- 
mation. Often  it  is  the  laryngeal  spasm,  rather  than  the  inflamma- 
tion, which  gives  rise  to  the  principal  symptoms.  This  spasm  is  only  one 
expression  of  the  great  reflex  irritability  of  young  children. 

CATARRHAL  SPASM  OF  THE  LARYNX 

(Spasmodic  Laryngitis;  Spasmodic  Croup;  Catarrhal  Croup). 

The  term  catarrhal  spasm,  first  suggested,  I  think,  by  Goodhart,  is 
fairly  descriptive  of  this  disease,  which  is  characterised  by  a  very  mild 
degree  of  catarrhal  inflammation  associated  with  marked  laryngeal 
spasm. 

Etiology. — It  is  not  often  seen  during  the  first  six  months,  but  is 
frequent  from  this  time  up  to  the  third  year.  After  five  years  it  is  rare. 
It  occurs  in  children  who  are  well  nourished,  as  well  as  in  those  who  are 
cachetic.  Certain  children  have  a  predisposition  to  such  attacks;  those 
who  have  had  one  attack  are  likely  to  have  others.  The  condition  has 
many  points  of  resemblance  to  spasmodic  asthma  which  may  replace  it 
in  later  childhood.  Heredity  seems  to  have  some  influence  in  producing 
this  extreme  susceptibility  of  the  air  passages.  Catarrhal  spasm  of  the 
larynx  is  most  frequently  associated  with  enlarged  tonsils  and  adenoid 
growths  of  the  pharynx,  sometimes  with  elongated  uvula.  The  exciting 
cause  may  be  exposure  to  cold,  especially  to  high  winds,  or  an  attack 
of  indigestion. 

Lesions. — The  catarrhal  inflammation  of  the  larynx  affects  chiefly 
the  parts  above  the  cords;  there  is  congestion  and  dryness,  and  later  in- 
creased secretion  of  mucus.  To  this  there  is  added  a  spasm  of  the 
muscles  of  the  larynx,  especially  the  adductors.  There  is  no  submucous 
infiltration,  and  no  tendency  to  oedema  glottidis. 

Symptoms. — The  attack  may  be  preceded  for  several  hours  by  slight 
hoarseness,  or  by  a  nasal  discharge.  During  the  day  the  child  may 
appear  perfectly  well.  Usually  there  is  lieard  during  the  evening  a 
hollow,  barking  cough,  at  first  infrequent  and  not  severe.  About  mid- 
night this  is  apt  to  increase  in  severity,  and  there  is  now  difficulty  in 


CATARRHAL  SPASM   OF  THE   LARYNX.  463 

breathing.  As  soon  as  tliis  becomes  marked  tlie  eliild  wakes,  and  presents 
the  characteristic  symptoms  of  an  attack.  In  the  mildest  cases  the 
dyspnoea  is  not  sufficient  to  waken  the  child.  In  severe  cases  there  is 
marked  dyspnoea,  especially  on  inspiration,  and  a  loud  stridor  as  the  air 
is  drawn  through  the  narrowed  opening  of  the  glottis.  This  may  often 
be  heard  in  an  adjoining  room.  There  is  seen  on  inspiration  deep 
recession  of  the  suprasternal  fossa,  the  supraclavicular  spaces,  and  the 
epigastrium;  also  depression  of  the  intercostal  spaces,  and  even  of  the 
walls  of  the  chest.  Any  excitement  increases  the  spasm  and  aggravates 
the  dyspnoea.  The  distress  may  be  very  great;  the  breathing  usually 
slow  and  laboured ;  the  voice  hoarse,  but  rarely  lost ;  the  cough  stridulous, 
hoarse,  and  metallic ;  the  pulse  rapid ;  the  temperature  normal  or  slightly 
elevated,  rarely  over  101°  F.  There  may  be  slight  lividity  of  the  finger- 
tips and  of  the  lips,  and  sometimes  considerable  prostration.  In  the 
course  of  three  or  four  hours  the  attack  slowly  wears  away  and  the  child 
falls  asleep.  During  the  following  day,  aside  from  slight  hoarse- 
ness and  occasional  cough,  he  is  apparently  well.  .  Most  of  tlie  cases 
are  not  so  severe  as  this;  there  are  the  croupy  cough,  hoarseness,  and 
general  discomfort,  but  not  marked  dyspnoea.  On  the  second  night 
there  is  a  repetition  of  the  experience  of  the  first,  usually  quite  as 
severe  unless  affected  by  treatment;  and  on  the  third  day  a  remission 
similar  to  that  of  the  day  previous.  On  the  third  night  the  attack,  if 
it  occurs  at  all,  is  generally  a  mild  one.  Slight  hoarseness  persists 
for  several  days,  but  otherwise  the  child  is  apparently  well.  Many 
children  have  such  attacks  every  few  weeks  in  the  course  of  the  cold 
season,  the  slightest  exposure  or  an  indiscretion  in  diet  being  sufficient 
to  induce  one. 

Prognosis. — This  is  good,  the  disease  never,  I  think,  proving  fatal, 
although  nothing  is  more  alarming,  at  least  to  parents,  than  to  witness 
for  the  first  time  one  of  these  severe  attacks  of  catarrhal  croup. 

Diagnosis. — Catarrhal  spasm  may  be  confounded  with  laryngismus 
stridulus  and  with  membranous  croup.  Laryngismus  stridulus  is  rela- 
tively a  rare  disease,  and  occurs  only  in  infancy.  In  it  we  have  not 
simply  stridulous  breathing,  but  periods  of  complete  cessation  of  respira- 
tion. These  may  be  repeated  many  times  during  the  day,  and  may  con- 
tinue for  weeks,  being  often  complicated  by  carpo-pedal  spasm,  some- 
times by  general  convulsions. 

From  membranous  laryngitis,  catarrhal  spasm  is  distinguished  by  its 
sudden  onset,  the  mildness  of  the  symptoms  of  inflammation,  the  spas- 
modic character  of  the  dyspnoea,  and  the  daily  remissions.  The  history 
of  previous  attacks  will  often  aid  in  diagnosis.  In  case  of  doubt,  a  posi- 
tive diagnosis  can  often  be  made  by  allowing  the  child  to  inhale  a  little 
chloroform.  This  at  once  relieves  dyspncea  due  to  spasm,  while  it  has 
scarcely  any  effect  upon  that  due  to  membrane. 


464  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Treatment. — The  purpose  of  treatment  during  the  attack  is  to  pro- 
duce relaxation  of  the  laryngeal  spasm.  This  is  accomplished  by  the  use 
of  emetics,  steam,  and  hot  fomentations  over  the  larynx.  A  favourite 
emetic  is  a  tablet  triturate  of  antimony  and  ipecac,  gr.  ^^  each.  To 
a  child  of  two  years,  one  tablet  may  be  given  every  ten  or  fifteen  minutes, 
until  free  vomiting  occurs;  or  a  teaspoonful  of  the  syrup  of  ipecac  and 
fifteen  drops  of  the  wine  of  antimony  at  the  same  intervals.  Given  at 
longer  intervals,  these  remedies  are  useful  in  relaxing  spasm  without 
causing  emesis.  When  children  do  not  vomit  after  two  or  three  doses  the 
antimony  should  not  be  repeated,  as  it  may  produce  serious  depression. 

Emetics  have  a  double  value  if  the  attack  is  due  to  indigestion.  If 
there  is  constipation,  an  enema  should  be  given.  Following  the  free 
vomiting  there  is  generally  some  improvement  in  the  symptoms,  but 
there  may  be  a  recurrence  of  the  spasm  unless  other  means  are  em- 
ployed. To  prevent  this,  antipyrine  is  one  of  the  most  useful  drugs. 
One  grain  may  be  given  to  a  child  one  year  old.  This  may  be  repeated 
every  two  hours  if  necessary.  Quite  as  much  relief  as  that  obtained  from 
the  drugs  mentioned  is  seen  from  the  use  of  steam  inhalations.  For 
this  purpose  the  child  should  be  placed  in  a  closed  tent,  and  steam  intro- 
duced from  a  croup  kettle.  This  may  be  used  in  conjunction  with  other 
measures,  and  continued  as  long  as  necessary.  Poultices  or  hot  fomen- 
tations over  the  larynx  are  often  useful.  In  one  case  in  which  severe 
spasm  had  recurred  for  eight  successive  nights  in  spite  of  everything 
that  was  tried,  the  child  being  in  great  distress  from  the  dyspnoea, 
I  performed  intubation,  which  gave  instant  relief.  Tracheotomy,  how- 
ever, would  scarcely  be  advisable. 

During  the  day  following  the  first  night  attack,  the  child  should 
be  kept  in  a  warm  room,  and  it  is  well  to  continue  the  antimony  and 
ipecac  in  doses  too  small  to  produce  vomiting,  e.  g.,  gr.  j^  each,  every 
four  hours.  After  6  p.m.  the  doses  should  be  doubled,  and  at  bedtime 
two  grains  of  antipyrine  given.  If  so  treated,  the  symptoms  may  not 
recur  upon  the  second  night,  or  there  may  be  only  the  cough  without 
the  severe  dyspnoea.  The  child  should  be  confined  to  the  house  for  two 
or  three  days  after  one  of  these  attacks,  the  drugs  being  gradually 
reduced ;  but  the  antipyrine  should  l)e  given  at  bedtime  for  three  or  four 
successive  nights. 

To  prevent  a  repetition  of  the  attacks  and  remove  the  tendency  to 
them,  it  is  most  important  that  the  child  should  have  plenty  of  fresh  air 
and  cold  bathing,  especially  cold  sponging  about  the  neck  and  chest. 
Everything  which  experience  has  shown  to  bring  on  the  attack  should  be 
carefully  avoided.  Local  causes,  such  as  adenoid  growths  and  hyper- 
trophied  tonsils,  should  receive  appropriate  treatment.  Generally  it  is 
not  necessary  to  exclude  fresh  air  from  the  sleeping  room.  Although  an 
open  window  on  a  cold,  damp  night  may  sometimes  excite  an  attack. 


ACUTE  CATARRHAL  LARYNGITIS.  465 

plenty  of  fresh  air  regularly  given  tends  rather  to  diminish  the  suscep- 
tibility. If  the  child's  condition  is  poor,  general  tonic  treatment  is  to 
be  employed. 

ACUTE  CATARRHAL  LARYNGITIS. 

Acute  laryngitis  is  not  nearly  so  frequent  as  the  disease  just  desoribed, 
although  it  is  much  more  severe,  and  may  even  be  fatal.  It  occurs  espe- 
cially in  children  from  one  to  five  years  of  age,  usually  in  the  cold 
season.  Predisposition  to  attacks  is  induced  by  the  same  conditions  as 
in  the  case  of  acute  rhinitis.  Catarrhal  laryngitis  may  be  primary,  when 
it  is  usually  excited  by  cold  or  exposure,^  or  it  may  be  secondary  to 
measles,  influenza,  scarlet  fever,  or  other  infectious  diseases.  It  may 
also  be  of  traumatic  origin,  from  the  inhalation  of  steam  or  irritating 
gases. 

Lesions. — There  is  a  moderately  intense  congestion  of  the  laryngeal 
mucous  membrane,  sometimes  general  and  sometimes  localised.  This 
may  be  seen  with  the  laryngoscope,  but  is  not  always  visible  after  death. 
With  the  congestion  there  are  swelling  and  dryness,  followed  by  increased 
secretion.  In  the  milder  cases  the  process  is  limited  to  the  mucosa.  In 
the  more  severe  cases  it  involves  the  submucosa  also,  which  is  congested, 
(Edematous,  and  may  be  infiltrated  with  cells.  The  changes  are  especially 
marked  in  the  lymphoid  tissue  of  the  subglottic  region.  The  swelling 
may  be  sufficient  to  produce  a  very  marked  degree  of  laryngeal  stenosis. 
In  many  mild  and  in  all  the  severe  cases  there  is  associated  catarrhal 
inflammation  of  the  trachea,  and  often  of  the  larger  bronchi.  In  young 
children  there  is  very  little  tendency  to  oedema  glottidis. 

Symptoms. — In  the  mild  form,  such  as  that  which  is  usually  seen  in 
older  children,  there  is  hoarseness,  or  even  loss  of  voice,  and  a  laryngeal 
cough  which  is  sometimes  hard  and  teasing,  always  worse  at  night. 
There  may  be  pain  and  soreness  over  the  larynx.  Constitutional  symp- 
toms are  mild  or  absent,  the  patient  not  usually  being  sick  enough  to  go 
to  bed,  and  often  rebelling  even  at  being  kept  indoors.  The  duration 
of  the  disease  is  from  four  to  ten  days,  with  a  strong  tendency  to  relapses 
from  slight  causes. 

The  severe  form  of  catarrhal  laryngitis  is  sometimes  preceded  by 
acute  coryza,  or  there  may  be  mild  laryngeal  symptoms  for  a  few  days 
before  the  development  of  the  more  severe  ones.     In  other  cases  the 

1  The  following  case  is  a  good  illustration  of  a  severe  attack  excited  by  cold:  A 
rather  delicate  infant,  eight  months  old,  an  inmate  of  the  New  York  Infant  Asylum, 
was  taken  out,  with  very  slight  covering,  on  a  raw  December  day.  In  a  few  hours 
hoarseness  and  stridor  were  noticed,  and  the  temperature  was  101°  F.;  three  hours 
later  it  was  103°  F. ,  and  in  spite  of  the  usual  remedies  which  were  employed  the  dyspnoea 
had  reached  such  a  degree  as  to  require  intubation.  The  tube  was  worn  only  three 
days  and  the  child  made  a  prompt  recovery. 
31 


466  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

disease  develops  rapidly  and  severe  symptoms  are  present  within  a  few 
hours  from  the  onset. 

When  the  case  is  fully  developed  the  voice  is  metallic  and  hoarse, 
and  occasionally  but  not  usually  lost.  There  is  a  hoarse,  dry,  barking 
cough,  which  is  very  distressing,  and  sometimes  almost  constant.  The 
cough,-like  the  voice,  is  stridulous,  and  more  or  less  stridor  is  present  on 
inspiration.  There  is  a  slight  amount  of  constant  dyspnoea,  but  this  is 
scarcely  noticeable  unless  the  chest  is  bared.  Severe  dyspnoea  occurs  in 
paroxysms,  usually  at  night.  Then,  we  may  get  the  signs  of  obstructive 
dyspnoea  similar  to  those  mentioned  in  severe  attacks  of  catarrhal  spasm. 
This  dyspnoea  is  chiefly  inspiratory,  but  in  some  cases  it  increases  stead- 
ily from  the  beginning  of  the  attack,  and  may  be  indistinguishable  from 
that  due  to  membrane.  Constitutional  symptoms  are  usually  present  and 
may  be  severe.  The  temperature  ranges  in  most  cases  from  101°  to 
103°  F.,  but  may  go  to  104°  or  105°  F.  The  pulse  is  rapid  and  full  and 
respiration  is  accelerated.  Children  sometimes  complain  of  pain  in  the 
larynx  and  trachea  which  is  increased  by  coughing.  The  symptoms  are 
severe  for  two  or  even  three  days,  the  fever  continuing  with  moderate 
prostration  and  paroxysms  of  dyspnoea,  sometimes  even  attacks  of  suf- 
focation and  cyanosis.  Usually  after  two  or  three  days  there  is  a  grad- 
ual subsidence  of  the  dyspnoea  and  the  inflammatory  symptoms,  and  the 
case  goes  on  to  recovery.  At  other  times  the  inflammation  extends  down- 
ward to  the  large  and  then  to  the  small  bronchi,  and  finally  results  in 
broncho-pneumonia.  The  attack  may  prove  fatal  from  laryngeal  ob- 
struction due  to  swelling  and  spasm. 

Diagnosis. — This  disease  is  chiefly  to  be  distinguished  from  mem- 
branous laryngitis.  The  onset  of  the  two  diseases  may  be  very  similar, 
and  for  the  first  twelve  hours  we  have  no  absolute  means  of  distinguish- 
ing between  them,  except  possibly  by  the  use  of  the  laryngoscope,  which 
is  often  conclusive  in  older  children  but  not  usually  so  in  infants.  All 
cases,  therefore,  should  be  looked  upon  with  a  degree  of  apprehension. 
The  temperature  in  the  catarrhal  is  usually  higher  than  in  the  mem- 
branous form.  The  dyspnoea  is  mainly  paroxysmal,  with  daily  remis- 
sions and  nightly  exacerbations,  and  is  chiefly  inspiratory,  while  that  of 
membranous  laryngitis  is  constant,  steadily  and  often  rapidly  increas- 
ing, and  is  present  both  on  inspiration  and  expiration.  In  catarrhal 
laryngitis  the  voice  is  not  usually  lost,  but  in  the  membranous  form  this 
is  the  rule.  There  can  be  little  room  for  doubt  when  there  are  enlarged 
glands,  membranous  patches  on  the  tonsils,  and  nasal  discharge.  Very 
often,  however,  all  these  evidences  of  diphtheria  are  wanting,  the  really 
difficult  cases  being  those  in  which  the  process  begins  in  the  larynx.  The 
prevalence  of  diphtheria  and  a  known  exposure  count  for  something  in 
favour  of  membranous  laryngitis.  If  cultures  from  the  pharynx  show 
the  presence  of  Klebs-Loeffler  bacilli,  diphtheria  of  the  larynx  is  certain ; 


ACUTE   CATARRHAL   LARYNGITIS.  467 

but  no  conclusions  can  be  drawn  from  negative  cultures.  In  catarrhal 
as  well  as  in  membranous  laryngitis  there  may  be  extreme  dyspnoea, 
cyanosis,  pallor,  prostration,  and  even  death. 

Prognosis. — This  depends  somewhat  upon  the  cause  of  the  disease 
and  also  upon  the  age  of  the  patient.  It  is  much  worse  when  it  is  sec- 
ondary to  measles  or  scarlet  fever.  It  is  better  in  children  over  three 
years  of  age  than  in  infants,  also  when  the  general  condition  of  the  child 
is  good.  The  prognosis  in  severe  catarrhal  laryngitis  should  always  be 
guarded,  not  only  on  its  own  account,  but  also  because  it  is  impossible 
at  first  to  be  certain  that  the  case  is  not  one  of  membranous  laryngitis. 

Treatment. — In  all  cases  children  affected  are  to  be  kept  in  bed,  and 
the  temperature  of  the  room  should  be  between  70°  and  72°  F.  The  diet 
should  be  light  and  fluid,  and  the  bowels  should  be  freely  opened.  A 
hot  mustard  foot  bath  should  be  given  at  the  outset.  Antipyrine  (one 
grain  every  two  hours  to  a  child  two  years  old)  is  useful  if  there  is 
much  spasmodic  dyspnoea.  For  this  symptom  emetics  are  beneficial, 
given  as  in.  catarrhal  spasm.  The  use  of  ipecac  and  squills  in  smaller 
doses  than  is  required  for  emesis  (five  drops  each  of  the  syrups  of  ipecac 
and  squills  every  two  hours)  may  give  relief,  especially  in  the  early  stage, 
when  the  cough  is  dry,  hard,  and  severe. 

All  the  remedies  mentioned  are  to  be  regarded  as  accessories  to  the 
essential  treatment,  which  consists  in  the  use  of  inhalations.  The  child 
should  be  placed  in  a  tent  into  which  steam  is  introduced  from  a  croup 
kettle.  Simple  steam  may  be  used,  or  turpentine,  compound  tincture 
of  benzoin,  lime-water,  or  creosote  may  be  added.  In  moderately  severe 
cases  inhalations  should  be  used  for  fifteen  minutes  every  two  hours; 
in  very  severe  ones  they  should  be  continued  the  greater  part  of  the 
time.  Poultices  or  hot  fomentations  may  be  applied  over  the  larynx. 
Belief  is  sometimes  obtained  by  using  counter-irritation  by  a  mustard 
paste,  but  blistering  should  never  be  allowed.  In  my  experience  the 
local  use  of  cold  is  very  unsatisfactory,  on  account  of  the  difficulty  of 
applying  it  properly,  and  the  objection  to  it  on  the  part  of  young  chil- 
dren. Stimulants  may  be  required  late  in  the  disease,  the  amount  of 
prostration  being  the  guide  to  their  use. 

In  cases  of  extreme  dyspnoea  operative  interference  may  be  needed. 
It  is  required  more  often  in  infants  and  young  children  than  in  those 
who  are  older.  Opinions  will  of  course  differ  as  to  when  the  dyspnoea 
has  reached  the  danger  point.  One  should  not  wait  for  general  cyanosis. 
If  pallor,  marked  prostration,  and  steadily  increasing  dyspnoea  are  pres- 
ent the  case  should  not  be  allowed  to  go  on  without  interference,  even 
though  one  may  be  perfectly  sure  that  the  case  is  one  of  catarrhal  inflam- 
mation only.  The  severity  of  the  dyspnoea  is  the  only  guide,  and  more 
than  once  I  have  seen  cases  shown  at  autopsy  to  be  catarrhal,  which  were 
regarded  during  life  as  undoubtedly  membranous.    If  intubation  is  done, 


468  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

the  tube  can  generally  be  dispensed  with  in  two  or  three  days.  Con- 
valescence is  usually  rapid,  but  there  is  danger  of  recurring  attacks 
during  the  remainder  of  the  cold  season. 

SUBMUCOUS  LARYNGITIS— (EDEMA  OF  THE  GLOTTIS. 

These  two  conditions  are  not  quite  identical,  although  they  are  closely 
associated  and  may  be  conveniently  considered  together.  They  are  both 
rare  in  early  life.  In  true  oedema  of  the  glottis  there  is  simply  a  drop- 
sical effusion  into  the  submucous  cellular  tissue  of  the  aryteno-epiglottic 
folds,  causing  them  to  project  as  large  rounded  swellings  on  either  side 
of  the  superior  isthmus  of  the  larynx.  They  may  be  of  sufficient  size 
to  cause  serious  or  even  fatal  obstruction  to  respiration.  With  the  laryn- 
goscope they  appear  as  pale  red  tumours,  lying  usually  in  contact  near 
the  base  of  the  tongue.  By  the  finger  their  presence  can  be  quite  as 
readily  distinguished.  (Edema  of  the  glottis  occurs  principally  in  the 
late  stages  of  nephritis. 

In  the  inflammatory  form  of  cedema,  or  true  submucous  laryngitis, 
there  is  the  same  sort  of  swelling  of  these  structures,  but  in  this  case 
it  is  due  to  some  active  inflammation  in  the  neighbourhood.  The  swell- 
ing is  partly  from  the  cedema  and  partly  from  cell  infiltration.  Usually 
all  the  parts  surrounding  the  upper  opening  of  the  larynx  are  in  a  state 
of  acute  inflammation.  The  epiglottis  may  be  swollen  to  the  thickness 
of  a  finger,  and  easily  seen  by  depressing  the  tongue. 

The  exciting  causes  may  be  the  mechanical  irritation  of  foreign 
bodies,  the  inhalation  of  steam  or  irritating  gases,  erysipelas  of  the  neck, 
primary  catarrhal  laryngitis,  or  retro-pharjugeal  abscess. 

The  symptoms  in  both  cases  consist  of  great  inspiratory  dyspncra 
with  attacks  of  suffocation,  while  expiration  may  be  quite  easy.  In  true 
cedema  there  are  in  addition  the  symptoms  of  the  primary  disease.  In 
the  inflammatory  form  there  are  the  evidences  of  local  inflammation — 
hoarseness,  cough,  pain,  and  difficulty  in  swallowing.  A  positive  diag- 
nosis may  be  made  by  a  digital  examination.  The  symptoms  develop 
with  great  rapidity  in  either  variety,  and  frequently  prove  fatal  in  a 
few  hours. 

The  treatment  of  true  oedema  consists  in  scarification  or  multiple 
puncture,  the  application  of  ice  externally,  and  even  the  swallowing  of 
ice;  in  the  inflammatory  form,  in  addition,  local  blood-letting  by  leeches 
and,  as  a  last  resort,  tracheotomy.    Intubation  is  useless  in  either  form. 

CHRONIC  LARYNGITIS. 

The  following  varieties  are  seen :  ( 1 )  A  simple  form  usually  asso- 
ciated with  adenoid  vegetations  of  the  pharynx;  (2)  tuberculous;  (3) 
syphilitic;   (4)   that  associated  with  new  growths. 


CHRONIC   LARYNGITIS.  469 

1.  With  Adenoid  Vegetations  of  the  Pharynx. — This  is  not  very  un- 
common. The  larynx  is  kept  in  a  state  of  chronic  congestion  by  the 
adenoid  growth,  and  there  finally  develops  a  slight  superficial  catarrhal 
inflammation.  The  symptoms  may  continue  for  many  months.  These 
cases  are  often  treated  for  a  long  time  unsuccessfully  by  the  use  of 
sprays,  inhalations,  etc.,  but  the  symptoms  disappear  rapidly  after  the 
removal  of  the  adenoid  growth.  Similar  symptoms  may  be  associated 
with  hypertrophic  rhinitis.  In  this  also  the  treatment  should  be  directed 
to  the  primary  condition. 

2.  Tuberculous  Laryngitis. — This  belongs  to  later  childhood,  and  is 
rare  even  then.  In  infancy  it  is  almost  unknown.  Eheindorf  has  re- 
ported a  case  in  a  child  of  thirteen  months,  which  was  regarded  during 
life  as  syphilitic,  but  was  shown  by  autopsy  to  be  tuberculous.  Of  six- 
teen cases  in  children,  reported  by  Eilliet  and  Barthez,  none  occurred 
during  the  first  three  years,  and  only  four  before  the  seventh  year.  The 
larynx  alone  may  be  affected,  or  the  larynx  and  trachea,  or  the  larynx, 
trachea,  and  lungs.  Pulmonary  tuberculosis  is  usually  found  to  be 
present  at  autopsy,  even  though  there  may  have  been  no  pulmonary 
symptoms.  Demme  has  reported  a  case  of  tuberculous  laryngitis  in  a 
boy  of  four  years,  whose  lungs  were  healthy,  death  resulting  from  tuber- 
culous meningitis. 

The  symptoms  are  hoarseness,  aphonia,  laryngeal  cough,  and  muco- 
purulent, sometimes  bloody,  expectoration.  The  sputum  may  contain 
tubercle  bacilli.  With  the  laryngoscope  tuberculous  deposits  may  be 
seen,  but  more  frequently  tuberculous  ulceration  of  the  mucous  mem- 
brane. In  children  this  is  usually  superficial,  the  deep  destructive  ulcera- 
tion seen  in  adults  being  very  rare. 

It  is  to  be  differentiated  from  syphilis  chiefly  by  the  general  symp- 
toms, as  the  laryngoscopic  appearances  may  be  very  similar.  The  treat- 
ment consists  in  keeping  the  ulcers  as  clean  as  possible  by  the  use  of 
sprays  and  the  local  application  of  astringent  powders,  like  nitrate  of 
silver  and  sulphate  of  zinc  or  iodoform. 

3.  Syphilitic  Laryngitis. — In  the  early  stage  of  syphilis  the  larynx  is 
often  the  seat  of  a  catarrhal  inflammation,  which  presents  nothing  espe- 
cially characteristic  except  its  protracted  course.  The  laryngitis  of  late 
hereditary  syphilis  is  quite  rare,  and  is  liable  to  be  overlooked  because 
of  the  difficulties  in  the  way  of  a  thorough  examination,  and  because  the 
disease  is  usually  painless. 

Strauss  has  collected  fourteen  cases  between  the  ages  of  three  and 
fifteen  years,  and  added  three  of  his  own.  He  states  that  deep-seated 
processes  are  much  more  rare  than  among  adults.  The  parts  most  fre- 
quently affected  are,  first,  the  epiglottis ;  secondly,  the  aryteno-epiglottic 
folds ;  thirdly,  the  posterior  laryngeal  wall.  The  epiglottis  was  involved 
in  twelve  of  fourteen  cases.     Usually  there  was  only  perichondritis;  in 


470  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

the  more  severe  cases  there  was  partial  or  complete  destruction  of  the 
cartilage.  In  four  cases  papillomatous  masses  were  seen.  In  five  cases 
the  process  extended  from  the  epiglottis  to  the  epiglottic  folds  of  one 
or  both  sides.  In  several  instances  the  superior  vocal  cords  were  thick- 
ened from  hyperplasia,  and  occasionally  small  tumours  were  form.ed. 
In  only  one  case  was  there  ulceration  of  these  folds.  Changes  in  the 
vocal  cords  and  the  arytenoid  cartilages  were  rare,  occurring  only  with 
extensive  inflammation.  The  symptoms  are  those  of  chronic  laryngitis: 
hoarseness,  sometimes  aphonia,  and  in  a  few  cases  chronic  laryngeal 
stenosis.  The  diagnosis  can  be  made  only  by  means  of  the  laryngoscope. 
In  most  of  the  cases  there  are  present  ulcerations  of  the  palate  or  uvula, 
or  scars  from  previous  ulcers;  sometimes  the  disease  extends  into  the 
nose.  Serious  s3'mptoms  often  result  when  to  old  syphilitic  lesions  there 
is  added  acute  laryngitis  or  oedema. 

In  addition  to  the  usual  constitutional  remedies  for  syphilis,  and 
to  the  means  ordinarily  employed  for  the  relief  of  chronic  laryngitis, 
intubation  may  be  required  in  these  cases  for  the  relief  of  laryngeal 
stenosis.  Nowhere  are  its  advantages  over  tracheotomy  more  striking 
than  here.     The  tube  must  usually  be  worn  for  many  months. 

NEW  GROWTHS. 

New  growths  of  the  larynx  are  not  very  rare  in  children.  Excluding 
the  granulations  which  follow  the  use  of  the  tracheal  canula,  the  only 
one  that  is  likely  to  be  met  with  is  papilloma.  This  may  occur  even  in 
infancy.  According  to  Rauchfuss,  the  majority  of  the  cases  begin  dur- 
ing the  first  year.    Boys  are  more  frequently  affected  than  girls. 

The  symptoms  depend  upon  the  size  and  location  of  the  tumour.  The 
earlier  manifestations  are  usually  ascribed  to  chronic  larjngitis.  There 
is  hoarseness,  sometimes  loss  of  voice,  and  a  paroxysmal  cough;  later, 
dyspnoea  develops  which  often  increases  by  paroxysms.  The  symptoms 
are  slowly  progressive,  and  it  may  be  several  months  before  they  are  suf- 
ficiently severe  to  attract  special  attention.  A  positive  diagnosis  is  made 
only  by  the  laryngoscope.  There  is  seen  a  whitish  granular  tumour, 
sometimes  pedunculated,  sometimes  with  a  broad  base,  attached  to  any 
part  of  the  larynx. 

The  treatment  of  these  cases  belongs  to  the  specialist.  Small  pedun- 
culated growths  may  be  removed  through  the  mouth  by  means  of  the 
forceps  or  snare.  Larger  ones  require  tracheotomy  or  thyrotomy.  The 
prognosis  after  removal  is  unfavourable,  on  account  of  the  likelihood  of 
recurrence  and  the  danger  of  broncho-pneumonia.  Papillomatous  tu- 
mours will  sometimes  disappear  entirely  if  complete  rest  for  the  larynx 
is  secured  by  means  of  tracheotomy;  but  the  tube  must  be  worn  for  from 
six  months  to  a  year. 


FOREIGN   BODIES  IN  THE   LARYNX   AND   BRONCHI.         471 

FOREIGN  BODIES  IN  THE  LARYNX  AND  BRONCHI. 

The  aspiration  of  foreign  substances  into  the  larynx  is  not  an  un- 
common accident  in  children.  It  usually  happens  from  an  attempt  to 
cough,  laugh,  or  cry  while  the  child  has  something  in  his  mouth.  If 
the  body  is  sharp  and  irregular,  like  a  pin,  the  shell  of  a  nut,  or  a  frag- 
ment of  bone,  it  is  liable  to  become  impacted  in  the  larynx.  If  smooth, 
like  a  pea  or  a  bead,  it  is  usually  drawn  into  one  of  the  bronchi,  generally 
the  right. 

When  the  body  enters  the  larynx  there  is  immediately  excited  a 
violent  paroxysmal  cough,  with  dyspnoea  amounting  almost  to  suffoca- 
tion. Often  the  body  is  dislodged  by  this  initial  attack  of  coughing. 
If  it  becomes  impacted  in  the  larynx,  it  may  cause  sudden  death  by 
occluding  the  glottis ;  elsewhere  it  may  excite  acute  laryngitis,  usually  of 
considerable  severity. 

The  impaction  of  a  foreign  body  in  one  of  the  primary  bronchi,  or 
one  of  the-  lobar  divisions,  is  indicated  by  cough  and  a  severe  localised 
pain  in  the  chest.  There  may  be  expectoration  of  blood.  On  auscultat- 
ing the  chest,  there  is  found  an  absence  of  respiratory  murmur  over  one 
lung  or  one  lobe,  according  to  the  situation  of  the  foreign  body.  Percus- 
sion gives  marked  dulness,  the  signs  thus  suggesting  pleural  effusion ;  or 
there  may  be  increased  resonance,  which  may  even  be  tympanitic,  owing 
to  the  emphysema  which  rapidly  develops.  If  the  foreign  body  remains 
impacted  in  one  of  the  bronchi,  it  usually  excites  a  localised  inflamma- 
tion, which  extends  to  the  surrounding  lung  and  may  terminate  in  the 
formation  of  an  abscess.  This  may  result  fatally,  or  there  may  follow 
a  prolonged  illness,  with  hectic  symptoms  resembling  pulmonary  tuber- 
culosis; and  finally,  after  weeks  or  months,  the  foreign  body  may  be 
expelled  by  an  attack  of  coughing,  and  the  patient  recover  completely. 

The  diagnosis  of  a  foreign  body  in  the  larynx  is  made  by  the  sudden- 
ness of  the  attack  and  the  violence  of  the  early  symptoms.  In  older  chil- 
dren the  body  may  be  seen  with  the  laryngoscope,  but  in  young  children 
this  is  very  difficult.  The  position  of  a  metallic  or  solid  body  may  be 
revealed  by  the  X-ray.  The  prognosis  is  always  doubtful,  and  depends 
upon  the  nature  of  the  foreign  body  and  the  point  at  which  it  has  been 
arrested.  The  usual  cause  of  death  either  with  or  without  operation  is 
broncho-pneumonia. 

The  first  thing  to  be  tried  is  inversion  of  the  patient.  By  this 
means,  assisted  by  the  cough,  the  foreign  body  is  not  infrequently  ex- 
pelled, even  though  it  has  passed  below  the  larynx.  The  symptoms  of 
laryngeal  obstruction  may  call  for  immediate  tracheotomy  or  laryn- 
gotomy,  intubation  not  being  applicable  to  these  cases.  If,  after  trache- 
otomy, the  foreign  body  can  be  located  in  the  larynx,  but  can  not 
be  extracted  through  the  tracheal  wound,  the  thyroid  cartilage  should 


472  DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

be  divided  in  the  median  line.  The  removal  of  a  foreign  body  from  the 
bronchi  or  the  tracheal  bifurcation  should  be  attempted  only  by  a  skilled 
surgeon. 

CHAPTER    III. 

DISEASES  OF  THE  LUNGS. 

THE  PECULIARITIES  OF  THE  LUNGS  IN  INFANCY  AND  EARLY 

CHILDHOOD. 

Thorax. — The  general  shape  of  the  thorax  is  somewhat  cylindrical, 
the  conical  or  dome-shape  of  the  adult  thorax  not  being  attained  until 
puberty.  The  antero-posterior  and  the  transverse  diameters  are  nearly 
equal  in  the  newly  born,  but  after  the  third  year  the  transverse  diameter 
is  always  greater,  the  difference  increasing  steadily  up  to  adult  life.  On 
account  of  the  shape  of  the  chest,  the  lungs  are  situated  rather  more 
posteriorly  in  the  infant  than  in  the  adult. 

The  thoracic  walls  are  very  elastic  and  yielding,  owing  to  the  carti- 
laginous condition  of  a  large  part  of  the  framework.  They  are  relatively 
thinner  than  in  the  adult,  chiefly  from  the  imperfect  development  of  the 
thoracic  muscles.  The  greater  part  of  the  thickness  of  the  thoracic  walls 
is  due  to  the  deposit  of  fat,  generally  abundant  in  well-nourished  in- 
fants; but  where  the  fat  is  scanty  the  walls  are  extremely  thin.  The 
capacity  of  the  thorax  is  considerably  encroached  upon  by  the  high  posi- 
tion of  the  diaphragm,  the  large  size  of  the  thymus  gland,  and  the  fre- 
quent distention  of  the  stomach  and  intestines. 

Eespiration. — According  to  Uffelmann,  the  rapidity  of  respiration 
during  sleep  at  the  different  ages  is  as  follows : 

At  birth 35  per  minute. 

At  the  end  of  the  first  year 27    "         " 

At  two  years 25    "         " 

At  six  years 22    "         " 

At  twelve  years 20    "         " 

During  waking  hours  this  rate  is  very  materially  increased,  and  from 
comparatively  slight  disturbance  it  may  be  nearly  twice  as  rapid. 

The  type  of  respiration  in  infants  is  diaphragmatic,  and  it  continues 
to  be  chiefly  so  until  after  the  seventh  year,  when  the  costal  element 
gradually  becomes  more  and  more  prominent.  The  rhythm  of  respira- 
tion is  easily  disturbed.  In  very  young  infants  the  regular  rhythm  is 
seen  only  in  sleep.  The  lungs  do  not  always  expand  equally;  at  certain 
times  and  in  certain  positions  respiration  may  be  carried  on  for  a  few 
moments  almost  entirely  with  one  lung.  For  some  moments  it  may  be 
very  superficial,  and  then  quite  deep.  The  length  of  the  interval  between 
inspiration  and  expiration   varies  much  at   different   times.     Regular 


THE  LONGS  IN  INFANCY  AND  EARLY  CHILDHOOD.    473 

rhythmical  respiration  is  not  fully  established  before  the  end  of  the  sec- 
ond year.  After  this  time  disturbances  of  rhythm  are  due  chiefly  to  pul- 
monary or  cerebral  disease;  but  in  infancy  quite  marked  irregularity 
may  have  little  or  no  significance.  It  is  very  common  in  all  asthenic 
conditions. 

Structure. — As  compared  with  the  adult,  the  trachea  of  the  young 
child  is  larger;  the  bronchi  are  larger,  more  numerous,  and  occupy  a 
greater  space;  the  air  cells  are  much  smaller  and  occupy  less  space;  and 
the  interstitial  tissue  is  much  more  abundant. 

Physical  Examination. — This  requires  tact  and  time,  but  yields  re- 
sults which  are  quite  as  satisfactory  as  in  adults.  It  should  be  under- 
taken only  in  a  room  having  a  temperature  of  about  73°  F.,  or  before 
an  open  fire. 

Inspection. — This  should  be  made  with  the  chest  bare.  There  should 
be  noted,  the  shape  of  the  chest,  the  presence  of  deformities  from  rickets, 
the  want  of  symmetry  in  the  two  sides,  bulging  of  the  intercostal  spaces, 
whether  the  two  lungs  expand  equally  or  not,  also  variations  in  rhythm, 
and  the  presence  and  extent  of  any  recession  of  the  soft  parts  or  bony 
walls  as  an  indication  of  obstructive  dyspnoea. 

Palpation.— ^T\i\?,  also  should  be  made  upon  the  bare  skin,  always 
with  the  hand  well  warmed.  Although  we  can  not  get  the  fremitus  of 
the  ordinary  voice,  we  can  get  that  of  the  cry.  This  is  usually  more 
intense  than  in  adults,  on  account  of  the  thinness  of  the  chest  walls.  We 
frequently  get  a  bronchial  fremitus — a  vibration  produced  by  mucus  in 
the  tubes.  The  position  of  the  apex  beat  of  the  heart  should  be  deter- 
mined, it  being  remembered  that  in  infancy  this  is  normally  in  the 
mammary  line,  or  just  outside  of  it,  and  usually  in  the  fourth  intercostal 
space. 

Percussion. — For  the  examination  of  the  back,  the  child  may  be  laid 
face  downward  upon  the  nurse's  lap,  or  be  seated  upon  her  arm.  For 
the  front  and  the  lateral  regions  of  the  chest,  the  child  is  most  con- 
veniently placed  upon  his  side  across  a  hard  pillow.  The  percussion  blow 
must  be  light,  either  with  a  single  finger  or  a  small  percussion  hammer, 
using  a  finger  of  the  opposite  hand  as  a  pleximeter.  Percussion  should 
be  made  both  during  inspiration  and  expiration.  The  normal  percus- 
sion note  is  somewhat  tympanitic,  this  being  due  to  the  relatively  large 
bronchi  and  the  thin  chest  walls.  This  note  is  exaggerated  in  the  inter- 
scapular region  and  beneath  the  clavicle,  especially  upon  the  right  side. 
Here  cracked-pot  resonance  may  be  obtained  even  in  health.  In  early 
infancy  the  thymus  gives  dulness  over  the  sternum  as  low  as  the  third 
rib,  sometimes  even  below  this  point,  this  gradually  diminishing  as  age 
advances. 

Auscultation. — This  may  be  practised  with  the  naked  ear  or  with  the 
stethoscope.    A  stethoscope  is  absolutely  necessary  for  a  thorough  exam- 


474  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

ination  of  the  apices  of  the  lungs  in  front  and  in  the  axillary  regions. 
Most  children  are  less  frightened  by  the  instrument  than  by  the  head  of 
the  physician  during  anterior  auscultation.  The  physician  should  always 
auscultate  the  posterior  part  of  the  chest  first,  because  he  is  most  likely 
to  find  signs  of  disease  there,  and  also  because  this  is  not  so  apt  to 
frighten  the  infant.  Every  part  of  the  chest  should,  however,  be  thor- 
oughly auscultated,  not  omitting  the  high  axillary  regions.  A  con- 
venient position  for  posterior  auscultation  is  to  have  the  child  held  over 
the  nurse's  shoulder. 

The  normal  respiratory  murmur  of  the  infant  is  generally  described 
as  "  puerile."  In  quality  this  has  been  likened  to  the  bronchial  breath- 
ing of  the  adult,  but  the  resemblance  is  not  a  very  close  one.  It  is  rude, 
rather  loud,  and  seems  very  near  the  ear.  Its  peculiar  character  is  due 
to  the  fact  that  the  tracheal  and  bronchial  sounds  are  more  distinct, 
because  not  transmitted  through  so  thick  a  layer  of  lung  and  chest  wall. 
It  is  especially  loud  in  the  regions  where  the  bronchi  are  superficial,  as 
between  the  shoulder-blades  and  beneath  the  clavicles,  particularly  of 
the  right  side.  A  careful  comparison  of  the  two  sides  of  tlie  chest  will 
generally  enable  an  observer  to  avoid  errors.  The  irregularity  of  rhythm 
which  occurs  from  slight  causes  should  be  remembered,  and  the  infant's 
position  changed  several  times  during  auscultation,  to  avoid  the  mis- 
take of  attaching  too  much  importance  to  a  feeble  respiratory  murmur 
of  one  side. 

On  account  of  the  thinness  of  the  chest  walls,  there  is  always  great 
difficulty  in  distinguishing  between  rales  produced  in  the  bronchi  and 
pleuritic  friction  sounds.  Before  drawing  any  inference  from  the  auscul- 
tatory signs,  both  lungs  must  be  examined  for  several  minutes,  changing 
the  child's  position,  and  often  inducing  a  cry  or  compelling  a  deep  inspi- 
ration by  other  means,  in  order  to  bring  out  signs  which  otherwise  may 
be  overlooked.  As  auscultation  is  extremely  difficult  or  impossible  in  a 
crying  infant,  this  part  of  the  physical  examination  should  be  made  first 
if  the  child  is  quiet,  since  upon  it  we  must  chiefly  depend  for  diagnosis. 
Inspection  and  percussion  can  be  deferred  until  later. 

Peculiarities  in  Disease. — There  are  several  peculiarities  connected 
with  the  respiratory  organs  in  infancy  and  early  childhood  which  must 
be  constantly  borne  in  mind  in  studying  their  diseases.  The  muscular 
development  of  the  thoracic  wall  is  feeble.  The  soft,  yielding  character 
of  the  thoracic  framework  causes  the  chest  to  sink  in  readily  from  at- 
mospheric pressure  whenever  there  is  obstructive  dyspnoea.  On  account 
of  the  small  size  of  the  air  vesicles,  acute  congestion  may  interfere 
with  their  function  almost  as  completely  as  does  consolidation.  Because 
of  the  delicate  walls  of  the  air  vesicles,  emphysema  is  readily  produced 
in  obstructive  dyspnoea,  but  it  is  rarely  permanent.  There  is  a  tendency 
to  collapse,  either  on  the  part  of  lobules  or  groups  of  lobules,  but  very 


ACUTE  CATARRHAL  BRONCHITIS.  475 

rarely  of  an  entire  lobe.  This  is  a  nnicli  less  important  factor  in  the 
production  of  symptoms  in  acute  pulmonary  disease  than  many  writers 
would  lead  us  to  suppose.  The  tendency  of  inflammation  to  spread  from 
the  large  to  the  small  bronchi  is  very  much  greater  than  in  adults.  In 
all  forms  of  pulmonary  disease  the  rapidity  of  respiration  is  much  greater 
than  in  adults.  Areas  of  consolidation  often  exist  without  appreciable 
(changes  in  the  percussion  note,  because  they  are  superficial  and  are  sur- 
rounded by  healthy  or  emphysematous  lung.  "Flatness  should  alwavs 
suggest  the  presence  of  fluid.  Disease  is  often  overlooked,  from  a  failure 
to  examine  the  whole  chest. 

Probably  the  most  common  mistakes  are  to  confound  bronchial  rales 
with  friction  sounds,  exaggerated  puerile  breathing  with  bronchial  breath- 
ing, and  to  overlook  the  existence  of  fluid  because  of  the  presence  of 
bronchial  breathing. 

ACUTE  CATARRHAL  BRONCHITIS. 

Acute  catarrhal  bronchitis  is  one  of  the  most  frequent  conditions  for 
which  the  physician  is  called  upon  to  prescribe  in  children.  It  occurs  at 
all  ages,  from  early  infancy  up  to  puberty.  Its  frequency,  however, 
diminishes  steadily  after  the  second  year.  The  predisposition  to  acute 
bronchitis  exists  with  the  same  constitutional  conditions,  and  is  acquired 
in  the  same  manner  as  the  predisposition  to  the  acute  catarrhal  inflam- 
mations of  the  upper  respiratory  tract.  ( See  Acute  Rhino-Pharyngitis. ) 
Bronchitis  is  very  common  in  children  who  are  sufl'ering  from  rickets  and 
malnutrition.  It  is  much  more  frequent  in  the  cold  months,  especially 
in  the  late  winter  and  early  spring,  when  there  are  sudden  atmospheric 
changes  and  high  winds.  The  presence  of  large  tonsils  and  adenoid 
vegetations  of  the  pharynx  are  important  predisposing  causes  of  bron- 
chitis.   • 

Bronchitis  may  be  a  primary  or  a  secondary  disease.  The  primary 
form  is  excited  by  cold,  exposure  with  insufficient  clothing  in  severe 
weather,  wetting  of  the  feet,  or  chilling  of  the  surface  in  any  manner. 
Under  these  conditions  it  may  occur  alone,  or  be  associated  with  or 
preceded  by  acute  catarrh  of  the  nose,  pharynx,  or  larynx.  In  rare  cases 
it  is  caused  by  the  inhalation  of  irritants.  Bronchitis  is  an  almost  in- 
variable accompaniment  of  measles  and  influenza.  It  is  very  common 
in  pertussis,  in  scarlet  and  typhoid  fevers,  and  diphtheria,  and  may 
occur  in  any  acute  infectious  disease;  it  also  complicates  pneumonia  and 
pleurisy.  The  micro-organisms  associated  with  bronchitis  are  chiefly 
the  staphylococcus  aureus  and  the  pneumococcus,  often  in  combination; 
next  in  importance  are  the  streptococcus  and,  especially  in  protracted 
cases,  the  influenza  bacillus. 

Lesions. — Acute  catarrhal  bronchitis  is  an  inflammation  of  the  mucous 
membrane  of  the  bronchi.     As  a  rule  it  is  bilateral,  both  sides  being 


476  DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

involved  in  the  same  degree.  Localised  bronchitis  is  secondary  to  some 
other  pathological  process  in  the  lungs,  usually  tuberculosis,  old  pleuritic 
adhesions,  or  pneumonia.  In  acute  bronchitis  only  the  larger  tubes  may 
be  affected,  this  usually  being  complicated  with  inflammation  of  the 
trachea  (ordinary  tracheo-bronchitis)  ;  or,  in  addition,  the  process  may 
extend  to  the  medium-sized  tubes  (severe  bronchitis)  ;  or,  in  infants 
especially,  it  may  extend  to  the  smallest  tubes  (capillary  bronchitis). 
In  the  last-mentioned  form  there  are  invariably  changes  in  the  zones 
of  air  vesicles  surrounding  the  bronchi,  and  these  cases  are  therefore 
more  properly  classed  as  broncho-pneumonia.  In  the  first  form  the  in- 
flammation is  superficial,  and  affects  only  the  mucous  membrane  of  the 
bronchi.  In  the  second  form  it  may  involve  the  entire  thickness  of  the 
bronchial  wall,  and  in  the  third  form  it  does  so  regularly. 

The  pathological  changes  consist  in  congestion  and  swelling  of  the 
mucous  membrane,  desquamation  of  the  epithelium,  and  an  exudation  of 
mucus  and  pus-cells.  At  autopsy  the  injection  of  the  mucous  membrane 
is  usually  distinct;  pus  and  mucus  line  the  walls  of  the  larger  bronchi, 
and  by  pressure  ooze  from  the  cut  extremities  of  the  smaller  tubes.  The 
chief  lesion  of  the  walls  of  the  bronchi  consists  in  an  infiltration  with 
leucocytes.  In  infants  dying  from  bronchitis,  the  lungs  are  much  more 
frequently  emphysematous  than  collapsed.  In  fact  the  readiness  with 
which  emphysema  occurs  in  bronchitis  is  one  of  its  distinguishing  feat- 
ures in  infancy.  However,  this  is  rarely  permanent  but  usually  sub- 
sides rapidly  after  the  acute  attack  is  over.  There  is  swelling  of  the 
lymph  nodes  at  the  root  of  the  lungs,  which  in  most  of  the  acute  cases 
is  slight,  but  in  protracted  cases,  and  after  recurring  attacks,  may  be 
quite  marked. 

Symptoms. — It  is  convenient  to  consider  separately  the  symptoms  in 
infants  and  in  older  children. 

The  Bronchitis  of  Infants. — 1.  The  Mild  Form  (Bronchitis  of 
the  Larger  Tubes). — The  onset  is  generally  gradual,  and  the  symptoms 
of  bronchitis  may  be  preceded  by  those  of  catarrh  of  the  nose,  pharynx, 
or  larynx.  The  change  in  the  character  of  the  cough,  the  slightly  ac- 
celerated breathing,  and  a  further  rise  in  temperature,  indicate  an  ex- 
tension to  the  bronchi.  The  cough  may  be  constant  and  severe,  or  very 
slight.  There  is  no  expectoration.  The  secretions  are  usually  coughed 
up  into  the  mouth  or  pharynx,  and  swallowed.  This  sometimes  excites 
vomiting.  At  other  times  the  mucus  is  coughed  only  into  the  trachea 
or  larynx,  and  aspirated  again  into  the  lungs.  The  respirations  are  from 
forty  to  fifty  a  minute,  and  often  accompanied  by  a  rattling  sound,  due 
to  mucus  in  the  large  bronchi  or  trachea.  The  general  symptoms  are 
not  severe,  and  unless  the  infant  is  very  young  or  very  delicate  no  ap- 
prehension need  be  felt  as  to  the  outcome.  The  temperature  is  generally 
from  100°  to  102°  F.  for  two  or  three  days,  then  below  100°  F.    A  mod- 


ACUTE   CATARRHAL  BRONCHITIS.  477 

erate  amount  of  restlessness  dependent  upon  the  severity  of  the  cough, 
anorexia,  and  sometimes  vomiting  and  diarrhoea,  are  usually  present. 

The  physical  signs  in  the  first  stage  are  dry,  sonorous  rales  over  the 
whole  chest.  A  little  later  these  give  place  to  coarse  mucous  rales  heard 
everywhere,  but  especially  distinct  between  the  scapulae  and  in  the  infra- 
clavicular regions.  On  palpation  there  is  usually  a  marked  bronchial 
fremitus.  Often  there  is  not  enough  dyspnoea  to  cause  recession  of  the 
soft  parts  of  the  chest.  Unless  the  disease  extends  to  the  smaller  bronchi 
and  the  air  vesicles,  the  illness  usually  lasts  about  a  week.  Coarse  rales 
in  the  chest  may  remain  for  some  time  after  the  symptoms  have  subsided. 
Relapses  are  exceedingly  common.  In  a  delicate  or  rachitic  child,  or  in 
one  whose  surroundings  are  bad,  one  attack  is  likely  to  be  followed  by  a 
succession  of  others,  so  that  the  child  may  not  be  really  well  until  warm 
weather  comes.  The  general  health  may  suffer  from  the  prolonged  con- 
finement to  the  house,  although  the  patient  may  never  have  been  seri- 
ously ill. 

2.  The  Severe  Form  (Bronchitis  of  the  Smaller  Tubes). — This  dif- 
fers from  the  preceding  variety  mainly  in  the  greater  severity  of  all  its 
symptoms.  The  onset  may  be  like  that  just  described,  the  severe  symp- 
toms not  appearing  until  the  patient  has  been  sick  two  or  three  days, 
or  they  may  be  severe  from  the  outset.  If  the  latter,  it  is  indistinguish- 
able from  broncho-pneumonia.  There  is  cough,  dyspnoea,  accelerated 
breathing,  fever,  and  moderate,  sometimes  severe,  prostration.  The 
cough  is  tighter,  and  more  frequently  of  a  short,  teasing  character  than 
severe  and  paroxysmal.  There  is  difficulty  in  nursing.  Dyspnoea  may 
be  quite  marked  and  is  shown  by  the  active  dilatation  of  the  alse  nasi  and 
the  recession  of  all  the  soft  parts  of  the  chest  on  inspiration.  The 
respirations,  as  a  rule,  are  from  50  to  80  a  minute.  The  temperature 
for  the  first  day  or  two  is  usually  101°  or  102°  F.,  but  it  may  be  103° 
or  104°  F.  So  high  a  temperature  does  not  continue  unless  pneumonia 
develops.  The  prostration  is  in  most  cases  more  closely  related  to  the 
dyspnoea  and  the  rapidity  of  respiration  than  to  the  temperature.  Often 
there  is  slight  cyanosis. 

In  the  beginning  the  chest  is  filled  with  sibilant  and  sonorous  rales. 
In  twelve  or  twenty-four  hours  these  are  wholly  or  in  part  replaced  by 
moist  rales — coarse  or  fine,  according  as  they  are  produced  in  the  large 
or  medium-sized  tubes.  The  rales  are  always  best  heard  behind,  but  they 
are  present  all  over  the  chest.  The  signs  are  often  precisely  like  those  of 
an  acute  asthma.  This  prominence  of  the  spasmodic  or  asthmatic  ele- 
ment in  bronchitis  is  characteristic  of  infancy  and  early  childhood.  The 
respiratory  murmur  is  feeble;  the  resonance  on  percussion  is  normal  or 
slightly  exaggerated.  As  the  case  progresses  toward  recovery,  the  finer 
rales  are  the  first  to  disappear.  After  the  acute  stage  has  passed  the 
loud  wheezing  sounds  sometimes  persist  for  two  or  three  weeks. 


478  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

At  the  onset  of  such  a  case  it  is  impossible  to  say  whether  the  disease 
will  be  limited  to  the  medium-sized  bronclii  or  will  extend  to  the  small- 
est bronchi  and  air  vesicles.  In  young  or  veiy  delicate  infants,  and  dur- 
ing measles,  it  is  very  common  for  the  disease  to  spread  rapidly  to  the  air 
vesicles.  In  other  cases,  usually  in  infants  under  six  months  old,  there 
may  develop  attacks  of  respiratory  failure  or  suffocation.  These  may 
occur  in  a  severe  case  at  any  time,  and,  because  of  the  infant's  inability 
to  empty  the  tubes  of  secretion,  the  dyspnoea  steadily  increases  until  the 
respiratory  muscles  are  exhausted,  the  inspiratory  force  being  too  feeble 
to  overcome  the  obstruction  in  the  tubes.  The  symptoms  which  follow 
are  usually  ascribed  to  pulmonary  collapse.  I  am,  however,  by  no  means 
certain  that  this  is  the  correct  explanation,  for  in  autopsies  made  in  such 
cases  I  have  usually  found  the  lungs  to  be  the  seat  of  acute  emphysema. 
The  clinical  picture  is  a  clear  one.  There  is  no  disposition  to  cough  or 
cry ;  the  pulse  is  feeble ;  the  respiration  very  rapid,  superficial,  often 
irregular;  the  skin  cyanotic,  and  often  clammy.  Finally,  there  may  be 
added  to  the  others  signs  of  carbonic-acid  poisoning,  dulness,  a])atliy, 
and  stupor.  Such  attacks  may  come  on  quite  suddenly  even  in  robust 
infants,  and  unless  the  treatment  is  energetic,  even  heroic,  death  often 
follows  in  a  few  hours,  being  frequently  preceded  by  convulsions. 

The  usual  course  of  the  disease  in  infants  previously  in  good  health 
is  that  the  severe  symptoms  continue  for  two  or  three  days  only,  after 
which  the  temperature  falls  to  100°  or  100 . 5°  F.,  and  gradually  becomes 
normal.  The  constitutional  symptoms  usually  decline  with  the  tempera- 
ture, and,  except  during  the  first  thirty-six  hours,  they  rarely  give  cause 
for  anxiety.  Eecovery  almost  invariably  occurs  unless  the  disease  ex- 
tends to  the  finer  bronchi. 

Bronchitis  is  principally  to  be  distinguished  from  broncho-pneumonia. 
The  differential  diagnosis  is  more  fully  considered  under  that  disease. 
The  most  important  points  are  that  in  pneumonia  the  temperature  is 
higher  and  more  prolonged,  the  prostration  greater,  the  rales  very  often 
localised — being  heard  only  behind,  often  over  only  one  lung — the  dura- 
tion is  more  protracted,  and  all  the  symptoms  are  more  severe.  In 
nearly  all  cases  of  severe  bronchitis  in  young  children  some  pneumonia 
is  present. 

The  Bronchitis  of  Older  Children. — This  is  not  nearly  so  serious 
as  in  infants,  because  the  same  danger  does  not  exist  of  extension  of  the 
inflammation  to  the  finer  bronchi  and  air  cells. 

1.  The  Mild  Form. — This  is  very  common.  The  constitutional  symp- 
toms are  slight,  and  often  entirely  absent  after  the  first  day.  The  patient 
is  never  sick  enough  to  go  to  bed.  The  first  symptoms  are  cough  and 
soreness  or  a  sense  of  oppression  beneath  the  sternum.  The  cough  is 
always  worse  at  night.  It  is  at  first  tight,  hard,  and  racking;  later  it  is 
loose,  and  in  children  over  five  years  old  there  is  usually  expectoration — 


ACUTE  CATARRHAL  BRONCHITIS.  479 

first  of  white,  frothy  mucus,  but  after  a  few  days  it  becomes  more  abun- 
dant, and  of  a  yellow  or  yellowish-green  colour,  from  the  presence  of  pus. 
The  physical  signs  are  only  coarse  rales,  at  first  dry,  and  later  moist,  but 
heard  over  both  sides  of  the  chest,  in  front  and  behind.  There  may  be 
some  disturbance  of  digestion,  anorexia,  constipation,  or  diarrhoea.  The 
usual  duration  of  the  attack  is  from  one  to  two  weeks.  If  the  patient  is 
not  kept  indoors  the  disease  may  pass  into  a  subacute  form,  lasting  for 
several  weeks  as  a  protracted  "  winter  cough,"  but  without  any  other  im- 
portant symptoms. 

Such  prolonged  or  recurring  attacks  of  bronchitis  of  a  subacute  form 
should  suggest  influenza  or  tuberculosis.  A  positive  cutaneous  tuberculin 
reaction  renders  tuberculosis  probable.  A  careful  search  for  bacilli  in 
the  sputum  should  then  be  made.  Although  they  may  not  be  found  at 
first,  repeated  examinations  will  usually  disclose  them.  Influenza  can 
be  determined  only  by  sputum  cultures. 

2.  The  Severe  Form.. — The  onset  is  abrupt,  with  fever,  chill,  pains  in 
the  back,  headache,'  cough,  and  sometimes  pain  in  the  chest.  There  is  a 
feeling  of  tightness  or  constriction  beneath  the  sternum.  The  onset 
resembles  that  of  pneumonia,  except  that  the  symptoms  are  less  severe. 
The  temperature  for  the  first  two  or  three  days  ranges  between  100°  and 
103°  F.  It  is  generally  highest  in  the  first  twenty-four  hours.  The 
cough  resembles  that  of  the  mild  form,  but  it  is  usually  more  severe. 
The  expectoration  is  more  profuse,  and  occasionally,  in  the  early  stage,  it 
may  be  streaked  with  blood. 

The  coarse  rales  of  the  mild  form  are  present,  and  in  addition  there 
are  finer  rales — at  first  dry,  and  later  moist — heard  all  over  the  chest. 
Frequently,  wheezing  rales  are  heard  on  expiration.  The  duration  of  the 
attack  is  ordinarily  from  two  to  three  weeks,  the  patient  being  sick 
enough  to  be  confined  to  bed  for  three  or  four  days  only.  There  is  fre- 
quently a  cough  for  some  time  after  all  physical  signs  have  disappeared. 
Eelapses  are  easily  excited  hy  any  indiscretion  before  the  patient  has 
quite  recovered. 

The  prognosis  in  the  primary  cases  is  good,  such  almost  invariably 
terminating  in  recovery,  and  very  exceptionally  passing  into  broncho- 
pneumonia; but  this  not  infrequently  happens  when  the  attack  compli- 
cates measles  or  pertussis. 

Treatment  of  Bronchitis. — To  remove  the  predisposition  to  bronchitis 
the  same  means  should  be  employed  as  those  mentioned  in  Acute  Ehino- 
Pharyngitis.  Children  with  tuberculous  antecedents,  and  those  who 
are  especially  prone  to  pulmonary  disease,  should,  if  possible,  spend  the 
winter  in  a  warm  climate.  The  sleeping  apartments  of  susceptible  in- 
fants should  not  be  too  cold — never  below  60°  F.— but  they  should  be 
well  ventilated.  It  is  important  in  infants  and  young  children  that  mild 
attacks  of  bronchitis  should  not  be  neglected. 


480  DISE.\SES  OF  THE   RESPIRATORY  SYSTEM. 

Every  young  child  who  has  an  acute  catarrh  of  the  nose,  pharynx,  lar- 
ynx, or  bronchi  should  be  kept  indoors.  In  every  such  catarrh  accompa- 
nied by  fever  the  child  should  be  kept  in  bed  while  the  fever  lasts,  even  if 
the  temperature  does  not  go  above  100 . 5°  F.,  and  is  accompanied  by  no 
other  constitutional  symptoms.  A  very  large  number  of  the  cases  will 
recover  promptly  when  no  other  treatment  is  employed  than  to  keep  the 
child  in  bed.  Fresh  air  is  indispensable.  But  the  advantages  of  cold  air 
have  not  yet  been  demonstrated.  According  to  my  experience,  the  wide- 
open  windows  have  no  place  in  the  treatment  of  acute  bronchitis  in  in- 
fants or  young  children  in  the  winter  and  spring  season.  The  tempera- 
ture of  the  room  should  be  about  70°  F.  The  room  should  be  well 
ventilated  and  frequently  aired,  the  child  meanwhile  being  removed  to 
another  room.  There  is  a  great  advantage  in  changing  the  child's  posi- 
tion in  the  crib  and  from  the  crib  to  the  nurse's  arms.  Careful  attention 
should  be  given  to  feeding  and  to  the  condition  of  the  bowels.  A  cathar- 
tic, preferably  castor  oil,  should  be  administered  at  the  outset. 

Poultices  are  objectionable  and  should  not  be  employed.  The  oiled 
silk  jacket  is  sometimes  useful.  Counter-irritation  is  very  valuable.  In 
infants,  the  best  results  are  obtained  by  the  frequent  use  of  a  mustard 
paste  (see  chapter  on  General  Therapeutics).  The  paste  may  be  re- 
peated, according  to  indications,  from  two  to  five  times  a  day.  If  prop- 
erly used,  it  will  not  injure  the  skin. 

Inhalations  may,  in  the  great  majority  of  cases,  take  the  place  of  the 
administration  of  drugs  by  the  mouth,  a  very  great  advantage  in  infants. 
They  may  be  used  by  means  of  the  croup  kettle,  the  child  always  being 
placed  in  a  tent.  In  the  early  part  of  the  disease  relaxing  inhalations, 
like  simple  aqueous  vapour  or  lime-water,  may  be  used.  Later  turpen- 
tine, creosote,  benzoin,  terebene,  or  eucalyptol  may  be  added.  Of  these, 
creosote  has  given  me  the  most  satisfaction.  Inhalations  are  to  be  used 
for  ten  or  fifteen  minutes  from  four  to  twelve  times  a  day. 

In  infanc}',  expectorants  may  advantageously  be  dispensed  with. 
For  older  children,  antimony  and  ipecac  may  be  used  in  the  first  stage. 
When  the  secretion  is  more  abundant,  creosote,  turpentine,  or  terebene 
may  be  given.  Small,  frequently  repeated  doses  usually  give  the  best 
results.  Opium  should  be  given  cautiously  to  infants.  The  dry,  har- 
assing cough  of  the  early  stage  sometimes  yields  to  nothing  so  quickly 
as  to  small  doses  of  Dover's  powder  (e.  g.,  one-tenth  of  a  grain  every 
two  hours  to  a  child  of  one  year).  The  use  of  emetics  to  get  rid  of 
bronchial  secretion  is  not  to  be  advised.  Stimulants  are  not  required 
in  most  of  the  cases.  The  indications  for  them  are  the  same  as  in  pneu- 
monia. When  there  is  much  dyspnoea  of  the  asthmatic  type,  nothing 
works  as  well  as  adrenalin.  It  should  be  given  h}'podermically ;  the  dose 
is  two  to  five  minims  of  the  1-1,000  solution.  The  effects  are  almost  im- 
mediate, but  often  only  transient. 


FIBRINOUS   BRONCHITIS.  481 

Should  attacks  of  suffocation  and  respiratory  failure  occur  in  infants, 
the  indications  are  to  excite  rcsijiratory  movements  and  to  get  as  much 
blood  as  possible  to  the  surface  and  tlie  extremities.  Flagellation  or 
spanking  and  the  use,  alternately,  of  hot  and  cold  douches  to  the  chest 
will  sometimes  induce  the  deep  respiratory  efforts  desired.  Other  useful 
measures  are  the  hot  mustard  bath  and  the  mustard  pack  applied  to  the 
entire  body.  Probably  the  most  effective  of  all  remedies  is  dry  cupping. 
The  chest  should  be  cupped  front  and  back  for  five  or  ten  minutes  every 
few  hours.  Oxygen  should  be  administered.  As  these  symptoms  are 
liable  to  recur  every  few  hours  for  a  day  or  two,  a  repetition  of  the 
treatment  may  be  needed.  For  such  patients  cold  air  is  injurious.  They 
should  be  kept  in  a  room  with  a  temperature  of  70°  to  72°  F. 

In  the  non-febrile  cases  in  older  children,  confinement  in  bed  is  un- 
necessary, but  they  should  be  kept  indoors.  In  the  early  stage,  with 
hard,  dry  cough,  one  of  the  best  remedies  is  brown  mixture  (the  mis- 
tura  glycyrrhizae  composita  of  the  U.  S.  P.).  It  will  be  found  advan- 
tageous in  most  cases  to  have  the  formula  made  up  with  one-half  the 
usual  amount  of  opium.  When  the  cough  is  especially  hard  and  dry, 
a  single  inhalation  may  be  used  at  bedtime.  In  the  second  stage,  muriate 
of  ammonia  may  be  added  to  the  brown  mixture;  or  terebene,  two  or 
three  drops  upon  sugar,  may  be  given  four  or  five  times  a  day,  and  in- 
halations should  be  used  several  times  a  day. 

In  the  more  severe  cases  the  patients  should  be  kept  in  bed  and  coun- 
ter-irritation to  the  chest  employed.  For  the  general  discomfort,  pain, 
headache,  etc.,  nothing  is  better  than  phenacetine  and  Dover's  powder 
(two  grains  of  the  former  to  one-half  grain  of  the  latter  to  a  child  of 
five  years),  repeated  every  three  to  six  hours.  All  patients  should  be 
kept  in  bed  as  long  as  the  temperature  is  above  normal. 

After  all  physical  signs  and  constitutional  symptoms  have  disap- 
peared, a  cough  continues  sometimes  for  weeks.  Expectoration  is  scanty, 
or  is  wanting  altogether;  the  cough  is  hard,  dry,  often  paroxysmal,  and 
in  some  cases  occurs  at  night  only.  For  this  condition  the  best  reme- 
dies are  cod-liver  oil  and  creosote.  When  t^iese  measures  are  not  effect- 
ive, a  change  of  climate  should  be  advised. 

FIBRINOUS  BRONCHITIS  {Bronchial  Croup). 

Fibrinous  bronchitis  is  seen  in  diphtheria,  usually  as  an  extension 
from  the  larynx  or  trachea.  There  is,  however,  another  form  of  bron- 
chitis attended  by  a  fibrinous  exudate,  which  occurs  as  a  primary  disease. 
This  is  very  rare  in  children.  Weil  has,  however,  collected -twenty  cases 
of  the  primary  form.  The  etiology  is  obscure.  It  is  seen  at  all  ages, 
from  infancy  up  to  puberty,  and  it  may  be  either  acute  or  chronic.  From 
the  cases  thus  far  reported  it  would  appear  that  the  acute  form  is  rela- 
32 


482  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

lively  more  common  in  children  than  in  adults.  The  disease  may  be 
confined  to  certain  branches  of  the  bronchial  tree,  or  it  may  affect  all  the 
bronchi,  even  to  the  minute  subdivisions.  The  fibrinous  membrane  is 
found  loose  in  the  tubes  or  adherent.  There  are  generally  associated 
other  pulmonary  changes,  such  as  emphysema,  atelectasis  or  broncho- 
pneumonia. 

The  acute  form  somewhat  resembles  ordinary  catarrhal  bronchitis. 
The  diagnostic  features  are,  the  severity  of  the  dyspnoea  and  the  expecto- 
ration of  tube  casts  from  the  larger  bronchi,  or  elongated  cylinders  from 
the  smaller  ones,  the  former  resembling  macaroni,  the  latter,  vermicelli. 
The  expectorated  masses  are  often  in  balls  or  plugs,  and  their  peculiar 
character  is  not  recognised  until  they  are  placed  in  water.  The  casts 
are  dissolved  by  alkalies,  especially  by  lime-water.  After  the  expulsion  of 
a  large  cast,  improvement  in  all  the  symptoms  occurs.  They,  however, 
return  as  the  exudate  reappears.  The  ordinary  duration  of  acute  cases 
is  from  one  to  three  weeks. 

In  the  chronic  form  there  are  no  constitutional  symptoms,  but  only 
dyspnoea  and  cough,  often  recurring  in  paroxysms,  with  the  expectora- 
tion of  fibrinous  casts.  The  patient  may  have  these  attacks  at  intervals 
of  a  few  days  or  weeks,  extending  over  a  period  of  montlis,  or  even  years. 
There  are  no  characteristic  physical  signs.  The  diagnosis  rests  upon  the 
peculiar  character  of  the  expectoration.  The  prognosis  in  acute  cases  is 
unfavourable,  the  mortality  being  75  per  cent  (Weil).  Chronic  cases  are 
not  dangerous  to  life. 

Treatment. — This  is  quite  unsatisfactory.  To  loosen  the  membrane 
and  facilitate  its  expulsion,  the  most  efficient  means  are  inhalations  of 
the  vapour  of  lime-water  and  the  internal  administration  of  pilocarpine. 
Occasionally  emetics  are  of  value.  Improvement  in  some  of  the  chronic 
cases  has  resulted  from  the  use  of  iodide  of  potassium. 

CHRONIC  BRONCHITIS. 

Chronic  bronchitis  is  not  a  very  common  disease  in  children,  partic- 
ularly in  young  children,  one  reason  being  that  chronic  emphysema,  so 
frequently  an  associated  condition  in  adults,  is  rather  rare  in  early  life. 
Chronic  bronchitis  always  accompanies  chronic  pulmonary  tuberculosis 
and  chronic  interstitial  pneumonia,  with  or  witliout  the  occurrence  of 
bronchiectasis.  It  is  seen  in  chronic  cardiac  disease,  especially  with 
lesions  of  the  mitral  valve.  It  may  occur  as  a  late  symptom  of  hereditary 
syphilis.  Excluding  the  varieties  mentioned,  it  usually  follows  attacks 
of  acute  bronchitis,  the  process  becoming  chronic  because  of  the  patient's 
constitutional  condition  or  his  unhygienic  surroundings.  The  acute  at- 
tack may  be  primary,  but  it  often  follows  measles  and  whooping-cough. 
Rickets,  general  malnutrition,  and  the  lymphatic  diathesis  are  the  con- 


REFLEX  COUGH -NERVOUS   COUGH.  483 

stitutional  conditions  in  which  acute  bronchitis  is  most  likely  to  pass 
into  the  chronic  form.  Deformities  of  the  chest,  the  result  either  of 
rickets  or  of  Pott's  disease,  are  occasionally  a  cause. 

Symptoms. — The  only  constant  symptom  is  cough,  which  is  per- 
sistent, obstinate,  and  nearly  always  worse  at  night  or  early  in  the  morn- 
ing. It  often  occurs  in  paroxysms  strongly  suggestive  of  pertussis.  Ex- 
pectoration is  not  generally  abundant,  but  in  older  children  it  is  usually 
present,  and  in  a  few  cases  it  is  profuse.  A  copious  morning  expectora- 
tion of  fcetid  pus  or  muco-pus  indicates  bronchiectasis.  There  is  no 
fever,  little  or  no  dyspnoea,  and  although  the  patients  are  thin,  they  are 
not  emaciated,  and  in  many  cases  the  general  health  is  not  much  affected. 
There  may  be  coarse  mucous  rales,  or  no  physical  signs  whatever.  The 
duration  of  the  disease  is  indefinite,  depending  upon  the  cause.  All 
these  patients  are  better  in  summer  than  in  winter,  and  suffer  fre- 
quently from  exacerbations  of  acute  or  subacute  bronchitis. 

The  diagnosis  is  to  be  made  mainly  from  pertussis  and  tuberculosis. 
From  mild  attacks  of  pertussis  the  diagnosis  may  be  impossible  except  by 
the  course  of  the  disease.  Tuberculosis  may  be  suspected  if  the  thermom- 
eter shows  regularly  a  slight  evening  rise  of  temperature,  if  there  is 
much  anaemia,  and  steady  loss  of  flesh.  It  may,  however,  be  present 
without  any  of  these  symptoms.  A  positive  cutaneous  reaction  is  sug- 
gestive, but  a  certain  diagnosis  can  be  made  only  by  the  discovery  of 
tubercle  bacilli  in  the  sputum. 

Treatment. — The  first  indication  is  to  treat  the  primary  disease.  In 
cardiac  cases  digitalis  is  the  best  remedy,  and  all  sedatives  are  to  be 
avoided.  Attention  should  be  directed  to  the  general  condition — rickets 
and  malnutrition  each  receiving  its  appropriate  treatment.  In  most 
cases  a  general  tonic  plan  of  treatment  is  best,  particularly  the  con- 
tinuous use  of  cod-liver  oil.  In  many  cases  a  change  of  climate  is  the 
only  thing  which  is  really  curative.  For  the  relief  of  cough,  opiates  are 
to  be  avoided  as  much  as  possible.  The  main  reliance  should  be  upon 
potassium  iodide,  creosote,  and  terebene,  the  last  two  being  given  both  by 
mouth  and  by  inhalation, 

REFLEX  COUGH— NERVOUS  COUGH. 

Strictly  speaking,  all  cough  is  reflex  and  of  nervous  origin.  The  term 
"  reflex  cough  "  is,  however,  commonly  used  to  denote  that  which  occurs 
without  any  evidence  of  disease  in  the  larynx,  trachea,  bronchi,  lungs,  or 
pleura.  On  account  of  the  close  connection  through  the  vagus  and  its 
branches  between  the  mouth,  ear,  throat,  stomach,  and  thoracic  organs, 
it  is  possible  for  cough  to  be  produced  by  many  forms  of  irritation  in 
these  organs  or  cavities.  Clinically,  the  following  varieties  of  nervous 
cough  are  observed: 


484  DISEASES  OF  THE   RESPIRATORY   SYSTEM. 

1.  That  dependent  upon  rhino-pharyngeal  irritation.  This  is  the 
most  frequent  form,  and  is  sometimes  caused  by  an  elongated  uvula,  but 
is  usually  due  to  adenoid  growths  of  the  pharynx,  though  enlargement 
of  all  the  lymphoid  tissues  of  the  neighbourhood  no  doubt  have  a  part. 
The  cough  is  generally  excited  by  an  accumulation  of  mucus  in  the 
posterior  pharynx,  and  is  dry,  tickling,  or  hemming  in  character.  It 
occurs  chiefly  at  night,  and  in  some  patients  only  then;  it  may  begin 
soon  after  the  child  falls  asleep  and  continue  the  greater  part  of  the 
night,  often  for  months,  especially  in  the  cold  season.  Formerly,  such 
coughs  were  often  attributed  to  disorders  of  digestion,  to  dentition,  to 
otitis,  etc. 

2.  Cardiac  cough.  This  is  usually  associated  with  mitral  disease, 
and  is  due  to  pulmonary  congestion.  The  cough  may  be  dry  and  hard, 
but  when  the  congestion  is  severe  there  may  be  frothy  and  blood-streaked 
expectoration. 

3.  A  variety  which  occurs  usually  about  the  time  of  puberty,  and 
is  often  associated  with  anaemia,  chorea,  or  other  nervous  conditions.  It 
is  a  short,  hacking,  or  teasing  cough,  sometimes  very  distressing,  and  it 
seems  to  be  a  manifestation  of  extreme  nervous  irritability. 

4.  A  periodical  night  cough,  which  is  generally  ascribed  to  irrita- 
tion of  the  vagus  or  its  branches  by  enlarged,  sometimes  caseous,  lymph 
nodes  of  the  tracheo-bronchial  group.  This  often  occurs  in  severe 
paroxysms,  the  character  of  which  is  very  much  like  pertussis.  The 
attacks  are  apt  to  come  on  about  the  middle  of  the  night  and  last  for 
several  hours.  Vomiting  is  rare.  The  cough  may  recur  regularly  every 
night  for  months.  On  account  of  the  loss  of  sleep  the  patient's  general 
health  may  be  considerably  undermined. 

5.  A  very  similar  cough  may  occur  in  connection  with  abscesses  in 
the  posterior  mediastinum,  due  to  Pott's  disease. 

Symptoms  and  Diagnosis. — These  cases  are  not  common  in  infants, 
but  are  quite  frequent  in  older  children.  In  nearly  all  the  varieties 
the  cough  is  worse  at  night,  and  in  many  it  may  be  confined  to  that 
time.  The  influence  of  habit  is  often  seen,  the  attacks  coming  on  regu- 
larly at  certain  periods.  The  general  health  may  not  be  affected,  except 
from  the  disturbance  of  sleep.  The  diagnosis  between  the  different 
forms  is  often  very  difficult.  The  precise  cause  in  a  given  case  is  dis- 
covered only  by  a  careful  examination  of  the  ear,  nose,  pharynx,  heart, 
stomach,  and  lungs,  and  by  a  consideration  of  the  patient's  general  con- 
dition. The  symptoms  by  which  a  diagnosis  of  enlarged  or  tuljerculous 
bronchial  glands  is  made  "are  discussed  in  another  chapter.  Symptoms 
in  some  respects  similar  to  these  may  exist  with  abscesses  from  Pott's 
disease. 

Treatment. — Opium  and  expectorants  are  not  indicated,  and  inhala- 
tions are  of  little  value.    The  only  successful  treatment  is  that  which  is 


ASTHMA.  485 

directed  to  the  cause  of  the  disease.  If  no  cause  can  be  found,  and  the 
cough  appears  to  be  of  purely  nervous  origin,  the  l)est  results  follow  the 
use  of  the  bromides  or  the  administration  of  antipyrine  at  bedtime. 

ASTHMA. 

Asthma  may  be  defined  as  a  vaso-motor  neurosis  of  the  respiratory 
tract.  It  is  characterised  by  attacks  of  severe  spasmodic  dyspnoea,  which 
may  be  preceded,  accompanied,  or  followed  by  a  bronchitis  of  greater 
or  less  severity.  In  infancy,  the  association  of  asthma  with  bronchitis  is 
a  very  close  one,  and  the  cases  present  quite  a  different  clinical  picture 
from  the  disease  as  seen  in  older  children,  which  differs  in  no  essential 
points  from  the  asthma  of  adults. 

Writers  differ  very  much  in  their  statements  regarding  the  fre- 
quency of  asthma  in  early  life,  mainly  because  of  a  want  of  agreement  in 
regard  to  what  shall  be  included  under  this  term.  The  asthmatic  attacks 
of  infants  are  considered  by  some  as  a  stage  of  bronchitis,  by  others  as 
distinct  from  that  disease.  Typical  attacks  resembling  those  of  adult  life 
are  rare  in  children,  and  extremely  so  before  the  seventh  year.  How- 
ever, of  225  cases  of  asthma  reported  by  Hyde  Salter,  the  disease  began 
before  the  tenth  year  in  nearly  one-third  the  number. 

Etiology. — The  general  or  constitutional  causes  are  the  same  in  chil- 
dren as  in  adults.  Asthma  is  often  hereditary.  It  occurs  especially  in 
children  whose  antecedents  have  suffered  from  gout  or  from  various  neu- 
roses. It  often  occurs  in  children  who  in  infancy  have  suffered  from 
eczema.  The  local  cause  may  be  any  form  of  irritation  in  the  nose  or 
pharynx — hypertrophic  rhinitis,  adenoid  growths  of  the  pharynx,  hyper- 
trophied  tonsils,  or  elongated  uvula — or  in  the  bronchial  mucous  mem- 
brane, as  a  result  of  previous  attacks  of  acute  bronchitis.  It  is  probable 
that  it  may  also  be  caused  by  the  irritation  of  enlarged  bronchial  glands. 
In  susceptible  persons  a  paroxysm  may  be  excited  by  high  winds,  by  cold 
and  damp  air,  indigestion,  constipation,  or  the  inhalation  of  various  irri- 
tating substances,  such  as  dust,  the  pollen  of  certain  plants,  also  from 
contact  with  horses,  cats,  and  other  animals.  First  attacks  of  asthma 
in  children  are  apt  to  follow  bronchitis. 

Sjrmptoms. — Four  quite  distinct  clinical  types  of  asthma  are  seen  in 
children:  (1)  Cases  which  in  their  onset  simulate  attacks  of  bronchitis. 
(2)  Those  in  which  asthmatic  symptoms  follow  an  attack  of  bronchitis, 
continuing  for  weeks  or  months,  but  not  necessarily  recurring.  (3) 
Hay  fever,  or  the  periodical  form  which  occurs  every  summer.  (4) 
That  which  resembles  the  ordinary  adult  asthma,  with  the  nervous 
element  predominating.  The  prominence  of  the  catarrhal  symptoms  is 
characteristic  of  all  forms  of  asthma  in  children,  the  first  two  varieties 
mentioned  being  peculiar  to  early  life. 


486  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

AttacJk's  Resembling  Acute  Bronchitis. — These  cases  are  rare,  but 
may  be  seen  even  in  infants.  The  onset  is  sudden,  with  moderate  fever, 
incessant  cougli,  severe  dyspnoea,  and  sometimes  symptoms  of  suffocation 
— cyanosis,  prostration,  and  cold  extremities.  The  chest  is  filled  with 
sonorous,  sibilant,  and  soon  with  subcrepitant  rales.  Instead  of  running 
the  usual  course  of  bronchitis  of  the  finer  tubes,  the  symptoms  may  pass 
away  very  rapidly,  and  in  forty-eight,  sometimes  in  twenty-four,  hours 
the  patient  may  be  quite  well.  It  is  only  by  the  course  of  the  disease 
and  by  recurring  attacks  that  their  time  nature  can  be  recognised.  In 
infants  this  form  of  asthma  may  be  fatal. 

Cdses  following  Attacks  of  Bronchitis — Catarrhal  Asthma. — This 
form  is  not  uncommon,  though  it  is  frequently  designated  by  some  other 
term  than  asthma — sometimes  as  spasmodic  bronchitis,  or  catarrhal 
spasm  of  the  bronchi.  The  symptoms  are,  however,  indistinguishable 
from  asthma,  and  they  evidently  belong  in  the  same  category.  This 
form  is  usually  seen  in  infants,  being  rare  after  the  third  year.  Many 
of  the  patients  are  rachitic ;  others  have  large  tonsils,  or  adenoid  growths 
of  the  pharynx;  while  in  still  others  there  is  every  reason  to  suspect 
the  presence  of  large  bronchial  glands.  Usually  there  is  nothing  pecu- 
liar about  the  antecedent  bronchitis;  in  most  cases  it  is  not  espe- 
cially severe,  and  is  limited  to  the  larger  tubes.  The  febrile  symptoms 
subside  in  a  few  days,  but  the  cough  continues,  as  do  also  the  dyspnoea 
and  wheezing.  When  the  symptoms  are  fairly  established  they  are 
very  uniform  and  characteristic.  The  respiration  is  accelerated,  usu- 
ally to  50  or  60,  sometimes  to  70  or  80,  a  minute.  The  temperature 
from  time  to  time  may  be  very  slightly  elevated,  or  it  may  remain 
normal.  The  respiration  is  noisy,  laboured,  and  accompanied  by  dis- 
tinct wheezing. 

On  auscultation,  there  is  prolonged  expiration  accompanied  by  loud, 
wheezing  and  sonorous,  or  sibilant  rales,  and  occasionally  coarse  moist 
rales  are  heard.  In  cases  which  have  lasted  some  time  a  moderate  amount 
of  emphysema  can  be  inferred  from  the  prominence  of  the  infra-clavicular 
regions,  and  exaggerated  resonance  over  the  chest  in  front  and  the 
depression  of  the  bases  posteriorly. 

These  symptoms  and  signs  may  continue  for  three  or  four  weeks  only, 
and  gradually  wear  off,  or  they  may  last  as  many  months — if  they  begin 
in  the  winter  or  spring,  often  continuing  until  the  middle  of  the  summer. 
While  they  are  constantly  present,  they  vary  in  intensity  from  time  to 
time,  being  usually  much  worse  at  night.  The  symptoms  are  always 
increased  by  exposure  to  a  cold,  damp  atmosphere,  by  any  fresh  acces- 
sion of  bronchitis,  and  often  by  trivial  digestive  disturbances.  The  usual 
duration  of  the  cases  I  have  seen  has  been  from  two  to  six  weeks.  The 
cough  is  not  usually  severe,  and  expectoration  in  most  cases  is  absent. 
The  general  health  is  often  but  little  affected.    With  recovery  from  the 


ASTHMA.  487 

asthmatic  symptoms  the  empliysema  usually  disappears  gradually,  al- 
though I  have  seen  one  severe  case  in  which  it  persisted. 

What  proportion  of  these  children  afterward  develop  ordinary  asthma, 
I  am  unable  from  personal  experience  to  say.  Some  undoubtedly  do, 
but  in  others  which  I  have  been  able  to  follow,  recovery  has  seemed  to 
be  permanent.  This  would  appear  more  likely  in  those  cases  closely 
associated  with  rickets,  or  with  other  causes  which  disappear  spontane- 
ously with  time  or  as  a  result  of  treatment. 

Hay  Fever. — This  is  very  rare  before  the  seventh,  and  but  few  well- 
marked  cases  are  seen  before  the  tenth  year.  In  its  clinical  aspects  it 
does  not  differ  essentially  from  the  disease  as  seen  in  adults,  except  pos- 
sibly by  the  greater  prominence  of  the  bronchial  catarrh. 

Ordinary  Attacks  of  the  Adult  Type. — These  usually  occur  at  inter- 
vals of  a  few  weeks  or  months,  depending  upon  the  nature  of  the  excit- 
ing cause.  The  beginning  is  usually  at  night,  with  dyspnoea,  a  short,  dry 
cough,  and  loud,  wheezing  respiration.  Deep  recession  of  the  soft  parts 
of  the  chest  is  seen,  as  in  laryngeal  stenosis.  There  is  prolonged  expira- 
tion, accompanied  by  loud,  sonorous,  sibilant  and  wheezing  rales,  and 
the  vesicular  murmur  is  very  feeble.  I^ater,  moist  rales  may  be 
heard.  After  many  attacks  emphysema  is  present.  This  occurs  more 
rapidly  than  in  adults,  and  may  be  extreme,  giving  rise  in  marked  cases 
to  serious  thoracic  deformity.  On  account  of  the  loss  of  sleep  and 
interference  with  nutrition,  the  general  health  may  become  seriously 
impaired. 

Diagnosis. — Typical  attacks  of  asthma  are  easily  recognised.  Some 
of  the  catarrhal  forms  seen  in  infancy,  however,  present  some  difficulty, 
and  a  positive  diagnosis  may  be  impossible  except  by  the  progress  of  the 
case.  The  blood  picture  in  asthma  is  characteristic  and  of  much  value 
in  diagnosis.  The  important  thing  is  the  presence  of  a  large  number  of 
eosinophile  cells.  They  may  form  as  high  as  15  to  20  per  cent  of  the 
leucocytes.  In  a  series  of  cases  examined  in  my  clinic  by  Wile,  the 
average  was  10.7  per  cent;  the  highest  being  26  per  cent.  The  eosin- 
ophilia  is  greatest  at  the  height  of  the  attack.  The  blood  examination 
serves  to  differentiate  asthma  from  simple  bronchitis  and  from  tuber- 
culosis. The  existence  of  marked  eosinophilia  definitely  establishes  the 
asthmatic  character  of  some  of  these  attacks  in  infancy. 

Prognosis. — This  is  best  in  the  cases  of  catarrhal  asthma  in  infants, 
and  in  older  patients  when  it  depends  upon  some  local  cause  which  can 
be  removed,  as  when  the  disease  is  due  to  reflex  nasal  or  pharyngeal 
irritation.  In  the  majority  of  other  cases,  asthma  is  likely  to  become 
chronic  unless  the  child  is  removed  to  some  climate  in  which  the  attacks 
do  not  occur.  The  younger  the  child,  the  shorter  the  duration  of  the 
disease,  and  the  less  marked  the  hereditary  tendency,  the  better  the 
prognosis. 


488  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

Treatment. — The  nose  and  the  rhino-pharynx  should  be  carefully 
examined  in  every  case  of  asthma,  and  any  pathological  condition  there 
present  should  receive  attention  as  the  first  step  in  the  treatment.  Spe- 
cial importance,  in  cliildren,  should  be  attached  to  the  removal  of  adenoid 
growths  of  the  pharynx.  I  must  admit,  however,  to  have  seen  very  few 
cases  of  asthma  cured  or  even  greatly  improved  by  these  means.  -During 
attacks,  the  best  means  of  relieving  the  symptoms  is  the  inhalation  of 
fumes  of  nitre  paper  or  stramonium  leaves.  Most  of  the  proprietary 
remedies  (Papier  de  Fruneau,  Himrod's  cure,  and  Kidder's  pastilles) 
contain  these  ingredients.  The  sleeping  room  may  be  filled  with  the 
fumes  of  these  substances,  or  the  child  may  be  placed  in  a  tent  into  which 
the  fumes  are  introduced.  Emetics  may  be  employed  when  the  attack 
is  brought  on  by  indigestion.  To  prevent  the  recurrence  of  night  attacks, 
nothing  in  my  experience  has  been  so  valuable  as  a  full  dose  of  antipyrine 
at  bedtime — four  grains  at  five  years  and  six  grains  at  ten  years. 
Between  the  attacks  the  main  reliance  should  be  upon  the  syrup  of 
hydriodic  acid  (for  a  child  of  five  years  the  dose  is  IT),  v  to  TTL  x,  t.i.d.) 
and  potassium  iodide  (gr.  ii  to  gr.  iv,  t.i.d.),  which  are  to  be  given 
for  a  long  time.  Tonics  are  to  be  used  in  nearly  all  cases.  Those  espe- 
cially valuable  in  asthmatic  patients  are  cinchonidia  (gr.  ii,  t.i.d.)  and 
arsenic  (gr.  y^,  t.i.d.).    They  may  be  advantageously  combined. 

In  the  severe  acute  attacks  nothing  gives  so  much  immediate  relief  as 
the  use  of  adrenalin  hypodermically — dose  TTl,  v  to  a  chikl  of  three  years. 

In  the  cases  of  catarrhal  asthma  following  bronchitis,  expectorants 
and  ordinary  cough  remedies  are  useless.  Cod-liver  oil  and  the  iodide  of 
potassium  are  valuable  in  some  of  the  cases.  Others  are  greatly  relieved 
by  the  regular  use  of  creosote  inhalations  several  times  a  day,  with  a 
nightly  dose  of  antipyrine.  The  fumes  of  nitre  and  stramonium  often 
afford  no  relief,  and  sometimes  the  cases  are  made  distinctly  worse  by 
them.  The  best  of  all  measures  is  to  send  the  child  at  once  to  a  warm, 
dry  climate. 

For  all  children  who  have  had  repeated  attacks,  whether  in  the  form 
of  hay  fever  or  for  those  whose  asthma  is  chiefly  in  the  winter  and  spring 
and  excited  by  attacks  of  bronchitis,  the  most  important  thing  is  re- 
moval to  a  place  where  they  do  not  have  the  disease,  and  a  residence 
there  long  enough  to  break  up  the  tendency  to  recurrence.  This  will 
usually  require  several  years.  The  region  best  suited  to  most  asthmatics 
is  one  which  is  high,  dry,  and  moderately  warm.  Some  do  exceedingly 
well  at  the  seashore;  others  much  better  in  the  mountains.  Patients 
often  suffer  less  in  cities  than  in  the  country.  If  taken  early,  asthma 
in  children  is  frequently  curable  by  these  means ;  if  neglected,  the  disease 
is  almost  sure  to  continue  until  adult  life. 


PNEUMONIA.  489 

CHAPTER    IV. 

DISEASES  OF  THE  LUNGS.— (Continued.) 

PNEUMONIA. 

In  early  life  the  lungs  are  more  frequently  the  seat  of  organic  disease 
than  anj'  other  organs  in  the  body.  Pneumonia  is  very  common  as  a 
primary  disease,  and  ranks  first  as  a  complication  of  the  various  forms 
of  acute  infectious  disease  of  children.  It  is  one  of  the  large  factors  in 
the  mortality  of  infancy  and  childhood. 

Cases  of  acute  pneumonia  are  divided,  from  an  anatomical  point  of 
view,  into  two  principal  groups:  (1)  Broncho-pneumonia,  also  known  as 
catarrhal  and  as  lobular  pneumonia.     (2)   Lobar  pneumonia,  also  known 


• 


Fig.  70. — Bkoncho-pneumonia.  The  jfictuic  shows  at  its  centre  one  entire  air  vesicle, 
and  at  its  margin  parts  of  four  or  five  other  vesicles;  they  are  filled  with  large  epi- 
thelial cells  having  small  nuclei.  There  are  also  seen  leucocytes  with  intensely 
black  nuclei  and  narrow  protoplasm.  Between  the  cells  is  a  finely  granular  ma- 
terial, which  is  the  exudation  fluid  coagulated  during  the  hardening  process.  The 
alveolar  septa  are  somewhat  infiltrated. — From  Karg  and  Schmorl. 

as  croupous  and  as  fibrinous  pneumonia.  These  differ  little  from  each 
other  in  etiology,  but  considerably  in  the  products  of  inflammation,  the 
distribution  of  the  disease  in  the  lung,  and  somewhat  as  to  the  parts 
involved  and  the  nature  of  the  changes  in  them. 

In  broncho-pneumonia  the  large  bronchi  are  the  seat  of  a  superficial 


490 


DISEASES  OF  THE   RESPIRATORY  SYSTEM. 


inflammation,  while  in  those  of  small  size  the  entire  bronchial  wall  is 
affected;  the  exudation  into  the  air  vesicles  is  mainly  cellular,  being 
made  up  of  epithelial  cells,  leucocytes,  and  red  blood-cells  (Fig.  70), 
fibrin  being  either  absent,  or  present  only  in  small  amount.  In  many 
cases  there  are  marked  changes  both  in  the  alveolar  septa  and  in  the 
interstitial  tissue  of  the  lung;  resolution  is  often  imperfect,  and  there 
is  a  strong  tendency  for  the  inflammation  to  pass  into  a  chronic  form, 
involving  the  connective-tissue  framework  of  the  lung.  The  lesion  is 
widely  and  often  irregularly  distributed,  usually  being  most  marked  in 
the  vicinity  of  the  small  bronchi  from  which  the  inflammation  spreads, 
and  in  the  most  superficial  lobules  of  the  lung. 

In  lobar  pneumonia,  bronchitis,  when  present,  is  usually  superficial, 
the  walls  of  the  bronchi  being  very  slightly  or  not  at  all  affected ;  the 


Fio.  71. — Lobar  Pneumonia.  In  the  air  vesicle  shown  in  the  picture  there  is  a  firm, 
close  network  of  fibrin,  in  the  meshes  of  which  are  leucocytes.  At  the  lower  part  the 
exudation  has  contracted  away  from  the  wall  in  consequence  of  the  process  of  hard- 
ening.— From  Karg  and  Schmorl. 


same  is  true  of  the  alveolar  septa.  The  principal  product  of  the  inflam- 
mation is  fibrin  (Fig.  71),  which  fills  the  alveoli  and  the  terminal  bron- 
chi, the  cells  being  relatively  few  and  chiefly  leucocytes.  The  process  is 
usually  sharply  circumscribed,  involving  an  entire  lobe  or  a  part  of  a 
lobe.  In  most  cases  it  clears  up  rapidly  and  completely,  there  being  but 
little  tendency  to  involve  the  framework  of  the  lung  in  a  chronic  process. 


PNEUMONIA.  491 

While  in  typical  cases  the  two  forms  of  inflammation  are  quite  dis- 
tinct, there  are  seen  many  intermediate  fonns  wliicli  partake  of  the  cliar- 
acters  of  both,  and  one  may  be  in  doubt,  even  after  a  microscopical  ex- 
amination, in  which  group  to  place  a  case.  It  not  intrccjuently  happens 
that  both  varieties  of  pneumonia  are  present  in  different  parts  of  the 
same  lung  or  in  both  lungs  at  the  same  time.  Tliese  mixed  forms  are 
especially  frequent  during  the  second  and  tliird  years;  but  during  the 
first  year,  and  after  the  third,  the  types  are  usually  well  marked. 

The  following  table  shows  the  relative  frequency  of  lobar  and  broncho- 
pneumonia in  three  hundred  and  seventy  cases,^  nearly  all  taken  from 
one  institution  (New  York  Infant  Asylum).  There  are  included  all 
the  cases  of  acute  primary  pneumonia  occurring  during  a  period  of 
seven  years : 

Under  six  months,  broncho-pneumonia,  73  cases;  lobar  pneumonia,  11  cases. 


Six  to  twelve  "                      "  96 

Second  year,  "  73 

Third       "  ■  "  19 

Fourth     "  "  0 

Totals,  "  261 


29 

40 

23 

6 

109 


Thus  it  will  be  seen  that,  of  the  cases  of  acute  pneumonia  occurring 
during  the  first  two  years,  twenty-five  per  cent  were  lobar  and  seventy- 
five  per  cent  were  broncho-pneumonia. 

When  we  come  to  a  consideration  of  the  micro-organisms  with  which 
the  different  forms  of  pneumonia  are  associated,  we  find  that  they  do 
not  correspond  to  the  anatomical  varieties.  Lobar  pneumonia  is  reg- 
ularly associated  with  the  presence  of  the  pneumococcus,  but  in  a  large 
number  of  cases  other  organisms  are  also  found.  In  broncho-pneumonia 
there  is  almost  always  a  mixed  infection.  In  the  primary  cases  the 
pneumococcus  is  usually  the  predominant  organism,  but  it  is  commonly 
associated  with  the  staphylococcus  aureus.  In  the  secondary  cases,  espe- 
cially when  pneumonia  follows  measles  or  scarlet  fever,  the  strepto- 
coccus is  usually  present,  such  cases  being  generally  of  a  severe  type.  In 
the  pneumonia  of  diphtheria,  besides  the  streptococcus  the  diphtheria 
bacillus  is  frequently  found.  In  winter  the  bacillus  of  influenza  may  be 
the  only  organism  present,  but  it  is  usually  associated  with  the  pneumo- 
coccus. The  organisms  mentioned  are  found  in  all  possible  combinations, 
sometimes  one  and  sometimes  another  predominating.  With  any  of  them 
the  bacillus  of  diphtheria  or  that  of  tuberculosis  may  be  found.  Some 
idea  of  the  nature  of  the  infection  in  broncho-pneumonia  may  be  gained 
from  the  following  table — the  sputum  cultures  representing  the  pneu- 


1  The  division  was  here  made  according  to  the  predominant  clinical  or  pathologi- 
cal features.     Most  of  the  doubtful  cases  were  classed  as  broncho-pneumonia. 


492  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

monias  of  one  winter  and  spring  in  the  Babies'  Hospital,  and  the  post> 
mortem  cultures  from  those  of  two  seasons  ^  in  the  same  institution : 


Staphylococcus  aureus . 

Pneumococcus 

Streptococcus 

Bacillus  influenzae 


Sputum  cultures  from  124 
cases  of  pneumonia. 


116 
94 
63 
47 


Post-mortem  cultures  from  the 
lungs  in  59  cases  of  pneumonia. 


36 
26 
17 
19 


Why  the  same  exciting  cause  in  one  case  produces  broncho-pneumonia 
and  in  another  lobar  pneumonia  may  be  in  part  owing  to  the  difference 
in  the  structure  of  the  lung  at  the  different  ages,  especially  the  relatively 
large  size  of  the  bronchi  in  infancy.  Again,  in  very  young  and  in  feeble 
children,  the  process  tends  to  become  diffuse  and  the  products  are  chiefly 
cellular;  in  those  who  are  older  and  more  vigorous  it  is  likely  to  be 
circumscribed,  with  fibrin  as  its  chief  product;  in  the  intermediate  ages 
and  intermediate  conditions  the  types  are  often  mingled. 

The  immediate  source  of  infection  of  the  lungs  is  the  mouth  or  the 
rhino-pharynx.  All  the  forms  of  bacteria  found  in  pneumonia  may  be 
found  in  these  cavities,  some  of  them  constantly,  others  only  at  certain 
times,  especially  during  an  attack  of  any  of  the  acute  infectious  diseases. 
Provided  the  other  conditions  are  favourable,  pneumonia  may  be  excited 
by  direct  contagion.  This  plays  a  small  part  in  inducing  primary  pneu- 
monia ;  there  seems,  however,  to  be  little  doubt  that  the  secondary  forms, 
especially  the  pneumonia  complicating  measles,  diphtheria  and  influenza, 
are  not  infrequently  communicated  in  this  way. 

The  different  forms  of  pneumonia  which  will  be  considered  are :  ( 1 ) 
Acute  broncho-pneumonia;  (2)  acute  lobar  pneumonia;  (3)  acute 
pleuro-pneumonia ;  (4)  hypostatic  pneumonia;  (5)  chronic  broncho- 
pneumonia. 

Tuberculous  broncho-pneumonia  will  be  discussed  in  the  chapter 
devoted  to  Tuberculosis. 

ACUTE  BRONCHO-PNEUMONIA. 
(Catarrhal  Pneumonia;  Lobular  Pneumonia;  Capillary  Bronchitis.) 

This  is  essentially  the  pneumonia  of  infancy.  Under  two  years,  the 
great  majority  of  the  cases  of  primary  pneumonia  are  of  this  variety,  and 
throughout  childhood  nearly  all  the  cases  of  secondary  pneumonia.  The 
term  broncho-pneumonia  describes  a  lesion  rather  than  a  disease,  several 
quite  distinct  forms  of  infection  being  included  under  this  head.  Its 
mortality  is  high,  because  of  the  tender  age  of  the  patients  in  which  the 

'  See  Archives  of  Internal  Medicine,  v,  449;  and  Journal  American  Medical 
Association,  Iv,  1241. 


ACUTE   BRONCHO-PNEUMONIA.  493 

primary  cases  occur,  and  also  because  wlien  secondary  it  complicates  the 
most  severe  forms  of  the  acute  infectious  diseases  of  children. 

Etiology. — The  426  cases  of  broncho-pneumonia  of  which  I  have 
notes  occurred  as  follows: 

During  the  first  year 224  cases,  or  53  per  cent. 

"         "    second  year 142      "       "  33    "       " 

"         "    third        "    46      "       "  11    "       " 

"         "   fourth     "    10      "       "    2    "       " 

"   fifth         "    4      "       "     1    "       " 

426  100 

After  four  years  broncho-pneumonia  is  infrequent  as  a  primary  dis- 
ease, although  it  is  seen  throughout  childhood  as  a  complication  of  the 
infectious   diseases. 

Of  the  cases  referred  to,  38  per  cent  occurred  during  the  winter 
months,  31  per  cent  during  the  spring,  13  per  cent  during  the  summer, 
and  18  per  cent  during  the  autumn.  While,  therefore,  nearly  70  per  cent 
of  the  cases  occurred  in  the  cold  months,  broncho-pneumonia  is  seen 
throughout  the  year. 

Broncho-pneumonia  affects  all  classes,  but  is  most  frequent  in  chil- 
dren having  poor  hygienic  surroundings,  especially  in  inmates  of  institu- 
tions, and  in  those  previously  debilitated  by  constitutional  or  local  dis- 
ease. In  246  consecutive  cases  of  primary  pneumonia,  110  were  in  good 
condition  prior  to  the  attack,  and  126  were  delicate,  rachitic,  or  syphilitic. 

The  following  table  gives  a  good  idea  of  the  conditions  with  which 
acute  broncho-pneumonia  is  most  frequently  seen ;  443  cases  were  classed 
as  follows: 

Primary  ^ 164 

Secondary  to  bronchitis  of  the  large  tubes 41 

Complicating  measles 89 

"            pertussis 66 

"            diphtheria 47 

"            acute  ileo-colitis 19 

"            scarlet  fever 7 

"            influenza 6 

"            varicella 2 

"            erysipelas 2 

443 

A  large  number  of  the  patients  had  previously  suffered  from  one  or 
more  attacks  of  bronchitis,  and  fifteen  previously  had  broncho-pneumonia. 

As  an  exciting  cause,  exposure  to  cold  must  still  be  classed  among  the 
potent  factors  of  primary  pneumonia.  The  organisms  concerned  in 
broncho-pneumonia  have  been  discussed  in  the  previous  chapter. 

1  It  is  probable  that  a  number  of  cases  complicating  influenza  were  included 
among  these  primary  cases. 


494 


DISEASES  OF  THE  RESPIRATORY   SYSTEM. 


Lesions. — The  term  broncho-pneumonia  is  now  generally  adopted  as 
a  generic  one,  and  it  is  to  be  preferred  either  to  lobular  or  catarrhal 
pneumonia,  as  it  gives  prominence  to  the  bronchial  element  in  the  inflam- 
mation.   The  process  may  begin  in  the  larger  tubes  and  gradually  extend 


Fig.  72. — Broncho-pneumonia,  with    i  inu  of  a  Bronchus.     In  the  centre  of 

the  picture  is  seen  a  small  bronchus,  B,  .which  is  cut  somewhat  obliquely;  the  degree 
to  which  its  wall,  C,  is  thickened  is  well  shown.  It  is  partially  filled  with  pus,  its 
mucous  membrane  is  nearly  destroyed,  and  its  walls  greatly  thickened  from  infiltra- 
tion with  leucocytes.  This  infiltration  extends  to  the  lung  tissue  in  the  neighbour- 
hood; it  forms  a  peri-bronchitic  zone  of  pneumonia.  Elsewhere  in  the  picture  the 
lung  tissue.  A,  is  practically  normal.  D  is  a  small  blood-vessel.  E  is  another  smaller 
bronchus.  Throughout  the  lung  everywhere  accompanying  the  small  bronchi  similar 
changes  were  seen,  in  addition  to  which  there  were  present  some  large  areas  of  con- 
solidation. The  disease  was  of  four  and  a  half  weeks'  duration;  the  child,  five  months 
old. 

to  those  of  smaller  calibre,  finally  involving  the  pulmonary  lobules  in 
which  these  tubes  terminate;  or  it  may  extend  to  the  air  vesicles  wliich 
surround  the  tube  in  its  course  through  the  lung,  so  that  in  whatever 
direction  the  lung  is  cut,  there  are  seen,  surrounding  the  small  bronchi, 
zones  of  pneumonia  (Fig.  72).    In  other  cases  the  process  seems  to  begin 


PLATE    XI. 


Acute  Broncho-Pneumonia. 

Primary  pneumonia  in  a  child  two  years  old,  showing  the  irregular  distribution  of 
the  consolidation  and  its  incomplete  character.  A  is  the  pleura  somewhat  thickened  ; 
B,  lung  tissue  which  is  practically  normal ;  C  C  are  consolidated  areas,  scattered  through 
which  are  groups  of  air  vesicles  still  containing  air.    (Slightly  magnihed.) 


ACUTE   BRONCHO-PNEUMONIA.  495 

almost  at  the  same  time  in  the  small  hronclii  and  tlie  air  vesicles,  as  hoth 
are  found  involved,  even  when  death  occurs  within  a  few  hours  of  the 
first  symptoms. 

There  are,  however,  cases  in  which  the  parts  of  the  lung  aiTected 
bear  no  relation  to  the  bronchi — where  there  are  found  simply  smaller 
or  larger  areas  of  pneumonia  irregularly  scattered  tlirough  the  lung, 
usually  near  the  surface  (Plate  XI).  From  the  distribution  of  the 
lesions  such  cases  might  better  be  termed  lobular  than  broncho-pneu- 
monia. 

Much  has  been  said  in  the  past  about  pulmonary  collapse  from  ob- 
struction of  the  small  bronchi,  as  a  condition  antecedent  to  this  form  of 
pulmonary  inflammation.  So  far  as  my  own  observations  go,  there  has 
been  adduced  but  little  evidence  that  this  is  the  rule,  or,  indeed,  that  it 
often  occurs.  Even  in  autopsies  made  very  early  in  the  disease,  but  little 
collapse  is  found,  most  of  the  cases  supporting  the  view  of  Delafield,  that 
when  the  disease  extends  from  the  bronchi  to  tlie  air  cells  it  involves 
those  surrounding  the  tube  quite  as  regularly  as  those  to  which  the  tube 
leads. 

The  following  observations  are  made  from  a  study  of  170  autopsies 
of  which  I  have  records,  microscopical  examinations  having  been  made  in 
about  one-third  of  the  number. 

Seat  of  the  Disease. — In  eighty-two  per  cent  of  the  autopsies  extensive 
disease  was  found  in  both  lungs.  The  parts  most  affected  were  the  lower 
lobes  posteriorly;  next  to  this  the  posterior  part  of  both  the  upper  and 
lower  lobes.  The  left  lower  lobe  was  more  extensively  diseased  than  the 
right  in  over  two-thirds  of  the  cases.  If  the  pneumonia  is  in  front  only, 
the  right  apex  is  the  most  frequent  seat. 

There  are  a  certain  number  of  cases  which  appear  to  follow  tolerably 
well-defined  stages  of  congestion,  consolidation,  and  resolution;  but  the 
disease  may  be  arrested  at  any  of  the  stages  and  the  case  recover,  or 
death  may  occur  at  any  stage  and  there  may  be  found  at  autopsy  differ- 
ent portions  of  the  lung  representing  all  the  stages  mentioned.  In  con- 
sidering, therefore,  the  lesions  of  broncho-pneumonia,  it  seems  best  to 
describe  the  condition  in  which  the  lungs  are  found  at  the  various  periods 
when  death  is  likely  to  occur,  rather  than  to  attempt  to  describe  the 
different  stages  of  the  disease,  as  in  lobar  pneumonia. 

1.  The  Acute  Congestive  Form  (Acute  Red  Pneumonia). — This  is 
the  condition  in  which  the  lung  is  usually  found  if  death  occurs  during 
the  first  two  or  three  days  of  the  disease.  In  the  cases  severe  enough  to 
cause  death  in  the  first  twenty-four  hours,  very  little  can  be  seen  by  the 
naked  eye  except  acute  congestion.  The  vessels  of  the  pleura  are  dis- 
tended, and  there  may  be  small  superficial  haemorrhages.  Both  lower 
lobes  are  usually  heavy  and  dark  coloured.  There  is  to  the  naked  eye 
no  consolidation.     All,  or  nearly  all,  the  lung  can  be  inflated.     On  sec-. 


496  DISEASES  OF  THE   RESPIRATORY   SYSTEM. 

tion,  there  is  found  intense  congestion  with  some  oedema.  When  the 
process  has  lasted  a  little  longer  the  affected  areas  are  more  sharply 
defined.  These,  usually  the  posterior  portions  of  both  lungs,  are  of  a 
brownish-red  colour,  and  appear  partially  consolidated,  although  with 
a  little  force  they  may  in  most  cases  be  inflated.  After  section,  pus  and 
mucus  flow  from  the  divided  bronchi,  and  the  whole  lung  may  be  more 
or  less  congested  or  oedematous. 

The  microscope  alone  reveals  the  fact  that  these  .are  not  cases  of  sim- 
ple pulmonary  congestion  or  bronchitis  of  the  finer  tubes.  In  one  case 
in  which  death  occurred  twelve  hours  from  the  first  symptoms,  I  found 
well-marked  evidences  of  inflammation  of  the  air  vesicles.  In  these 
hyper-acute  cases,  the  microscope  shows  great  distention  of  all  the  small 
blood-vessels  of  the  affected  area,  and  small  or  large  extravasations  of 
blood  just  beneath  the  pleura,  into  the  alveoli  and  interstitial  tissue  of  the 
lung.  In  some  cases  these  haemorrhages  form  the  most  striking  feature 
of  the  lesion.  The  air  vesicles  are  partially,  some  almost  completely, 
filled  with  red  blood-cells,  swollen  and  desquamated  epithelial  cells,  and 
a  few  leucocytes  (Fig.  70).  The  red  blood-cells  predominate.  Tlie  in- 
flammation may  be  diffuse,  involving  nearly  a  whole  lobe,  or  in  small 
areas  in  the  neighbourhood  of  the  small  bronchi.  The  mucous  mem- 
brane of  the  large  and  small  bronchi  is  the  seat  of  catarrhal  inflammation, 
and  the  walls  of  the  latter  are  infiltrated  with  round  cells. 

When  the  process  has  lasted  from  twenty-four  to  forty-eight  hours 
all  the  changes  described  are  more  marked,  but  the  red  colour  of  the 
inflammatory  products  still  persists.  Such  cases  give  during  life  only 
the  signs  of  congestion  and  bronchitis. 

2.  The  Mottled,  Bed  and  Gray  Pneumonia. — This  is  the  usual  ap- 
pearance when  the  disease  has  lasted  somewhat  longer,  and  is  found  in 
most  of  the  cases  dying  between  the  fourth  and  fourteenth  days.  There 
are  usually  at  this  time  quite  large  areas  of  consolidation,  sometimes 
affecting  nearly  an  entire  lobe,  so  that  at  first  sight  the  case  may  resemble 
lobar  pneumonia.  This  is  sometimes  described  as  the  "  pseudo-lobar  " 
form.  The  extent  of  these  areas  depends  largely  upon  the  duration  of 
the  disease.  In  most  cases  there  is  pleurisy  over  the  consolidated  por- 
tions. This  may  cause  the  lung  to  adhere  to  the  chest  wall,  the  firmness 
of  the  adhesions  depending  upon  the  duration  of  the  process.  The  sur- 
face of  the  lung  is  usually  of  a  mottled  red  and  gray  colour ;  it  often  has 
a  coarsely  granular  feel,  due  to  the  consolidation  of  some  of  the  super- 
ficial lobules  of  the  lung.  On  section,  it  is  rarely  found  that  an  entire 
lobe  is  consolidated,  the  superficial  portion  being  most  affected,  while 
the  central  part  is  normal  or  only  congested.  The  colour  is  mottled,  like 
that  of  the  surface.  In  some  places  the  consolidation  appears  complete; 
in  others  the  consolidated  areas  are  separated  by  healthy,  congested,  or 
emphysematous  lung  tissue   (Fig.  73).     The  gray  areas  surround  the 


ACUTE   BRONCHO-PNEUMOXIA. 


497 


small  bronchi  and  vary  in  size.  The  smallest  ones  look  very  much  like 
miliary  tubercles.  The  larger  ones  are  seen  where  the  process  has  existed 
for  a  longer  time  and  has  gradually  invaded  the  contiguous  air  cells.  If 
the  lung  is  cut  parallel  with  the  bronclii,  there  may  be  seen  small  gray 
striae  of  pneumonia  along  their  course  (Fig.  72,  C).  From  the  cut 
bronchi,  pus  flows  quite  freely  on  pressure.     The  bronchial   walls   are 


Pio.  73. — Acute  Broncho-pneumonia.  In  the  centre  is  shown  a  small  bronchus,  B, 
with  a  zone  of  pneumonia  about  it.  The  greater  part  of  the  section  is  made  up  of 
emphysematous  lung  tissue,  E  E,  showing  dilatation  of  the  alveolar  spaces  and  rup- 
ture of  some  of  the  alveolar  septa.  At  the  border,  AAA,  are  seen  the  margins  of 
consolidated  areaa  of  lung. 

often  seen  to  be  thickened  even  by  the  naked  eye.  The  parts  affected 
are  usually  the  posterior  portions  of  the  lower  lobe  of  one  or  both  sides, 
the  remainder  of  the  lobes  being  congested  or  oedematous,  while  in  front 
the  lung  is  emphysematous. 

Under  the  microscope  the  smaller  bronchi  (Fig.  73)  are  seen  to  be 
much  thickened  and  infiltrated  with  leucocytes.  The  gray  areas  sur- 
rounding the  bronchi  are  made  up  of  groups  of  air  vesicles,  which  are 
packed  with  leucocytes  (Fig.  74).  Fibrin  is  sometimes  seen  in  small 
amount,  also  red  blood-cells  and  desquamated  epithelial  cells,  but  the 
leucocytes  predominate.  Surrounding  the  areas  densely  infiltrated  are 
groups  of  air  vesicles  which  are  normal  or  congested,  or  which  show 
only  the  earlier  stages  of  the  inflammatory  process. 
33 


498  DISEASES   OF  THE   RESPIRATORY   SYSTEM. 

3.  Gray  Pneumonia  {Persistent  Broncho-pneumonia). — This  form 
is  seen  in  protracted  cases  where  there  have  been  continuous  symptoms 
usually  for  from  three  to  six  weeks.  The  pleuritic  adhesions  are  more 
general  and  firmer.  The  amount  of  lung  involved  may  be  very  great, 
often  nearly  the  whole  of  both  lungs  posteriorly.  The  ailected  lung  aj)- 
pears  completely  consolidated  and  slightly  enlarged.  On  section,  it  is 
of  a  nearly  uniform  gray  colour,  sometimes  of  a  yellowish-gray.     On 


Fio.  74. — Broncho-pneumonia.  Dense  infiltration  of  pus  cells  in  and  about  a  small 
bronchus;  under  a  low  power.  The  cavity  shown  in  the  specimen  is  a  cross-section 
of  one  of  the  small  bronchi,  which  is  partially  filled  with  pus  cells;  the  epithelium  is 
destroyed.  The  bronchial  wall  and  the  pulmonary  tissue  in  the  neighbourhood  are  so 
densely  infiltrated  with  leucocytes  that  almost  every  trace  of  normal  structure  is 
effaced.  Child  fifteen  months  old,  disease  of  four  weeks'  duration.  Extensive  areas 
like  this  were  found  in  botfc  lungs. 

pressure,  pus  exudes  from  the  smaller  and  larger  bronchi.  The  bronchial 
walls  are  markedly  thickened,  and  in  some  places  there  may  be  a  slight 
dilatation  of  the  smaller  bronchi.  The  part  of  the  lung  not  consolidated 
may  be  almost  white,  owing  to  vesicular  emphysema.  In  some  cases 
there  is  also  interstitial  emphysema.     Small  cavities  containing  pus  may 


ACUTE   BRONCHO-PXEUMONIA. 


499 


be  found  in  the  lung.     The  bronchial  glands  are  frequently  swollen  to 
the  size  of  a  large  bean,  and  are  of  areddisli-gray  colour. 

The  microscope  shows  that  the  air  vesicles  of  the  consolidated  por- 
tions are  distended  chiefly  witli  leucocytes,  but  tbere  arc  also  epithelial 


Fig.  75. — Persistent  Broncho-pneumonia;  Highly  Magnified.  There  is  shown  at 
A  A  marked  thickening  of  the  alveolar  septa,  encroaching  upon  the  alveolar  spaces. 
All  the  alveoli,  B  B,  are  densely  packed  with  leucocytes.  A  similar  condition  also 
through  nearly  the  whole  of  the  affected  lung.  (For  history  and  temperature,  see 
Fig.  84.) 

and  connective-tissue  cells.  The  alveolar  septa  may  be  so  much  thick- 
ened as  to  encroach  upon  the  alveolar  spaces  (Fig.  75).  Complete  reso- 
lution is  then  impossible. 

Terminations. — Death  may  occur  at  any  stage,  or  the  pathological 
process  may  be  arrested  at  any  stage  and  the  case  go  on  to  recovery. 
Resolution  may  take  place  before  any  consolidation  recognisable  by  phys- 
ical signs  has  occurred;  in  such  cases  it  is  usually  rapid  and  complete. 
If  there  has  been  consolidation,  resolution  may  take  place  after  two  or 
three  weeks  and  be  complete,  or  it  may  be  delayed  for  five  or  six  weeks 


500  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

and  still  be  complete.  In  many  cases,  especially  those  in  which  it  is 
delayed,  resolution  is  only  partial,  and  there  are  relapses  or  recurring 
attacks.  After  the  first,  or  after  several  attacks,  there  may  develop  a 
chronic  interstitial  pneumonia;  or  simple  pneumonia  may  be  followed 
by  tuberculosis.  Such  cases  as  these  are  to  be  carefully  distinguished 
from  the  much  more  frequent  ones  in  which  the  broncho-pneumonia  is 
tuberculous  from  the  outset. 

Associated  Lesions  of  the  Lungs. — Pleurisy  is  almost  invariably  found 
over  every  large  area  of  consolidation,  and  in  cases  of  more  than  three  or 
four  days'  duration;  while  in  most  of  those  fatal  within  the  first  two 
or  three  days  the  pleura  is  normal  or  only  congested.  It  is  seen  in  all 
grades  of  severity,  from  a  slight  gray  film  of  fibrin  that  can  hardly  be 
stripped  off,  to  a  yellowish-green  exudation  one-fourth  of  an  inch  thick. 
A  small  amount  of  serum — one  or  two  ounces — in  the  pleural  sac  is  not 
uncommon,  but  a  large  syous  effusion  is  very  rare.  Cases  in  v/hich  there 
is  an  excessive  inflammation  of  the  pleura  are  considered  elsewhere  under 
the  head  of  Pleuro-pneumonia.  Empyema  occurs  both  during  the  stage 
of  acute  inflammation  of  the  lung  and  while  this  is  subsiding,  but  it  is 
less  frequent  than  in  lobar  pneumonia. 

Bronchial  Glands. — In  all  the  recent  acute  cases  these  are  swollen 
and  red ;  the  usual  size  is  that  of  a  pea  or  a  bean.  They  show  microscopic- 
ally the  usual  changes  of  acute  hyperplasia.  In  protracted  cases,  and 
after  repeated  attacks,  they  may  be  two  or  three  times  the  size  mentioned, 
and  of  a  gray  colour.  It  is  rare  that  they  are  large  enough  to  give  rise 
to  symptoms  unless  they  become  the  seat  of  tuberculous  deposits. 

Emphysema. — This  is  one  of  the  regular  and  striking  features  of 
acute  broncho-pneumonia  in  infancy,  it  being  especially  marked  in  the 
protracted  cases.  It  is  usually  vesicular,  involving  the  greater  part  of 
the  upper  lobes  in  front  and  the  anterior  margin  of  the  lower  lobes.  Oc- 
casionally interstitial  emphysema  is  seen,  forming  either  large  striae  upon 
the  surface  of  the  lung,  or  blebs  of  considerable  size  along  the  anterior 
margin.  This  may  occur  even  in  cases  uncomplicated  by  pertussis  or 
laryngeal  stenosis. 

Gangrene. — Gangrenous  areas  were  found  in  six  cases  of  the  series 
mentioned.  In  four  of  these  the  pneumonia  was  primary,  in  one  it 
followed  diphtheria,  and  in  one  ileo-colitis.  It  occurred  in  scattered  areas 
of  a  grayish-green  colour,  varying  from  one-fourth  of  an  inch  to  two 
inches  in  diameter. 

Abscesses  of  the  lung  are  by  no  means  uncommon.  They  were  noted 
in  seven  per  cent  of  the  autopsies.  They  are  usually  minute  and  mul- 
tiple, varying  in  size  from  one-sixth  to  one-half  inch  in  diameter.  Some- 
times a  portion  of  a  lobe  is  fairly  honeycombed  with  minute  abscesses. 
In  one  case  a  large  abscess  was  found  occupying  the  greater  part  of  a 
lobe,  the  symptoms  resembling  those  of  empyema.    Abscesses  are  usually 


ACUTE   BRONCHO-PNEUMONIA.  501 

found  in  regions  where  the  inflammatory  process  has  been  especially- 
intense.  They  may  be  found  in  prolonged  cases,  in  those  of  unusual  se- 
verity, as  shown  by  excessively  high  temperature  and  rapid  extension  of 
the  disease,  and  in  very  delicate  subjects.  The  microscope  shows  that 
these  abscesses  usually  begin  as  an  accumulation  of  pus  in  the  small 
bronchi,  whose  walls  become  softened  and  break  down  on  account  of  the 
intensity  of  the  inflammation.  They  may  be  superficial,  but  are  more 
commonly  in  the  interior  of  the  lung;  they  contain  yellow  pus  and 
sometimes  broken-down  lung  tissue.  Small  abscesses  can  not  be  recog- 
nised clinically ;  the  large  ones  give  the  symptoms  and  signs  of  empyema. 
They  are  discussed  more  fully  elsewhere.  In  several  instances  they  have 
been  successfully  operated  on,  though  wrongly  diagnosticated. 

The  lesions  in  other  organs  will  be  considered  under  Complications. 

Symptoms. — Broncho-pneumonia  has  no  typical  course.  The  cases 
differ  from  each  other  very  markedly,  but  they  may  be  divided  into  a 
few  quite  distinct  groups. 

1.  The  Acute  Congestive  Type. — This  may  be  seen  at  any  age,  but 
is  more  frequent  in  young  infants.  It  may  be  either  primary  or  secondary, 
being  not  uncommon  in  either  form.  Its  symptoms  are  few  and  irreg- 
ular, and  the  disease  is  often  unrecognised.  The  entire  duration  may 
be  only  twenty-four  hours.  High  temperature,  extreme  prostration, 
cyanosis,  and  rapid  respiration  may  be  the  only  symptoms.  The  tem- 
perature varies  between  104°  and  107°  F.,  usually  rising  steadily  until 
death  occurs.  The  prostration  is  extreme  from  the  outset,  the  patient 
being  overwhelmed  by  the  suddenness  and  severity  of  the  attack.  Cya- 
nosis is  frequently  present,  and  is  almost  always  seen  shortly  before  death. 
The  respirations  are  from  60  to  80  a  minute,  but  in  most  cases  not  strik- 
ingly laboured.  Cough  is  frequently  absent.  Cerebral  symptoms  are 
often  marked.  There  are  dulness  and  apathy,  sometimes  quite  profound 
stupor,  and  not  infrequently  convulsions  Just  before  death.  The  physical 
signs  are  few  and  inconclusive".  There  is  often  nothing  abnormal  except 
very  rude  breathing  over  both  lungs  behind;  sometimes  the  breathing 
on  one  side  is  feeble,  and  on  the  other  much  exaggerated.  There  may 
be  no  rales  whatever,  and  no  change  in  the  percussion  note. 

The  suddenness  and  severity  of  these  symptoms  are  something  which 
it  is  hard  for  one  who  has  not  observed  them  to  appreciate.  I  have 
known  an  infant  to  die  in  twelve  hours  from  the  time  in  which  he  was 
apparently  in  perfect  health,  and  had  an  opportunity  to  confirm  the 
diagnosis  of  pneumonia  by  a  microscopical  examination  of  the  lung.  The 
diagnosis  can  not  be  positively  made  during  life,  and  in  most  of  the  cases 
the  disease  passes  under  some  other  name.  It  is  often  regarded  as  malig- 
nant scarlet  fever  or  measles  with  suppressed  eruption,  or  cerebro-spinal 
meningitis. 

If  the  children  are  sufficiently  strong  to  withstand  the  onset  of  vio- 


502  DISEASES   OF  THE   RESPIRATORY   SYSTEM. 

lent  symptoms,  tliey  may  recover  completely  in  four  or  five  days,  the 
lung  clearing  up  very  rapidly.  In  other  cases  these  grave  symptoms  may 
abate  in  a  day  or  two,  to  be  followed  by  those  of  ordinary  broncho- 
pneumonia, which  runs  its  usual  course. 

The  symptoms  of  some  of  these  cases  may  be  explained  by  the  sudden 
intense  engorgement  of  the  lung,  which,  owing  to  the  small  size  of  the 
air  vesicles,  interferes  with  its  function  almost  as  much  as  does  consoli- 
dation. In  other  cases  the  symptoms  are  due  not  so  much  to  the  pulmo- 
nary condition  as  to  a  general  pneumococcus  infection.  A  case  lately 
came  under  my  notice  in  which  death  occurred  after  a  thirty  hours'  ill- 
ness, where  the  pneumococcus  was  found  by  culture  in  both  kidneys,  the 
spleen,  heart's  blood,  and  both  lungs. 

2.  Acute  Disseminated  Buoncho-pneumonia  (Capillary  Brox- 
cHiTis). — Although  the  symptoms  in  this  class  of  cases  are  chiefly  due  to 
the  bronchitis,  I  have  never  failed  to  find  at  autopsy  evidences  of  pneu- 
monia also.  These  are  not  very  common  cases.  The  process  begins  as  an 
inflammation  of  the  medium-sized  and  small  bronchi,  but  not  of  the 
finest  bronchi.  The  onset  is  acute,  with  fever,  very  rapid  and  laboured 
breathing,  severe  cough,  moderate  prostration,  and  in  most  cases 
cyanosis. 

The  temperature  is  not  high,  usually  only  from  100°  to  102°  F.,  and 
it  often  continues  so  for  three  or  four  days.  The  pulse  is  rapid,  and  at 
first  is  full  and  strong.  The  respirations  are  exceedingly  rapid,  often 
from  80  to  100  a  minute.  There  is  dyspnoea  with  marked  recession  of 
all  the  soft  parts  of  the  chest  during  inspiration.  Cough  is  always  pres- 
ent, usually  severe,  and  sometimes  almost  incessant.  The  prostration  is 
not  so  great  as  in  the  cases  previously  described,  and  the  development  of 
the  symptoms  is  much  less  rapid. 

There  are  at  first  sibilant  and  afterward  subcrepitant  rales  over  the 
entire  chest,  with  which  are  usually  mingled  coarser  moist  rales.  There 
are  no  evidences  of  consolidation.  The  'respiratory  murmur  is  every- 
where feeble,  but  not  otherwise  altered.  Percussion  generally  gives  ex- 
aggerated resonance,  owing  to  the  emphysema  which  is  present,  the  note 
being  sometimes  almost  tympanitic. 

The  symptoms  may  gradually  increase  in  severity  until  death  takes 
place  by  the  third  or  fourth  day,  from  respiratory  or  cardiac  failure. 
There  is  usually  marked  cyanosis,  and  toward  the  end  rapidly  increasing 
prostration.  Just  before  death  the  temperature  often  rises  rapidly  to 
106°  or  107°  F.  At  the  autopsy  there  are  found  evidences  of  bronchitis 
of  the  tubes  of  all  sizes,  and  minute  zones  of  pneumonia  about  the  smaller 
bronchi.  The  lungs  are  generally  in  a  state  of  hyper-inflation,  on  account 
of  which  they  do  not  collapse  on  opening  the  chest.  There  may  be  in 
addition  extensive  congestion  or  oedema,  the  development  of  which  has 
been  the  immediate  cause  of  death. 


ACUTE   BRONCHO-PNEUMONIA.  503 

In  cases  which  do  not  prove  fatal  there  is  iisiially  by  the  third  or 
fourth  day  great  improvement  in  the  general  symptoms;  the  finer  rales 
may  disappear,  and  the  coarse  ones  become  more  and  more  prominent. 
By  the  end  of  a  week  there  may  be  complete  recovery.  Instead  of  this, 
there  may  be  a  continuance  of  the  constitutional  symptoms,  and  disap- 
pearance of  the  fine  rales  in  front  only,  while  behind  there  are  gradually 
added  to  them  the  signs  of  consolidation  in  one  of  the  lower  lobes  near 
the  spine.  From  this  time  the  case  may  progress  as  one  of  ordinary 
broncho-pneumonia. 

The  prognosis  in  this  class  of  cases  is  very  much  better  than  in  the 
congestive  variety,  recovery  being  probaljle  unless  the  patients  are  very 
young  or  very  delicate  infants. 

3.  Broxcho-pxeumoxia  of  the  Com:mox  Type. — When  primary, 
this  usually  begins  suddenly  with  sym])toms  not  unlike  those  of  lobar 
pneumonia.  This  was  the  mode  of  onset  in  two-thirds  of  my  cases. 
In  only  ten  per  cent  was  the  pneumonia  preceded  by  bronciiitis  of  the 
large  tubes.  •  In  these  the  symptoms  of  bronchitis  may  slowly  or  rapidly 
(Fig.  76)  merge  into  those  of  pneumonia.  When  the  onset  is  sudden 
it  is  marked  by  high  fever,  frequently  by  vomiting,  rarely  by  convul- 
sions. In  addition  there  are  rapid  respiration,  cough,  prostration,  and 
sometimes  cyanosis.  The  symptoms  are  more  distinctly  pulmonary  than 
is  generally  the  case  in  lobar  pneumonia. 

The  temperature,  as  a  rule,  is  high ;  rarely  is  it  continuously  so,  but 
it  is  of  a  remittent  type.  The  daily  fluctuations  often  amount  to  four  or 
five  degrees.  The  fever  usually  continues  from  one  to  three  weeks,  and 
gradually  subsides.  It  is  rare  for  it  to  terminate  by  crisis.  Although, 
as  a  rule,  we  expect  a  high  temperature  with  acute  pneumonia,  this  is 
not  invariable.  Primary  cases  may  run  their  course,  and  even  terminate 
fatally,  although  the  temperature  has  not  been  above  101°  F.  I  have 
records  of  several  such  cases.  A  low  temperature  is  more  often  seen 
in  young  and  delicate  infants  than  in  those  who  are  older  and  more 
robust. 

The  respirations  are  frequent  and  laboured;  there  is  real  dyspnoea. 
On  inspiration,  there  are  marked  recessions  of  all  the  soft  parts  of  the 
chest,  and  the  alae  nasi  dilate  actively.  The  usual  rapidity  of  the  respira- 
tions is  from  60  to  80  per  minute;  very  often,  however,  it  rises  to  100, 
and  on  several  occasions  I  have  seen  it  even  120.  Eespiration  generally 
seems  more  embarrassed  than  does  the  action  of  the  heart,  and  respiratory 
failure  is  a  more  frequent  cause  of  death  than  cardiac  failure.  The 
pulse  is  always  rapid — from  150  to  200  a  minute — and  when  so  it  is  often 
irregular.  The  pulse  rate  is  of  much  less  importance  than  its  character. 
Early  it  is  full  and  strong,  but  soon  it  becomes  soft,  compressible,  and 
weak. 

The  prostration  is  usually  moderate  for  the  first  day  or  two,  but 


504  DISEASES  OF  THE   RESPIRATORY   SYSTEM. 

steadily  increases  as  the  lung  becomes  more  and  more  involved,  and 
toward  the  close  of  the  disease  may  be  extreme. 

Cough  is  much  more  constant  than  in  lobar  pneumonia,  and  more 
distressing;  sometimes  it  is  almost  incessant.  It  disturbs  rest  and  sleep, 
and  may  cause  vomiting  if  the  paroxysm  occurs  soon  after  eating.  There 
is  no  expectoration.  Mucus  is  sometimes  coughed  up  into  the  trachea,  or 
even  the  pharynx,  to  be  swallowed  again,  or  more  frequently  aspirated 
into  the  lung.  If  during  a  severe  paroxysm  the  patient  is  turned  upon 
his  face  or  inverted,  much  of  this  mucus  may  be  dislodged.  A  strong 
cough  is  a  good  symptom;  suppression  of  the  cough  is  a  bad  symptom, 
indicating  a  loss  of  the  reflex  sensibility  of  the  bronchial  mucous  mem- 
brane and  of  the  respiratory  centre. 

Pain  in  the  chest  is  not  common,  and  is  rarely  an  annoying 
symptom. 

Cyanosis  is  present  at  some  time  in  most  of  the  severe  cases.  It  may 
occur  at  the  onset,  or  at  any  time  during  the  course  of  the  disease.  It 
is  usually  due  to  sudden  congestion  of  a  portion  of  the  lung  not  previ- 
ously involved.  Even  when  slight,  it  is  always  a  danger-signal  of  re- 
spiratory failure,  and  when  present  only  in  the  finger  tips  or  lips  indi- 
cates that  the  patient  must  be  carefully  watched  and  energetically  treated. 
In  the  severe  cases  the  whole  body  may  be  of  a  dull  leaden  hue. 

Nervous  symptoms  at  the  onset  are  not  so  frequent  as  in  lobar  pneu- 
monia, convulsions  being  rare;  but  late  convulsions,  particularly  in  the 
pneumonia  which  complicates  pertussis,  are  frequent,  and  when  present 
the  disease  is  usually  fatal.  Delirium  may  occur  at  any  time  during  the 
attack.  In  infants  this  shows  itself  by  excitement  and  inability  to  recog- 
nise the  nurse  or  mother.  Occasionally  patients  present  marked  cerebral 
symptoms  throughout  the  disease  closely  simulating  meningitis.  As 
elsewhere  stated,  the  nervous  symptoms  depend  not  upon  the  location  of 
the  disease,  but  upon  its  extent,  the  intensity  of  the  infection,  and  upon 
the  susceptibility  of  the  patient,  such  symptoms  being  especially  common 
in  rachitic  children  and  in  those  suffering  from  pertussis. 

Gastro-enteric  symptoms  are  frequent  in  infancy,  and  are  of  much 
importance.  Often  there  are  from  four  to  six  stools  a  day,  of  a  green 
colour,  containing  mucus  and  undigested  food.  These  symptoms  depend 
upon  the  feeble  digestion  which  is  associated  with  the  febrile  process, 
and  are  often  aggravated  by  improper  feeding  and  overmedication.  Vom- 
iting and  diarrhoea  add  much  to  the  danger  of  the  attack.  In  summer 
this  complication  is  more  frequent  and  is  likely  to  be  more  severe.  Dis- 
tention of  the  stomach  or  intestines  from  gas  may  be  the  cause  of  dis- 
tressing symptoms,  owing  to  the  added  embarrassment  of  respiration 
produced  by  this  upward  pressure.  In  infants  it  may  lead  to  attacks  of 
cyanosis,  and  even  to  convulsions. 

The  blood  in  acute  broncho-pneumonia  shows  regularly  the  changes 


ACUTE   BRONCHO-PNEUMONIA. 


505 


of  a  moderate  secondary  anaemia,  which  in  protracted  cases  becomes  very 
marked.  A  leucocytosis  is  almost  invariably  present.  In  an  average 
case  this  ranges  from  20,000  to  40,000.  It  sometimes  is  excessively  high 
without  any  apparent  reason.  I  have  several  times  seen  it  over  100,000. 
The  increase  is  chiefly  in  the  polymorphonuclear  cells  which  usually 
form  from  sixty  to  eighty  per  cent  of  the  total  leucocytes.  With  the  fall 
in  temperature  the  leucocytosis  in  most  cases  rapidly  disappears.  A 
rapid  diminution  in  the  leucocytosis  may  indicate  a  marked  loss  of  re- 
sistance in  the  patient;  and  may  be  seen  with  either  a  high  or  a  low 
temperature.  In  the  pneumonia  which  complicates  pertussis,  the  in- 
crease in  the  white  cells  is  chiefly 
of  the  lymphocytes. 

The  urine  in  most  cases  is 
scanty,  high-coloured,  and  loaded 
with  urates.  A  trace  of  al- 
bumin is  often  present  wlien 
the  temperature  is  very  high ; 
but  casts,  renal  epithelium,  and 
a  large  amount  of  albumin  are 
rare. 

The  accompanying  tempera- 
ture chart  (Fig.  76)  is  a  good 
example  of  a  very  frequent  course  of  primary  pneumonia  of  moderate 
severity  terminating  in  recovery.  In  cases  of  this  type  the  constitu- 
tional symptoms  are  not  grave,  and  follow  very  closely  the  temperature 
curve. 

The  next  chart  (Fig.  77)  illustrates  a  more  severe  but  not  uncom- 
mon course  of  the  disease  in  which  the  fever  is  prolonged.     The  usual 


105° 

1  !  2 

3 

i 

5 

6 

1 

8 

9  llO 

11 

18 

W 

IT 

15jl6| 

101° 
103° 
102° 
101° 
100° 
99° 

A 

i 

Aa 

A 

/Wl/^ 

\/ 

\ 

A 

\ 

7 

^\l 

1 

\  V 

j 

V 

v 

K 

Av 

1 

■ 

"\. 

^Iv 

Fig.  76. — Temperature  Curve  in  Typical 
Broncho-pneumonia  of  the  Milder  Form. 
History. — Male,  sixteen  months  old;  delicate 
child;  previous  bronchitis;  onset  gradual; 
signs  of  consolidation  at  left  base  on  fifth 
day,  but  fine  rales  over  both  lower  lobes 
behind;  resolution  slow,  rales  persisting  for 
a  long  time  in  both  lungs. 


107° 
106° 
105° 
104° 

ioa° 

108° 
101° 
100° 
99° 

1 

8     3 

4 

Vf  6 

7 

8 

VT\ 

10  11 

18 

^ 

11    15 

16  1 17  1 18  1 19 

80|21 

28 

23   21 

25 

26 

27   28 

29 

30 

31 

38 

1 

\ 

A 

A  » 

\ 

j 

t 

f 

/ 

^^ 

A 

-f-/h^ 

/I 

1  '\ 

J 

t 

/  !\ 

> 

«l 

JTVT7 

v 

lA 

V 

/ 

1 

V\ 

A 

r 

V  V 

V 

y 

v 

V 

y 

/, 

/ 

^ 

/ 

^ 

1 

\ 

V 

^\ 

/ 

\    / 

\l 

I 

V" 

M 

V 

'^ 

«,<' 

, , 

98° 

. 

_ 

Fig.  77. — Temperature  Curve  of  Broncho-pneumonia  with  a  Prolonged  Course; 
Recovery.  History. — Female,  eighteen  months  old;  in  fair  condition;  sudden  onset. 
Early  signs  were  localised,  fine  rales  over  left  base;  on  fifth  day  signs  of  consolidation 
at  left  base,  with  rales  on  both  sides  behind.  General  symptoms  of  moderate  severity. 
Signs  of  consolidation  disappeared  about  a  week  after  cessation  of  fever:  rdles  per- 
sisted nearly  two  weeks  longer. 

duration  of  cases  of  this  type  is  between  three  and  four  weeks.  The 
irregular  fluctuations  of  the  temperature,  rarely  touching  the  normal  line, 
are  exceedingly  characteristic  of  broncho-pneumonia. 


506 


DISEASES  OF  THE   RESPIRATORY   SYSTEM. 


The  chart  shown  in  Fig.  78  is  that  of  relapsing  pneumonia.     The 
first  attack  was  fairly  typical,  with  about  the  usual  duration.     Eesolu- 


107  =    1     2     3     4  !  5     6  1  7  1  IS  i  »    10 

11 ,  12  1 1.1 ;  14 

lb  lb 

17]  18 

19,20|2l|22l23 

24l25 

2012712^  29i£0  31   32  33|S*1 

lOft^ 

III            1 

1  J.J  _  i  _.  U 

105' 
104° 
103° 
108° 
101° 
100° 
99° 

1 

1 

1 

fi  »    K  fi     \ 

ura- 

A  A  /\A  A  /\  A  A  1a 

f 

K 

.  hfr 

t^ 

A 

y  \i  V  V\/  iV  V il  1/ 

J 

Y 

A/I 

V 

n 

\r 

V        1    V  !  •    »  III  i|/ 

V 

^     A 

\  I 

,  1  / 

■  1 

V 

^  ^ 

'  '         i 

»i' 

[/\ 

it 

r  ■]/ 

Ml  . 

! 

1     i 

jVi* 

V 

V-1 

y< 

H               !     1     i 

M   A     ^     A 

M^!                  :      1      1 

I         1     1 

V 

1  V    1     1             i     i    !    1    1     V  ^-^^  1         1 

Fig.  78.  —  Temper.\ture  Curve  of  Relapsing  Broncho-pneumonia;  Recovery. 
History. — Male,  nineteen  months  old ;  delicate.  Consolidation  on  sixth  day  in  left  lower 
lobe  behind;  two  days  later  small  area  of  consolidation  in  right  lower  lobe  behind; 
many  rdles  both  sides;  eighteenth  day,  signs  of  consolidation  had  disappeared,  but 
many  rales  persisted.  Accession  of  fever  on  nineteenth  and  twentieth  days,  accom- 
panied by  extension  of  disease  as  shown  by  new  rales,  but  no  evidences  of  consolida- 
tion during  second  attack.     Slow  resolution  and  convalescence. 


1     2     1     1     5  i  6 

7 

107° 
106° 
105° 
101° 
103° 
102° 
101° 
100° 
90° 

i       ■       1-     1-J— 1 

_i_  rlj 

1  1 

t    A  / 

fl 

11  Ll' 

V 

y 

Fig.  79. — Temperature  Curve 
OF  Broncho  -  pneumonia; 
Fatal.  History. — Male,  six 
months    old;     markedly    ra- 


tion had  Ijegun,  and  was  apparently  progressing  favourably,  when  there 
was  a  return  of  the  fever,  accompanied  by  new  signs  in  the  chest,  the 

second  attack  being  shorter  and  milder  than 
the  first.  Very  often  the  temperature  falls 
to  normal  without  any  signs  of  resolution, 
and  after  an  interval  varying  from  two  or 
three  days  to  a  week  there  is  a  recurrence  of 
the  fever  and  other  constitutional  symp- 
toms, the  second  attack  frequently  proving 
fatal. 

A  frequent  course  in  fatal  cases  is  sliown 
in   Fig.   79.     The  duration  of   the  disease, 
chitic;  sudden  onset.    Signs    instead  of  being  five  days  as  in  this  case,  is 

first  day  were  fine  moist  rales        e,  i      j.i  £      '        mu      x  j. 

throughout  the  chest,  marked    ^^^eu  only  three  or  four.     The  temperature 

prostration,  and  cyanosis;  on  at   first   fluctuates   widely,  then  rises  grad- 

third  day,  a  small  area  of  con-  ^^^^     ^^^^^  ^^^^^^ 

solidation  in  upper  lobe  of  left 

lung  behind;  increasing  pros-  Duration  Of  the  Fever. — The  following 

tration,  cj-anosis,  and  death,  figures  give  the   duration  of  the   fever  in 

Autopsy. — No  pleurisy;  con-     .^o-.  mu  •      -a 

solidation  at  left  apex  behind.  ^^^  ^ases.  The  majority  were  primary; 
and  posterior  two-thirds  of  left  none  were  secondary  to  diplitlieria,  and 
lower  lobe;  consolidation  of    ^^j     ^   f^^^   complicated   measles.      Of   the 

right  apex  posteriorly,  lower  "^  ^ 

lobe  intensely  congested.  169  cases  that  were  fatal — 

There  died  during  the  first  six  days 2.5 . 0  per  cent. 

"         "     between  the  seventh  and  twenty-first  days.     55.5    "       " 
"         "  "  '*  twenty-first  and  sixtieth  days.     19.5    "       " 

100.0    "       " 


Of  78  cases  which  recovered,  the  duration  of  the  fever  was — 


ACUTE   BRONCHO-PNEUMONIA.  507 

Less  than  seven  days 11.5  per  cent. 

From  seven  to  twenty-one  daj^s 66 . 6    "       " 

"      twenty-one  to  ninety  days 21 .9    "       " 

100.0    "       " 

Physical  Signs. — In  considering  the  signs  of  hroncho-pneunionia,  it  is 
better  to  connect  them  with  the  different  conditions  in  the  lung  than  to 
group  them  in  stages,  as  in  lohar  pneumonia. 

(a)  WitJioiit  Consolidation. — It  can  not  too  often  he  repeated  that 
broncho-pneumonia  may  exist  withoiit  signs  of  consolidation  at  any 
period  during  the  course  of  the  disease.  "When  the  attack  is  primary,  the 
earliest  signs  are  due  to  congestion  of  the  lung,  associated  with  bronchitis 
of  the  fine  tubes,  which  is  usually  localised,  but  which  may  be  general. 
If  the  disease  has  followed  bronchitis  of  the  large  tul)es,  its  signs  are 
added.  Congestion  of  the  lung  gives  feeble  l)reathing  over  the  affected 
area,  and  occasionally  slight  dulness  or  diminished  resonance.  With  this 
are  found  coarse  sonorous,  and  finer  sibilant  rales,  due  to  congestion  and 
swelling  of  the  mucous  membrane  of  the  larger  and  smaller  bronchi 
respectively.  These  signs  are  soon  replaced  by  very  fine  moist  rales, 
which  are  usually  localised  in  one  of  the  lower  lobes  l)ehind  (Fig.  80). 
These  localised  fine  rales  are  the  first  distinctive  sign  of  broncho-pneu- 
monia. Soon  a  change  in  the  respiratory  murmur  is  heard  in  the  affected 
area,  which  becomes  feebler  in  intensity  and  higher  in  pitch.  Elsewhere 
in  the  chest  there  may  be  coarse  rales,  due  to  bronchitis  of  the  large  tubes. 
In  such  cases  the  areas  of  pneumonia  are  so  small  and  so  scattered  as  to 
give  in  themselves  no  additional  signs,  and  the  case  may  go  on  to  recovery 
without  presenting  anything  more  distinctive  than  the  signs  mentioned. 

(&)  \yith  Areas  of  Partial  Consolidation. — In  the  lung  at  this 
time  there  are  small  areas  of  consolidation,  generally  superficial  and 
separated  by  healthy  or  congested  lobules.  Percussion  in  these  cases 
usually  gives  negative  results,  but  sometimes  there  is  very  slight  dulness. 
The  vocal  fremitus  is  not  usually  altered.  The  fine  moist  rales  may  be 
heard  over  quite  a  large  area,  but  at  some  point,  usually  near  the  spine, 
over  one  of  the  lower  lobes,  they  are  sharper,  louder,  higher  pitched,  and 
more  metallic,  and  seem  close  under  the  ear  (Fig.  81).  Respiration  is 
feebler  here  than  elsewhere,  and  broncho-vesicular  in  quality,  approach- 
ing bronchial  breathing  more  and  more  as  the  consolidation  increases. 
The  resonance  of  the  voice  and  cry  is  exaggerated. 

(c)  With  Areas  of  Consolidation  More  or  Less  Complete. — On 
percussion  there  is  dulness,  but  surprisingly  little  in  comparison  with 
the  other  signs  of  consolidation  present.  It  is  due  to  the  fact  that 
the  consolidated  portion,  though  extensive,  does  not  involve  the  lung 
to  any  great  depth,  and  also  that  there  are  in  the  consolidated  area 
many  alveoli  which  still  contain  air  (Plate  XI).  On  palpation  there 
is  usually  a  slight  increase  in  the  vocal  fremitus.    On  auscultation,  there 


Fig.  80. — First  Stage.  Coarse  rales  over  both 
lungs;  localised  fine  (subcrepitant)  rales  at  the 
left  base.     No  change  in  breath  sounds. 


Fig.  81. — Second  Stage.  Coarse  and  fine  rales 
over  both  lungs  behind ;  at  left  base  an  area 
of  partial  consolidation,  with  broncho-vesic- 
ular breathing,  exaggerated  voice,  and  very 
sharp  rales. 


Fig.  82. — Third  Stage.     A  larger  area  of  partial     Fig.  83. — Fourth  Stage.    Extensive  disease  of 


consolidation,  and  in  the  centre  a  small  area  of 
complete  consolidation,  with  bronchial  breath- 
ing and  voice  and  slight  dulness.  Signs  over 
the  right  lung  similar  to  what  were  previously 
present  over  the  left. 


both  sides;  large  area  of  complete  consoli- 
dation on  the  left,  with  dulness,  bronchial 
breathing  and  voice,  and  no  rales;  surround- 
ing this,  broncho-vesicular  breathing,  with 
many  rdles.  Signs  in  the  right  lung  similar 
to  those  previously  present  over  the  left. 


Nqte. — The  large  circles  indicate  coarse  rales;  the  small  ones  finer  rdles;  the  red  areas 
indicate  consolidation  partial  or  complete.  The  disease  may  stop  at  any  one  of  these  stages 
and  resolution  take  place. 

508  • 


ACUTE   BRONCHO-PKEUMONIA.  509 

are  still  present  the  evidences  of  bronchitis,  usually  only  behind,  l)ut 
sometimes  over  the  entire  chest.  Coarse  and  fine  rales  are  inter- 
mingled. Over  the  consolidated  parts  are  heard  bronchial  breath- 
ing and  bronchial  voice.  At  the  centre  of  these  areas  the  bronchial 
breathing  is  pure  and  rales  are  usually  absent,  but  at  the  margin 
rales  are  present  and  the  breathing  approaches  the  broncho-vesicular 
type  (Fig.  82).  The  signs  of  consolidation  are  rarely  sharply  circum- 
scribed as  they  are  in  lobar  pneumonia,  but  shade  off  gradually.  The 
consolidated  area  is  at  first  small,  usually  in  one  of  the  lower  lobes  near 
the  spine,  but  may  gradually  extend  until  nearly  the  whole  of  one  or 
even  both  lungs  behind  are  more  or  less  completely  solidified  (Fig.  83). 
The  signs  are  found  as  far  forward  as  the  axillary  line,  but  usually  stop 
there.  Friction  sounds  may  be  heard  over  the  consolidated  areas,  but 
very  rarely  except  where  signs  of  complete  consolidation  are  present.  It 
is  often  impossible  to  obtain  any  idea  of  the  condition  of  an  infant's  lung 
during  quiet,  superficial  respiration.  Sometimes  over  a  part  which  is 
completely  consolidated  there  is  heard  only  very  feeble  breathing,  or 
the  lung  may  be  almost  silent.  If,  however,  the  child  is  made  to  cry 
or  to  take  a  deep  inspiration,  both  the  bronchial  breathing  and  rales  are 
distinctly  brought  out.  The  intensity  of  the  consolidation  increases  as 
the  case  advances,  and  the  signs  become  more  and  more  like  those  of  lobar 
pneumonia.  During  resolution  there  is  first  a  disappearance  of  the 
signs  of  consolidation,  which  may  be  quite  rapid,  but  friction  sounds 
and  rales  of  all  kinds  often  persist  for  three  or  four  weeks  longer. 

The  following  statistics  are  of  some  interest,  as  showing  the  frequency 
with  which  signs  of  consolidation  were  found,  and  the  day  when  they 
were  discovered.  Their  value  is  increased  by  the  fact  that  the  children 
were  under  observation  in  an  institution  at  the  time  they  were  taken 
sick,  and  that  in  aU  the  fatal  cases — thirty-six  in  number — in  which  signs 
of  consolidation  were  absent,  the  diagnosis  of  pneumonia  was  confirmed 
by  autopsy: 

Consolidation  noted  on  or  before  the  fourth  day 47  cases. 

"  "      from  the  fifth  to  the  seventh  day 36      " 

"  "         "     the  eighth  to  the  twelfth  day 12      " 

"  "      after  the  twelfth  day 9      " 

No  signs  of  consoUdation 62 

106  " 
In  general,  it  must  be  borne  in  mind  that  in  many  cases  signs  of 
consolidation  are  never  present,  as  the  areas  of  pneumonia  are  small  and 
widely  scattered;  that  where  there  is  consolidation  it  is  usually  incom- 
plete, because  there  are  small  areas  of  healthy  lung  tissue  between  the 
hepatised  portions;  that  the  signs  of  consolidation  usually  shade  off 
gradually;  and  that  both  sides  are  almost  invariably  involved,  although 
one  side  usually  to  a  greater  degree  than  the  other. 


510 


DISEASES   OF  THE   RESPIRATORY   SYSTEM. 


4.  The  Protracted  Form — Persistent  Broncho-pxeumoxia. — 
This  is  seen  in  primary  cases,  especially  among  delicate  children,  and 
in  the  pneumonia  complicating  pertussis,  influenza  and  measles,  and  is 
the  form  which  often  follows  diphtheria.  The  onset  and  course  of  the 
disease  for  the  first  two  or  three  weeks  do  not  differ  from  an  ordinary 
attack  of  moderate  severity,  but  at  the  end  of  this  period  there  is  seen 
no  tendency  in  the  process  to  subside.  The  fever  continues,  although  it 
may  not  be  high,  but  by  physical  examination  it  is  found  that  the  areas  of 
consolidation  are  gradually  increasing  day  by  day,  until  sometimes  the 
greater  part  of  both  lungs  behind  are  involved.  The  air  vesicles  become 
so  distended  with  cells  that  the  signs  of  consolidation  are  more  complete 
than  in  ordinary  broncho-pneumonia.  There  is  marked  dulness,  some- 
times almost  flatness;  bronchial  breathing  is  exaggerated  in  intensity, 
until  it  resembles  cavernous  breathing,  and  it  may  be  impossible  to  dis- 
tinguish between  them.  However,  the  fact  that  it  is  heard  over  so  large 
an  area,  that  it  shades  off  gradually,  and  that  it  is  accompanied  by  fric- 
tion sounds,  usually  make  a  distinction  possible. 

The  temperature  in  these  protracted  cases  for  the  first  two  or  three 
weeks  is  from  100°  to  105°  F. ;  but  after  this  time  it  is  generally  lower 
— from  100°  to  102°  or  103°  F.     The  course  is  not  at  all  regular,  but 


1 

23 

4   S 

6 

1 

rg 

9 

w 

nsa 

T3 

u\ii 

16 

It 

iS 

19«)21!222324l»a« 

Q 

a 

B 

B 

s 

SirB 

s 

K 

a 

^ia 

5i 

iS 

a 

^ 

m 

SS 

$1 

lor' 
loar 

101° 

,       i  1 

!     ■ 

t 

■     1     1 

/ 

J 

/ 

1 

1 

J  1 

J.  . 

\ 

[/ 

/ 

1 

A  f 

1 

Al 

J  J 

hf 

i 

A      K 

/ 

\ 

/ 

V 

\ 

1^ 

V  w 

1 

•l 

/ 

V\a/\/\a 

1 

1 

\   / 

f 

I 

l^ 

1  /, 

Hwr 

V 

\ 

f 

'V 

lA 

A*   / 

J/V\/Vm  v-v/,      /  V  V 

V 

A/ 

V    A_y^(V,llIl    [J 

"w 

i 

r 

L/s/VK/ 

\\ 

ly    M     \    /       i        '      V,    *"  \/vi 

w° 

- 

_ 

.1. 

. 

\  1  n 

i 

1 

FiQ.  84. — Temperature  Curve  of  Persistent  Broncho-pneumonia,  Terminating 
Fatally.  History. — Male,  two  and  a  half  years  old;  healthy;  sudden  onset;  for  two 
weeks  the  only  signs  were  very  fine  moist  rales  throughout  both  lungs,  froht  and  back. 
The  rales  in  front  in  great  part  gradually  cleared  up;  those  behind  persisted,  but  it  was 
not  until  the  thirty-fourth  day  that  positive  signs  of  consolidation  were  discovered  in 
the  left  lower  lobe  behind;  these  signs  gradually  extended,  and,  before  death,  were 
present  over  nearly  the  whole  left  lung  behind  and  over  the  right  lower  lobe.  There 
were  also  friction  sounds  over  both  lungs.  Autopsy. — Old  and  recent  pleurisy  with 
general  adhesions;  left  lower  lobe  completely  solid,  patches  of  consolidation  in  left 
upper  lobe.  Right  lower  lobe  about  one-half  consolidated,  with  patches  elsewhere. 
Bronchial  glands  large,  but  not  cheesy.  No  evidence  of  tuberculosis  upon  either 
gross  or  microscopical  examination  (see  Fig.  75). 


marked  by  frequent  exacerbations  and  remissions.  The  general  symptoms 
are  those  of  progressive  asthenia.  There  is  continued  wasting,  anaemia, 
and  steadily  increasing  prostration.  The  appetite  is  lost,  often  there  is 
an  aversion  to  food,  and  vomiting  is  easily  excited  if  food  or  stimulants 
are  forced.  The  stools  show  that  even  what  food  is  taken  is  very  im- 
perfectly digested  and  assimilated.  The  skin  becomes  dry  and  loses  its 
elasticity;  bed-sores  may  form;  fine  punctate  haemorrhages  are  seen  over 
the  abdomen,  sometimes  over  the  chest  and  extremities.     The  latter  is 


ACUTE   BRONCIiO-PNElMONIA. 


511 


always  a  very  bad  symptom,  and  I  liave  never  seen  recovery  from  pneu- 
monia when  it  was  present. 

Death  takes  place  from  slow  asthenia,  usually  after  five  or  six  weeks, 
but  the  attack  may  be  prolonged  for  eight  or  ten  weeks.  The  general 
symptoms,  the  temperature,  and  the  wasting  strikingly  resemble  cases  of 
tuberculosis,  and  such  is  the  diagnosis  often  made. 

Although  the  majority  of  the  cases  in  which  the  fever  lasts  over  four 
weeks  run  the  fatal  course  just  described,  such  apparently  hopeless  cases 
occasionally  recover.  The  temperature  gradually  falls  lower  and  lower, 
until  it  remains  at  the  normal  point.  For  some  time  after  this,  often 
two  or  three  weeks,  little  change  can  be  seen,  either  in  the  general  symp- 
toms or  in  the  physical  signs.  Gradually  tlie  appetite  returns,  the  child 
is  brighter  and  begins  to  take  an  interest  in  its  surroundings,  the  cough 
abates,  and  little  by  little  the  signs  in  the  lungs  clear  up,  and  the  case 
may  go  on  to  complete  recovery.  Convalescence,  however,  is  always  slow, 
and  may  be  interrupted  by  relapses,  it  being  many  months  before  health 
is  fully  restored.  Although  the  signs  of  consolidation  disappear  in  a 
few  weeks,  rales  are  apt  to  persist  for  a  much  longer  time.  It  is  probable 
in  such  cases,  even  though  all  signs  of  disease  disappear  from  the  chest, 
that  the  lung  does  not  become  quite  normal,  and  relapses  and  second 
attacks  are  always  possible.  The  general  health  may  be  so  undermined 
that  the  child  never  regains  his  former  vigour;  yet  in  a  surprising 
number  of  these  cases  recovery  seems  to  be  complete.  Protracted 
cases  of  a  mild  type  are  sometimes  seen,  and,  although  the  temperature 
persists  for  a  number  of  weeks,  it  is  never  high.  The  course  of  the 
disease  suggests  tuberculosis.  One  such  case  in  a  young  infant  under 
my  care  was  due  to  a  staphylo- 
coccus infection,  and  was  cured 
by  vaccines. 

5.  Secondary  Pneumonia. 
—  (a)  Complicating  Pertussis. — 
It  is  not  often  that  pneumonia 
develops  during  the  first  two 
weeks  of  this  disease.  The  most 
frequent  time  is  from  the  third 
to  the  fifth  week,  when  the  pa- 
tient has  become  exhausted  from 
the  previous  severity  of  the  per- 
tussis. In  two-thirds  of  my 
cases  the  development  of  the 
pneumonia  was  gradual,  fol- 
lowing bronchitis  of  the  larger 
tubes.  The  temperature  chart  shown  in  Fig.  85  well  illustrates  this 
course. 


107° 
106° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 

1 

2 

3 

i 

5 

6 

7 

T 

rr 

10  111 

12 

13 

11 

15 

16 

/ 

-J 

r 

^ 

A 

r' 

-^ 

'V 

'■ 

/ 

J 

J 

/ 

/ 

V 

J 

s 

/ 

v 

98° 

^ 

^ 

s 

Fig.  85. — Temperature  Curve  of  Fatal 
Broncho-pneumonia,  Complicating  Per- 
tussis. History. — Male,  six  months  old; 
delicate;  pertussis  for  three  weeks.  Early- 
signs  of  bronchitis  of  large  tubes  only;  on 
the  eleventh  day  signs  of  consolidation  in 
right  upper  lobe.  Increasing  prostration, 
cyanosis,  and  death.  Autopsy.  —  Large 
areas  of  consolidation  in  right  middle  and 
upper  lobes,  small  scattered  spots  through- 
out left  lung. 


512  DISEASES  OF  THE   RESPIRATORY   SYSTEM. 

When  the  onset  is  sudden,  the  symptoms  do  not  differ  essentially  from 
those  of  primary  pneumonia.  The  temperature  of  pertussis-pneumonia 
is  usually  not  high,  in  a  very  large  number  of  cases  not  rising  above 
103.5°  F.,  and  ranging  most  of  the  time  from  101''  to  103°  F.  These 
cases  are  very  apt  to  be  prolonged,  the  fever  often  lasting  for  three  or 
four,  and  sometimes  even  for  six,  weeks.  The  physical  signs  of  consoli- 
dation may  persist  for  a  long  time  after  the  temperature  has  become 
normal,  and  yet  the  case  may  recover  entirely.  I  have  seen  one  case  in 
which  complete  recovery  occurred  after  the  signs  of  consolidation  had 
persisted  for  six  months,  and  another  in  which  they  had  persisted  for 
over  eight  months.  Very  often  the  signs  continue  during  the  entire 
attack  of  pertussis.  Cerebral  symptoms  are  common,  especially  toward 
the  close  of  the  disease.  Of  fifty-four  fatal  cases,  twenty-five  had  con- 
vulsions, and  in  twenty-two  this  was  the  mode  of  death.  Only  one  case 
which  developed  convulsions  recovered. 

(h)  Complicating  Measles. — In  a  small  number  of  cases  the  pneu- 
monia begins  simultaneously  with  the  invasion  of  measles,  but  generally 
not  until  the  eruption  appears.  Instead  of  gradually  falling  to  normal 
with  the  fading  of  the  eruption,  the  temperature  continues  high.  Any 
of  the  clinical  types  of  primary  pneumonia  may  occur  in  measles, 
the  acute  congestive  variety,  which  is  fatal  in  two  or  three  days, 
being  especially  common.  In  its  course  and  duration  the  pneumonia 
of  measles  resembles  the  severe  form  of  primary  pneumonia.  The 
broncho-pneumonia  of  scarlet  fever  differs  in  no  way  from  that  of 
measles. 

(c)  Complicating  Diphtheria. — In  many  cases  this  does  not  give  a 
distinct  clinical  picture  of  its  own,  its  symptoms  being  mingled  with 
those  of  diphtheritic  bronchitis,  with  which  it  is  frequently  associated. 
In  others  the  forms  resemble  those  seen  in  measles.  The  majority  of 
cases  occur  as  a  complication  of  diphtheria  of  the  larynx,  although  it  is 
not  infrequent  in  the  septic  cases  in  which  only  the  upper  air  passages  are 
involved.  Pneumonia  after  laryngitis  may  develop  within  two  days 
from  the  beginning  of  laryngeal  symptoms,  and  run  a  rapid  course;  or 
it  may  come  as  late  as  the  second  or  third  week.  In  a  child  wearing  a 
tube,  the  diagnosis  of  pneumonia  presents  difficulties,  owing  to  the 
alteration  in  the  respiratory  sounds  and  the  existence  of  the  loud 
tracheal  rales  which  obscure  the  usual  auscultatory  signs.  Although 
pneumonia  may  be  apparent  by  sym[)toms,  its  situation  may  be 
difficult  to  determine.  The  most  important  signs  for  diagnosis  are 
the  diminished  respiratory  murmur,  localised  rales,  and  dulness  on 
percussion. 

(d)  Complicating  Influenza. — Without  doubt  many  cases  usually  re- 
garded as  primary  are  really  secondary  to  influenza,  particularly  when 
that  disease  is  prevalent.    While  the  pneumonia  of  influenza  may  differ 


ACUTE  BRONCHO-PNEUMONIA.  513 

in  no  essential  points  from  the  primary  form,  there  are  types  which  are 
quite  characteristic.  In  one  variety  the  cases  are  of  short  duration,  fre- 
quently lasting  but  three  or  four  days,  but  with  high  and  often  widely 
fluctuating  temperature,  the  general  symptoms  being  of  only  moderate 
severity.  A  second  type  is  a  prolonged  pneumonia  with  exacerbations 
and  remissions,  which  may  last  for  two  or  three  months.  A  third  form 
is  the  recurrent  type  of  pneumonia,  of  wliich  a  child  will  sometimes  have 
three  or  four  attacks  in  a  single  season,  separated  by  several  weeks  in 
which  a  moderate  cougli  and  a  few  coarse  rales  in  the  chest  are  the  only 
signs  of  disease. 

(e)  Complicating  Ileo-colitis. — This  is  usually  a  somewhat  subacute 
form  of  pneumonia  which  is  scarcely  recognisable  except  by  the  physical 
signs.  It  is  seen  in  the  protracted  cases  of  ileo-colitis,  usually  the  ulcera- 
tive variety,  and  occurs  late  in  its  course.  Very  often  pneumonia  is  not 
suspected  during  life,  the  constitutional  symptoms  being  sufficiently  ex- 
plained by  the  intestinal  lesions,  although  the  autopsy  discloses  the  fact 
that  death  was  due  in  part  to  pneumonia. 

Complications. — Most  of  those  relating  to  the  lungs  have  been  de- 
scribed with  the  lesions.  Pleurisy  will  be  separately  considered.  Pul- 
monary emphysema  is  always  present  to  a  greater  or  less  degree,  but 
can  not  be  made  out  by  physical  signs.  In  very  rare  instances  subcutane- 
ous emphysema  has  been  seen.  Abscess  and  gangrene  can  seldom  be 
recognised  by  physical  signs.  Pneumothorax  occurs  even  in  infancy,  but 
is  very  infrequent.  Otitis  is  exceedingly  common,  and  one  should  be 
constantly  on  the  lookout  for  it.  It  is  recognised  only  by  examination 
of  the  ear  with  a  speculum. 

Meningitis  may  complicate  acute  broncho-pneumonia.  It  has  oc- 
curred in  about  two  per  cent  of  my  cases.  It  is  in  all  respects  similar  to 
that  occurring  with  lobar  pneumonia.  Meningeal  haemorrhage  I  have 
seen  only  once,  and  was  the  cause  of  death  in  a  patient  eleven  months 
old,  who  a  few  days  before  was  seized  with  convulsions,  followed  by  a 
gradually  increasing  stupor,  which  continued  until  death.  The  haemor- 
rhage covered  the  entire  convexity  of  the  brain.  Endocarditis  is  ex- 
tremely rare ;  it  was  not  observed  in  any  of  my  cases.  Acute  pericarditis 
is  also  rare,  and  when  it  occurs  it  is  usually  with  pneumonia  of  the  left 
side.  Complications  referable  to  the  digestive  tract  are  quite  common. 
Herpetic  stomatitis  is  frequent,  and  occasionally  the  ulcerative  variety 
is  seen.  Thrush  often  occurs  in  the  protracted  cases  among  very  young 
infants.  Gastro-enteritis  is  not  very  common,  considering  the  frequency 
of  vomiting  and  diarrhoea,  these  depending  usually  upon  functional  de- 
rangement. In  only  three  of  my  cases  was  there  nephritis.  In  all  it 
was  of  the  acute  exudative  variety,  and  in  only  one  case  was  it  severe 
enough  to  affect  the  prognosis. 

Old  lesions  of  tuberculosis — cheesy  nodules  in  the  lungs  and  some- 
34 


514  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

times  in  the  pleura — are  not  infrequently  met  with  in  patients  dying  of 
acute  pneumonia  of  a  non-tuberculous  character. 

Diagnosis. — An  acute  onset  with  continuous  high  fever,  rapid  respira- 
tion, and  cough,  should  always  lead  one  to  suspect  pneumonia.  When 
to  these  symptoms  are  added  prostration  and  a  leucocytosis,  the  diag- 
nosis of  pneumonia  is  almost  certain.  Cases  of  the  acute  congestive  type 
are  the  ones  most  frequently  unrecognised,  and  in  many  of  these  cases 
a  positive  diagnosis  is  impossible  during  life.  Many  atypical  cases  of 
pneumonia  are  seen,  particularly  in  young  infants.  An  unusual  tem- 
perature course  is  perhaps  the  symptom  most  likely  to  lead  to  a  mistake. 
While  this,  as  a  rule,  is  high  and  remittent,  it  is  sometimes  not  so,  and 
may  be  but  little  above  normal.  Eapid  respiration  is  almost  always 
present,  but  cough  may  be  very  slight,  especially  in  infants.  In  very 
young  infants,  the  diagnosis  often  rests  upon  the  prostration,  cyanosis, 
and  rapid  respiration,  the  other  acute  inflammatory  symptoms  being 
absent.  Only  the  physical  signs  of  the  disease  can  positively  settle  the 
question  of  diagnosis. 

When  pneumonia  follows  bronchitis  of  the  large  tubes,  whether  the 
bronchitis  is  primary  or  complicates  one  of  the  infectious  diseases,  the 
extension  of  the  disease  to  the  lungs  is  usually  marked  by  three  symp- 
toms— a  'steadily  rising  temperature,  more  frequent  respiration,  and  in- 
creasing prostration.  It  may  be  twelve  or  twenty-four  hours  before  the 
change  is  indicated  by  the  physical  signs. 

The  diagnosis  of  broncho-pneumonia  from  congenital  atelectasis  has 
to  be  considered  only  during  the  first  three  or  four  months  of  life,  it 
being  rare  for  atelectasis  to  give  symptoms  after  this  time.  In  early  in- 
fancy the  danger  of  confusing  the  two  is  increased  by  the  fact  that  atelec- 
tasis and  broncho-pneumonia  may  be  associated.  If  the  infant  has  been 
strong  and  well  for  the  first  two  months,  congenital  atelectasis  can  be 
excluded.  It  is  likely  to  be  found  in  delicate  infants,  where  there  is  a 
history  of  difficulty  in  resuscitation  at  birth  and  feeble  cry  during  the 
early  days  of  life.  The  temperature  is  low,  often  subnormal,  the  cyanosis 
is  out  of  proportion  to  the  other  symptoms,  and  the  physical  signs  are 
doubtful  or  absent. 

At  the  outset,  pneumonia  can  not  be  positively  diagnosticated  from 
severe  bronchitis.  Such  a  bronchitis  often  begins  with  severe  pulmonary 
symptoms  and  a  temperature  of  103°  or  104°  P. ;  but  this  high  tempera- 
ture is  of  short  duration,  usually  falling  after  twenty-four  or  forty-eight 
hours  to  100°  or  101°  F.  The  prostration  is  much  less  and  all  the 
symptoms,  possibly  excepting  the  cough,  less  severe.  The  only  physical 
signs  are  coarse  rales,  which  are  heard  throughout  the  chest. 

The  same  rules  apply  to  bronchitis  of  the  smaller  tubes.  The  rales 
are  heard  both  in  front  and  behind,  and  usually  over  both  sides.  If  with 
such  rales  the  temperature  continues  to  rise  for  three  days  in  succession 


ACUTE  BRONCHO-PNEUMONIA. 


515 


above  103°  F.,  it  may  be  assumed  that  pneumonia  is  present,  provided 
there  is  no  other  disease  which  might  explain  the  temperature.  If,  in- 
stead of  being  generalised,  the  signs  of  bronchitis  are  limited  to  a  single 
lung,  or  to  one  lung  posteriorly,  the  existence  of  broncho-pneumonia 
may  be  regarded  as  certain.  Localised  bronchitis,  then,  is  always  to  be 
interpreted  as  broncho-pneumonia,  provided  tuberculosis  can  be  ex- 
cluded. In  doubtful  cases  the  chances  largely  favour  broncho-pneumonia 
rather  than  bronchitis.  Attention  is  again  called  to  the  fact  already 
mentioned,  that  there  are  a  large  number  of  cases  of  pneumonia  without 
signs  of  consolidation. 

The  differential  diagnosis  of  broncho-pneumonia  from  lobar  pneu- 
monia will  be  considered  in  connection  with  the  latter  disease.  On 
account  of  the  remittent  temperature,  broncho-pneumonia  may  be  con- 
founded with  malarial  fever ;  or  malaria  may  be  suspected  as  a  complica- 
tion.   An  examination  of  the  blood  will  remove  the  doubt. 

Both  the  acute  and  the  persistent  forms  of  simple  broncho-pneumonia 
may  be  confounded  with  the  tuberculous  form ;  the  points  of  distinction 
are  considered  in  the  chapter  on  Tuberculosis. 

Prognosis. — Broncho-pneumonia  is  always  a  serious  disease,  and  in  an 
infant  dangerous  to  life.  The  prognosis  depends  upon  the  age,  sur- 
roundings, and  previous  condition  of  the  patient,  upon  the  nature  of  the 
infection,  whether  the  disease  is  primary  or  secondary,  and,  if  the  latter, 
upon  the  character  of  the  primary  disease.  In  private  practice  the  mor- 
tality from  broncho-pneumonia  is  from  ten  to  twenty  per  cent,  depend- 
ing upon  the  conditions  mentioned.  One  whose  knowledge  of  broncho- 
pneumonia is  derived  from  observations  in  private  practice  can,  however, 
form  but  little  idea  of  the  frequency  and  severity  of  this  disease  in  hos- 
pitals and  asylums  for  infants  and  young  children,  particularly  when  it 
occurs  with  epidemics  of  measles,  diphtheria,  and  pertussis.  The  statis- 
tics in  the  following  table  are  taken  from  the  records  of  two  institutions 
with  which  I  was  at  the  time  connected,  and  fairly  represent  the  re- 
sults seen  in  such  places  in  children  under  three  years : 


Forms  of  Pneumonia. 


Primary  broncho-pneumonia 

Following  bronchitis  of  the  large  tubes 
Secondary  to  measles 

"  "  pertussis 

"  "  scarlet  fever 

"  "  diphtheria 

"  "  ileo-colitis 

"  "  epidemic  influenza 

"  '■'  varicella 

"  "  erysipelas 


Totals 


Cases. 


194 

29 

89 

66 

7 

47 

19 

6 

2 

2 

461 


Deaths. 


96 

19 

56 

54 

7 

47 

18 

1 

2 

2 

302 


Percentage 
mortality. 


49.4 

65.5 

62.9 

81.8 

100.0 

100.0 

94.7 

16.6 

100.0 

100.0 

65.5 


516 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


The  mortality  varies  with  the  age  of  the  patient,  being  highest  dur- 
ing the  first  year,  and  diminishing  steadily  thereafter,  as  shown  by  the 
following  table  giving  the  result  in  346  cases : 


Age. 


During  the  first  year  .  . 
"         "    second  year 
"    third 
"   fourth     " 
"   fifth 


Percentage 
mortality. 


66 
55 
33 
16 


In  this  table  are  included  no  cases  secondary  to  measles,  scarlet  fever, 
or  diphtheria. 

Probably  the  best  of  all  guides  to  the  nature  and  severity  of  the  in- 
fection is  the  temperature.  x\n  excessively  high  temperature  iisually 
indicates  a  severe  type  of  infection.  Some  idea  of  this  may  be  gained 
from  these  figures,  giving  the  highest  temperature  and  the  mortality  in 
two  hundred  and  thirty-one  cases,  not  including  cases  with  measles  or 
diphtheria : 


HioREST  Tebipesatube. 

Cases. 

Deaths. 

Percentage 
mortality. 

106°    F.  or  over 

55 
94 
53 
22 

7 

47 
56 
26 
13 
5 

85.5 

105°    or  105.5°  F 

60.0 

104°    or  104.5°  F 

49.0 

102°    to  103.5°  F 

60.0 

99.5°  to  101.5°  F 

71.0 

The  high  mortality  of  the  cases  with  unusually  low  temperature  is 
due  to  the  fact  that  they  nearly  always  were  seen  in  infants  with  very 
feeble  vitality.  The  outlook  in  cases  with  a  steadily  high  temperature — 
between  102.5°  and  104°  F. — is  usually  more  favourable  than  in  those 
with  wide  fluctuations,  such  as  100°  to  105 . 5°  F.  As  a  rule,  the  danger 
from  the  disease  increases  steadily  with  every  degree  of  temperature 
above  104.5°  F. 

An  important  factor  in  the  prognosis  is  the  previous  condition  of  the 
patient.  The  association  with  rickets  is  unfavourable,  both  on  account 
of  the  feeble  muscular  power  of  these  children  and  their  thoracic  de- 
formities. Marked  and  persistent  tympanites  is  always  an  unfavourable 
symptom.  Any  condition  which  diminishes  the  general  vitality  increases 
the  danger  from  broncho-pneumonia.  As  a  rule,  second  attacks  are 
more  serious  than  the  primary  ones,  especially  if  the  interval  between 
them  is  short. 

In  making  the  prognosis  in  any  given  case,  the  symptoms  to  be  con- 


ACUTE   BRONCHO-PNEUMONIA.  517 

sidered  are  the  height  and  course  of  the  temperature,  the  presence  or 
absence  of  nervous  symptoms,  the  condition  of  the  organs  of  digestion, 
the  presence  of  cyanosis  and  the  extent  of  the  disease  as  shown  by  the 
physical  signs.  I  have  not  found  the  examination  of  the  blood  to  aid 
much  in  prognosis. 

Nervous  symptoms  early  in  the  disease  do  not  affect  the  prognosis. 
Three  cases  in  which  convulsions  occurred  at  the  onset  recovered,  but 
of  thirty-seven  cases  in  which  convulsions  occurred  at  a  late  period  dur- 
ing the  course  of  the  disease,  all  but  one  proved  fatal. 

So  long  as  the  nutrition  of  the  patient  can  be  well  maintained,  no 
protracted  case  is  hopeless,  no  matter  how  extensive  the  local  disease 
may  be;  but  the  existence  of  vomiting,  diarrhoea,  or  persistent  tym- 
panites makes  the  issue  doubtful,  even  though  the  other  symptoms  are 
favourable. 

Treatment. — The  most  important  part  of  prophylaxis  is  to  give  care- 
ful and  early  attention  to  every  attack  of  bronchitis  in  an  infant,  for 
every  such  attack  should  be  regarded  as  a  possible  precursor  of  pneu- 
monia. It  is  striking  that  one  sees  broncho-pneumonia  so  seldom  in 
private  practice  among  the  better  classes,  even  though  bronchitis  is  very 
frequent;  while  among  hospital  and  dispensary  patients,  where  bron- 
chitis is  very  often  neglected,  broncho-pneumonia  is  constantly  seen.  Cases 
of  measles  and  diphtheria  which  are  complicated  by  pneumonia  should, 
if  possible,  be  carefully  isolated  from  others,  and  wards  in  which  they 
are  treated  should  be  thoroughly  disinfected  before  they  are  used  for 
simple  cases. 

The  hygienic  treatment  of  broncho-pneumonia  is  important,  and 
usually  it  receives  too  little  attention.  It  is  much  the  same  as  that  of 
cases  of  acute  bronchitis  already  discussed.  What  was  said  in  that  con- 
nection regarding  the  necessity  for  fresh  air  and  the  caution  as  to  very 
cold  air,  may  be  here  repeated.  The  cold-air  treatment  is  not  admis- 
sible in  very  young  or  delicate  infants,  nor  in  cases  of  disseminated 
pneumonia  (capillary  bronchitis).  The  best  results  from  this  treat- 
ment are  seen  in  the  cases  with  extensive  consolidation  and  with  the 
minimum  amount  of  bronchitis,  and  it  is  to  be  highly  recommended  in 
the  pneumonia  of  the  severe  acute  infections — diphtheria,  measles,  and 
scarlet  fever.  The  dress  and  protection  of  the  patient  with  the  cold-air 
treatment  are  discussed  under  Lobar  Pneumonia. 

Older  children  with  pneumonia  should  be  kept  in  bed.  Infants  for 
a  considerable  part  of  the  time  may  be  held  in  the  nurse's  arms.  A  fre- 
quent change  of  position  in  all  cases  is  essential;  no  child  should  be 
allowed  to  lie  for  hours  directly  on  the  back.  The  general  rules  pre- 
viously laid  down  for  feeding  all  sick  children  should  be  followed  here. 
As  a  rule,  medicine  should  not  be  administered  in  the  food. 

The  same  local  treatment  may  be  employed  as  in  cases  of  bronchitis. 


518  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Counter-irritation,  best  by  means  of  the  mustard  paste,  may  be  em- 
ployed from  three  to  six  times  daily.  It  is  of  the  greatest  value  in  the 
early  stage  of  acute  pulmonary  congestion,  and  during  attacks  of  cardiac 
or  respiratory  failure.  The  oiled-silk  jacket  may  be  applied  with  advan- 
tage in  some  cases  in  infants  with  low  temperature,  but  should  not  be 
used  when  the  temperature  is  high,  as  it  interferes  with  the  means  em- 
ployed for  its  reduction.    Poultices  should  not  be  used  at  all. 

Alcohol  is  usually  needed  in  pneumonia  secondary  to  diphtheria, 
measles,  or  scarlet  fever,  also  in  many  primary  cases.  Its  use  has  been 
greatly  abused  in  this  disease.  Although  tliere  is  little  doubt  that  it  is 
at  times  of  much  benefit,  there  is  considerable  doubt  as  to  its  mode  of 
action.  The  dose  is  to  be  regulated  by  the  condition  of  the  patient.  Not 
over  one-half  ounce  daily  should  be  given  to  an  infant  of  one  year. 

Of  the  circulatory  stimulants,  caffein,  camphor,  digitalis,  and  strych- 
nine may  be  used,  and  are  recommended  in  the  order  named. 

For  a  child  of  one  year  the  following  doses  are  suitable :  Caffein,  gr. 
^  to  gr.  ^  every  three  hours;  camphor  is  especially  valuable  for  quick 
effect ;  n\,  i j  or  iij  of  a  ten-per-cent  solution  in  oil  may  be  given  hypoder- 
mically ;  digitalis,  the  fluid  extract  is  generally  to  be  preferred  as  more 
reliable  than  the  tincture,  Vll  ^  may  be  given  every  four  hours ;  strychnine, 
S^'  ri^TT  to  gr.  yhf  every  three  hours.  For  immediate  effect  in  sudden 
heart  or  respiratory  failure,  nothing  compares  with  adrenalin  given  hypo- 
dermically — doses  nx  ij  to  TIX  v  of  a  1-1,000  solution ;  atropliine,  also  used 
hypodermically,  is  sometimes  useful — dose,  gr.  -^.  Oxygen  may  be 
given  continuously,  but  always  mixed  with  atmospheric  air.  It  some- 
times seems  to  benefit  greatly  cases  with  marked  cyanosis;  often  it  does 
no  good.  Gentle  friction  of  the  chest  wall,  without  disturbing  the  pa- 
tient, is  sometimes  useful  in  stimulating  the  respiratory  muscles,  espe- 
cially in  protracted  cases. 

It  should  be  remembered  that  the  normal  range  of  temperature  in 
broncho-pneumonia  is  from  101°  to  104.5°  F.  This  temperature  is  not 
in  itself  exhausting,  and  the  chances  of  recovery  are  not,  I  think,  im- 
proved by  reducing  it  so  long  as  it  remains  within  these  limits.  Too 
much  can  not  be  said  in  condemnation  of  the  practice  of  giving  the 
coal-tar  products  in  full  doses  for  the  reduction  of  temperature.  In 
small  doses  they  are  often  useful  to  allay  nervous  irritability,  restless- 
ness, and  promote  sleep. 

Antipyretic  measures  are  indicated  in  cases  of  hyperpyrexia,  which 
we  may  define  as  105°  F.  or  over,  especially  when  extreme  nervous  symp- 
toms exist.  Under  these  circumstances,  the  most  certain,  the  most 
within  our  control,  and  hence  the  safest  antipyretic,  is  cold.  It  may  be 
used  by  the  evaporation  bath,  the  cold  pack,  sponging,  cold  compresses, 
or  an  ice-bag  applied  to  the  chest.  (See  chapter  on  General  Thera- 
peutics. ) 


ACUTE  BRONCHO-PNEUMONIA.  519 

Not  all  children  bear  cold  well,  and  in  its  use  and  frequency  of  repe- 
tition one  must  be  guided  by  its  effect  upon  the  child's  general  condition 
as  well  as  upon  the  temperature.  When  with  hyperpyrexia  we  have 
general  cyanosis,  cold  surface,  feeble  pulse,  shallow  respiration,  and 
stupor,  cold  is  contraindicated  and  a  hot  mustard  bath  should  be  used. 

Inhalations  are  of  more  value  in  relieving  cough  and  in  promoting 
bronchial  secretion  than  any  other  means  we  possess.  The  same  sub- 
stances are  to  be  used,  and  in  the  same  way  as  mentioned  in  the  article 
on  Bronchitis. 

The  nervous  symptoms,  restlessness,  loss  of  sleep,  etc.,  are  often  best 
controlled  by  cold  or  tepid  sponging;  in  otlier  cases  by  small  doses  of 
phenacetine — i.  e.,  one  grain  every  three  hours  to  a  child  of  six  months. 
Opium  is  to  be  avoided  unless  there  is  severe  pain,  which  is  very  rare; 
or  when  the  incessant  cough  is  not  relieved  by  inhalations.  Codeine  may 
be  given  in  doses  of  gr.  ^  every  three  or  four  hours  to  a  child  of  one 
year,  or  morphine  in  half  this  dose. 

Sudden  attacks  of  general  collapse  with  cyanosis  are  frequent  in 
severe  cases  of  broncho-pneumonia.  They  may  come  on  at  any  period  in 
the  disease.  When  occurring  in  the  early  stage,  if  promptly  and  ener- 
getically treated,  recovery  may  take  place,  but  when  they  come  on  in  the 
late  stages  they  are  usually  fatal.  They  may  be  due  to  acute  congestion 
or  oedema  of  the  lung  not  previously  involved,  or  to  circulatory  failure, 
the  result  of  vaso-motor  paralysis.  The  most  efficient  treatment  is  the 
use  of  dry  cups  or  the  hot  mustard  bath,  the  administration  of  adre- 
nalin and  caffein  or  camphor  hypodermically,  and  to  give  oxygen  con- 
tinuously. 

When  the  fever  continues  for  five  or  six  weeks,  with  no  disposition 
on  the  part  of  the  disease  to  subside,  one  should  continue  the  sustain- 
ing treatment  adopted  in  the  earlier  part  of  the  disease — careful  feed- 
ing and  judicious  stimulation,  but  most  of  all  should  these  patients  be 
given  the  benefit  of  the  fresh-air  treatment.  Some  apparently  hopeless 
cases  recover ;  but,  unfortunately,  in  the  majority  the  continuance  of  the 
pneumonic  process  is  in  itself  evidence  of  the  weakened  vitality  of  the 
patient,  and,  though  he  may  live  a  long  time,  most  such  attacks  ulti- 
mately prove  fatal. 

When  the  fever  has  disappeared,  and  there  is  only  a  persistence  of 
the  physical  signs  and  the  general  cachexia,  the  cases  are  more  hopeful. 
Here,  a  change  of  air  is  more  important  than  all  other  means  of  treat- 
ment. If  in  the  winter  or  spring  the  child  can  be  removed  to  a  warm, 
dry  climate  where  he  can  be  kept  in  the  open  air,  or  if,  in  the  summer, 
he  can  be  taken  to  the  mountains,  immediate  improvement  is  often  seen, 
followed  by  rapid  recovery.  This  experience  we  see  repeated  every  year 
with  hospital  patients  when  they  are  transferred  from  the  city  to  the 
country  in  May  or  June.    With  the  change  of  air  a  general  tonic  plan 


520 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


of  treatment  should  be  followed,  cod-liver  oil,  arsenic,  and  iron  being 
used,  according  to  the  indications  in  each  particular  case. 

One  should  never  declare  one  of  these  cases  of  protracted  pneumonia 
to  be  hopeless,  nor  should  he  be  too  ready  to  assume  that  tuberculosis 
is  present  because  the  child  is  wasted  and  anaemic,  and  the  physical  signs 
have  persisted. 

No  specific  treatment  of  pneumonia  has  yet  been  proposed  which  can 
be  recominended. 


CHAPTER    V. 


DISEASES  OF  THE  LUNGS.— (Continued.) 

LOBAR  PNEUMONIA. 
(Fibrinous  Pneumonia;  Croupous  Pneumonia.) 

Etiology. — Age. — Lobar  pneumonia  may  occur  at  any  age.  I  have 
seen  it  in  an  infant  of  three  months;  but  it  is  not  until  after  the  first 
year  that  it  begins  to  be  frequent.  After  the  third  year  nearly  all  the 
cases  of  primary  pneumonia  are  of  this  variety. 

Of  500  cases  the  ages  were  as  follows: 


AOE. 

Cases. 

Per  cent. 

During  the  first  year 

From  the  second  to  the  sixth  year 

"       "   seventh  to  the  eleventh  year 

"       "   twelfth  to  the  fourteenth  year 

76 
309 
104 

11 

15 

62 

21 

2 

Totals 

500 

100 

Season. — In  136  cases  the  seasonal  occurrence  was  as  follows: 


Season. 

Cases. 

Per  cent. 

In  the  three  winter  months 

48 

62 

6 

20 

35 

"     "       "     spring        "         

46 

"     "       "     summer     "         

4 

"     "       "     autumn      "       

15 

Totals 

136 

100 

Lobar  pneumonia,  in  children  therefore,  as  in  adults,  occurs  most 
frequently  during  the  spring  months.  April  shows  the  largest  number 
of  any  single  month. 

Previous  Condition. — In  my  hospital  cases,  eighty-two  per  cent  of  the 
children  were  previously  in  good  condition,  and  only  eighteen  per  cent 


LOBAR  PNEUMONIA. 


521 


were  delicate,  rachitic,  or  syphilitic.  This  observation  has  been  borne  out 
by  my  experience  in  private  practice,  viz.,  that  as  a  rule  lobar  pneumonia 
affects  children  who  were  previously  healthy.  Or  to  state  the  matter  dif- 
ferently, if  a  strong  child  contracts  pneumonia  it  is  nearly  always  of  the 
lobar  variety. 

Previous  Disease. — Previous  attacks  of  pneumonia  arc  observed  in  but 
a  small  proportion  of  cases.  It  was  noted  only  five  times  in  160  cases. 
In  the  vast  majority  of  cases  lobar  pneumonia  is  a  primary  disease,  al- 
though it  occasionally  occurs  as  a  complication  of  pertussis,  measles, 
typhoid  or  scarlet  fever,  and  even  diphtheria — chiefly,  however,  in  chil- 
dren over  three  years  old. 

Epidemics  of  lobar  pneumonia  I  have  never  Avitnessed,  although  on 
several  occasions  I  have  seen  two  children  in  a  family  attacked  either 
simultaneously  or  in  rapid  succession.  Exhaustion,  fatigue,  and  exposure 
are  to  be  ranked  as  associated  exciting  causes. 

In  addition  to  other  causes,  there  is  required  for  the  production  of 
the  disease"  the  presence  and  growth  of  the  pneumococcus.  Associated 
with  it  are  often  found  the  staphylococcus  aureus  and  occasionally  the 
bacillus  of  influenza. 

r. 

Lesions. — The  Seat  of  the  Disease. — In  950  cases  in  children  under 
fourteen  years,  this  was  as  follows : 


Seat  or  Disease. 

Personal 
ca.ses. 

Collected 
cases. 

Totals. 

Right  lung,  upper  lobe  only 

39                   137 

8          1              4 

26          1          142 

13          !           64 

176 

"     middle  "       " 

12 

"         "     lower     "       "    

168 

"         "     more  than  one  lobe 

77 

Totals,  right  lung 

86                   347 

433 

Left  lung,  upper  lobe  only 

25 

49 

9 

68 

214 

29 

93 

"       "     lower     "       "    

263 

"       "     more  than  one  lobe 

38 

Totals,  left  lung 

83          '         311 

394 

Both  lungs,  upper  lobes 

3 
9 

13 
38 
60 

13 

"      lower      "     

41 

"         "      elsewhere        

69 

Totals,  both  lungs 

12 

111 

123 

The  right  lung  was  thus  affected  in  45.5  per  cent ;  the  left  lung  in* 
41 .5  per  cent;  both  lungs  in  13  per  cent.  In  the  order  of  frequency,  the 
disease  involves,  first,  the  left  base;  second,  the  right  apex;  third,  the 
right  base;  forth,  the  left  apex.  The  disease  affects,  as  a  rule,  a  single 
lobe,  and  often  only  a  circumscribed  portion  of  a  lobe. 


522  DISEASES  OF  THE   RESPIRATORY   SYSTEM. 

Lobar  pneumonia  among  children  is  so  rarely  fatal  that  the  oppor- 
tunities for  a  study  of  the  peculiarities  of  the  lesion  have  been  some- 
what limited.  The  anatomical  changes  resemble  those  seen  in  the  adult 
lung.  There  is  an  exudation  into  the  alveoli  and  smaller  bronchi  of 
fibrin,  serum,  leucocytes,  and  red  blood-cells  (Fig.  71).  There  is  usually 
in  addition  an  inflammation  of  the  mucous  membrane  of  the  larger 
bronchi  and  of  the  pleura.  The  frequency  and  severity  of  the  pleurisy  is 
a  peculiarity  of  the  lesion  in  children. 

In  the  first  stage,  that  of  congestion,  the  portion  of  lung  involved  is 
dark-coloured,  heavy,  and  cedematous,  and  shows  under  the  microscope  a 
serous  and  cellular  exudation  into  the  air  vesicles,  with  swelling  of  the 
epithelial  cells  lining  the  alveoli. 

In  the  second  stage,  that  of  red  hepatisation,  there  is  usually  some 
exudation  upon  the  pulmonary  pleura,  generally  a  thin  layer  of  fibrin, 
giving  it  a  dull,  granular  look.  The  lung  itself  is  of  a  uniform  dark-red 
colour.  It  is  solid  and  cuts  like  liver.  It  looks  as  if  it  had  been  inflated 
to  its  utmost  extent  and  then  injected  with  a  material  which  had  solid- 
ified.* The  consolidated  area  is  sharply  defined.  Under  the  microscope 
the  air  vesicles  are  seen  to  be  distended  with  an  exudation  which  is 
chiefly  fibrin,  but  with  some  leucocytes,  red  blood-cells,  and  desijuamated 
epithelial  cells.  The  cells  are  chiefly  leucocytes,  and  are  usually  more 
abundant  than  in  the  pneumonia  of  adults. 

In  the  third  stage,  that  of  gray  hepatisation,  the  lung  is  more  moist, 
and  the  inflammatory  products  are  partly  decolourised.  This  change 
takes  place  irregularly  throughout  the  lung,  giving  it  a  mottled  appear- 
ance. 

The  fourth  stage,  that  of  resolution,  follows  gray  hepatisation,  and 
consists  in  the  degeneration  and  liquefaction  of  the  products  of  inflam- 
mation, which  are  ultimately  carried  away  by  the  lymphatics,  or  pushed 
out  into  the  bronchi  and  removed  by  coughing. 

The  duration  of  the  stage  of  congestion  is  from  a  few  hours  to  sev- 
eral days;  that  of  the  stage  of  red  hepatisation  from  two  days  to  two 
or  three  weeks.  This  is  the  condition  in  which  the  lung  is  most  often 
seen  at  autopsy.  The  stage  of  gray  hepatisation  is  commonly  shorter. 
Resolution  usually  begins  when  the  temperature  falls  to  normal,  but 
occasionally  it  may  be  delayed  for  several  days.  It  is  generally  complete 
in  about  a  week. 

Variations  in  the  Lesions. —  (1)  Instead  of  clearing  up  at  the  usual 
time,  the  lung  may  remain  consolidated  for  several  weeks,  and  then  re- 
•solve.  (2)  The  stage  of  gray  hepatisation  may  be  followed  by  a  great 
exudation  of  pus  cells,  which  may  everywhere  infiltrate  the  affected  lung; 
or  these  may  be  circumscribed  so  as  to  form  a  single  large  abscess  or 
many  small  ones.  (3)  There  may  be  small  areas  of  gangrene.  All  these 
conditions  are  very  rare  in  children.     (4)  There  may  be  excessive  pleu- 


LOBAR  PNEUMONIA.  523 

risy,  or  pleuro-pneumonia.     This  is  found  at  autopsy  in  about  one-half 
the  cases^  and  will  be  separately  considered  elsewhere. 

The  lesions  in  the  other  organs  are  for  the  most  part  due  to  the  pneu- 
mococcus.  There  may  be  pericarditis,  especially  with  pneumonia  of  the 
left  side,  if  complicated  by  excessive  pleurisy.  This  is  seen  even  in  in- 
fants. The  pericardial  inflammation  closely  resembles  that  of  the  pleura. 
There  is  a  very  abundant  exudation  of  fibrin  and  pus,  coating  both  sur- 
faces of  the  pericardium.  Acute  meningitis  is  rather  rare.  It  is  an 
acute  purulent  inflammation,  with  a  very  abundant  exudation  of  green- 
ish-yellow fibrin  and  pus,  chiefly  at  tlie  convexity.  Less  frequently  peri- 
tonitis is  present.  Acute  parotitis  and  acute  arthritis  are  seen  as  rare 
complications  of  pneumonia.  In  most  of  the  complicated  cases  the  other 
lesions  are  second  to  those  in  the  lungs ;  but  they  may  begin  simultaneously 
with,  or  even  precede,  the  pneumonia.  In  cases  with  complications  other 
than  thoracic  ones,  a  general  pneumococcus  septicaemia  is  usually  pres- 
ent. From  reports  thus  far  published  it  would  appear  that  pneumococci 
are  found  in  the  blood  of  children  with  pneumonia  much  less  frequently 
than  in  that  of  adults.  In  seventy  cases  examined  by  Often,  positive 
blood  cultures  were  obtained  but  nine  times;  while  in  adults  fully  half, 
the  cases  give  positive  results. 

The  heart  is  generally  found  in  diastole,  with  the  cavities,  especially 
those  of  the  right  side,  distended  with  soft  clots.  There  may  be  found 
ante-mortem  thrombi,  which  may  extend  into  the  pulmonary,  artery  or 
the  aorta. 

Symptoms. —  (1)  The  Typical  Course. — A  child  three  or  four  years  of 
age,  after  a  few  hours  of  slight  indisposition,  is  suddenly  taken  with 
vomiting,  followed  by  a  rapid  rise  in  temperature.  He  is  dull  and  heavy, 
complains  of  headache  and  general  weakness,  refuses  food,  and  is  easily 
persuaded  to  remain  in  bed.  He  has  the  appearance  of  being  quite  ill, 
even  after  a  few  hours.  Occasionally  sharp  pain  in  the  side  is  complained 
of.  The  skin  is  dry ;  there  are  marked  thirst,  restlessness,  and  the  other 
symptoms  which  accompany  fever.  The  temperature  is  found  to  be  104° 
F.,  or  even  higher;  the  respirations  40  to  50  a  minute;  the  pulse  full, 
strong,  and  120  to  130.  On  the  second  day  the  patient  is  no  better. 
The  temperature  remains  high;  the  tongue  is  coated;  the  anorexia 
continues ;  the  pain  is  more  severe ;  cough  is  present  and  may  be  quite 
frequent. 

After  the  second  or  third  day  the  patient  is  usually  more  comfortable, 
and  sleeps  better,  but  may  be  disturbed  by  the  cough.  At  times  there 
is  restlessness,  and  at  night  there  may  even  be  slight  delirium.  The 
respiration  continues  rapid  and  the  temperature  high.  These  general 
symptoms  show  very  little  change  until  the  sixth  or  seventh  day,  when, 
after  a  long  sleep,  which  has  been  more  natural  than  before,  the  patient 
wakes,  decidedly  improved  as  to  all  his  symptoms.     There  is  less  fever, 


524  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

and  the  temperature  continues  to  fall  rapidly  until  it  touches  the  normal 
line,  or  it  may  even  go  below  this.  As  the  fever  subsides  the  pulse  drops 
to  90  or  100,  and  the  respirations  to  25  or  30  a  minute.  The  appetite 
soon  returns,  and  convalescence  is  usually  rapid.  In  a  week  the  patient 
is  out  of  bed,  and  in  two  or  three  weeks  more  he  is  out  of  doors.  This 
is  the  course  seen  in  fully  two-thirds  of  all  the  cases  of  lobar  pneumonia 
at  this  age. 

(2)  Pneumonia  of  Short  Duration, — Instead  of  running  the  usual 
course  of  from  five  to  eight  days,  cases  are  seen  in  which  the  duration  is 
only  three  or  four  days,  although  the  physical  signs  indicate  that  the 
process  in  the  lung  passes  through  the  usual  stages.  These  differ  from 
the  ordinary  type  chiefly  in  their  duration.    They  are  always  mild. 

(3)  Abortive  Pneumonia. — This  form  of  the  disease  is  rarely  seen 
in  hospitals,  but  it  is  not  infrequent  in  private  practice  where  the  phy- 
sician is  summoned  at  the  earliest  signs  of  illness.  The  onset  is  precisely 
like  that  of  ordinary  pneumonia,  and  may  even  be  as  severe  as  the  aver- 
age case.  The  physical  examination  of  the  chest  gives  all  the  signs  of 
the  first  stage  of  the  disease,  but  on  the  second  or  third  day  the  physician 
is  greatly  surprised  to  find  that  the  temperature  has  fallen  to  normal, 
and  that  all  the  physical  signs  have  disappeared.  The  process  in  such 
cases  does  not  seem  to  go  beyond  the  first  stage  of  congestion;  there  is 
no  evidence  of  hepatisation  of  the  lung.  The  course  is  often  such  as  to 
lead  the  physician  to  the  opinion  that  he  has  made  a  mistake  in  his 
diagnosis.  This  type  of  pneumonia  corresponds  with  abortive  types  of 
other  infectious  diseases  so  frequently  met  with  in  children.  The  tem- 
perature curve  in  such  a  case  is  shown  in  Fig.  89.  The  diagnosis  of 
these  cases  is  always  attended  with  some  uncertainty.  There  can  be  no 
doubt  that  many  of  the  unexplained  high  temperatures  of  brief  duration 
which  are  seen  in  children  are  from  this  cause.  Exactly  why  it  is  that 
the  disease  sometimes  terminates  in  this  way  can  not  always  be  explained. 
It  may  be  because  the  resistance  of  the  patient  is  greater  than  usual,  or 
the  virulence  of  the  pneumococcus  is  less. 

(4)  The  Prolonged  Course. — Although  usually  lasting  about  a  week, 
it  is  not  rare  for  pneumonia  to  continue  ten,  twelve,  or  even  fifteen  days. 
This  prolonged  course  is  usually  due  to  the  fact  that  the  disease  spreads 
from  one  part  of  the  lung  to  another,  or  even  to  the  opposite  lung,  in- 
volving in  succession  two,  three,  or  more  lobes.  This  is  sometimes  known 
as  "  creeping "  pneumonia ;  it  is  always  severe  and  the  outlook  is  gen- 
erally unfavourable.  A  prolonged  temperature  with  physical  signs  lim- 
ited to  a  single  lobe  should  always  suggest  complications,  most  frequently 
empyema,  occasionally  pericarditis. 

(5)  Cerebral  Pneumonia. — This  term  was  first  applied  by  Killiet 
and  Barthez  to  cases  of  pneumonia  in  which  the  cerebral  symptoms  pre- 
dominate.   They  will  be  considered  later. 


LOBAR  PNEUMONIA.  525 

Onset. — Prodromal  symptoms  of  more  tlian  a  few  liours'  duration  are 
quite  rare.  The  onset  of  lobar  pneumonia  is  almost  invariably  abrupt, 
with  well-marked  symptoms — vomiting,  diarrhoea,  chill,  or  convulsions. 
Vomiting  is  altogether  the  most  frequently  seen.  In  summer  partic- 
ularly, there  may  be  vomiting,  and  diarrhoea.  A  distinct  chill  is  rare  in 
a  child  under  five  years  of  age,  and  is  not  very  common  even  in  older 
children.  Convulsions  are  not  very  infrequent,  being  seen  in  about  five 
per  cent  of  the  cases.  Their  occurrence  depends  upon  the  suddenness  of 
the  invasion  and  the  susceptibility  of  the  patient. 

Cough. — This  is  present  in  most  of  the  cases  throughout  the  disease, 
but  often  is  not  marked  for  the  first  day  or  two.  It  is  seldom  a  distress- 
ing symptom.  A  disposition  to  suppress  the  cough  on  account  of  pain  is 
very  frequently  noticed. 

Expectoration. — This  is  rarely  seen  in  early  childhood,  and  practically 
never  under  five  years  of  age.  Children  of  ten  or  twelve  may  have  the 
same  expectoration  as  adults — white  and  viscid,  or  brownish-red  early 
in  the  disease,  yellow  and  abundant  toward  its  close.  This  shows  the 
presence  of  the  pneumococcus  in  great  numbers. 

Pain. — Headache  and  general  muscular  pains  in  the  back  and  ex- 
tremities are  frequent  during  the  invasion.  The  characteristic  pain,  how- 
ever, is  pleuritic.  It  is  not  necessarily  felt  in  the  region  of  the  affected 
lung,  and  often  not  in  the  chest  at  all.  It  is  frequently  referred  to  the 
loin,  the  epigastrium,  or  to  any  region  to  which  the  intercostal  nerves 
are  distributed.  I  have  seen  a  number  of  cases  in  which  there  was  intense 
localised  pain  in  the  right  iliac  fossa,  associated  with  such  extreme 
tenderness  as  to  lead  to  the  suspicion  that  the  case  was  one  of  appen- 
dicitis. 

Prostration. — This  is  one  of  the  characteristic  features  of  pneumonia. 
The  patient  is  generally  willing  to  go  to  bed  on  the  first  day  of  the 
attack,  and  shows  little  desire  to  leave  it  while  the  disease  continues. 
"  Walking  cases  "  are  not  common  in  children. 

Respiration. — This  is  always  accelerated,  and  generally  out  of  propor- 
tion to  the  pulse.  The  normal  ratio  of  the  respiration  to  the  pulse  is  one 
to  four;  in  pneumonia,  frequently  one  to  two.  The  respiration  is  not 
laboured  and  not  quite  panting,  although  this  term  is  sometimes  used 
to  describe  it.  It  is  jerky.  There  is  a  short  inspiration,  then  a  momen- 
tary pause,  followed  by  a  quick  expiration,  which  is  accompanied  by  a 
short  moan.  This  expiratory  moan  is  very  characteristic.  The  rapidity 
of  respiration  is  usually  in  proportion  to  the  amount  of  lung  involved, 
but  it  is  also  modified  by  the  temperature,  as  the  respirations  often  drop 
from  60  to  30  in  the  course  of  a  few  hours  at  the  crisis. 

Pulse. — In  the  early  part  of  the  disease  this  is  frequent,  full,  and 
strong,  from  120  to  150  a  minute.  Later  it  may  be  weak,  small,  com- 
pressible, and  sometimes  irregular.    It  is  much  more  rapid  in  the  child 


526 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


than  in  the  adult,  160  and  180  being  often  seen  in  eases  not  especially 
severe.    The  pulse  rate  is  of  less  importance  than  its  character. 

Temperature. — The  typical  temperature  curve  of  lobar  pneumonia 
(Fig.  86)  is  characterised  by  an  abrupt  rise  usually  to  104°  or  105°  F., 
and  by  daily  fluctuations  generally  within  the  limits  of  two  or  three 


105°    1 

2 

.*)  I 

6     6 

7 

8 

101° 

/\ 

r\  ' 

10S°  _1 

y 

i 

A 

102° 

I 

(^ 

A 

101» 

V 

100° 

99° 

^ 

./ 

98° 

, 

L- 

Fio.  86. — Typical  Tempera- 
ture Curve  of  Lobar  Pneu- 
monia. History. —  Male, 
three  years  old;  in  fair  con- 
dition ;  sudden  onset ;  signs  of 
consolidation — bronchial  res- 
piration and  voice,  and  dul- 
ness — over  left  lower  lobe  be- 
hind, not  distinct  until  the 
morning  of  the  fifth  day.  On 
the  seventh  day  the  lung  was 
resolving. 


107° 

1 

2     3  i  1 

5  1  6  1  7 

8 

9 

10 

11112 

13 

U 

15 

16 

17 

18|19 

20 

106° 
105° 
101" 
103° 
102° 
101° 
100° 
99° 

/I 

/ 

A  ^ 

A. 

'A 

f 

\ 

/ 

/ 

I 

i/ 

' 

\ 

V 

1 

1 

98° 
97° 

i, 

z 

1   (* 

^ 

»^- 

•s/" 

_] 

1 

.V 

Fig.  87. — Lobar  Pneumonia  with  Remittent  Tem- 
perature. History. — Female,  eighteen  months  old; 
in  fair  condition  ;  sudden  onset;  repeated  examina- 
tions of  chest  made,  but  no  abnormal  signs  until  the 
ninth  day,  when  there  were  very  rude  respiration 
and  slight  dulness  at  the  right  apex,  in  front;  on  the 
twelfth  day  all  the  signs  of  consolidation  at  the  same 
point,  no  r&les;  four  days  after  the  crisis  the  lungs 
were  clear. 


degrees  until  the  crisis,  at  which  time  the  temperature  falls  to  normal, 
usually  in  the  course  of  twenty-four  hours.  After  this  time  it  does  not 
go  above  the  normal  line.    Such  a  curve  is  seen  in  the  majority  of  cases 

over  three  years  of  age. 

In  cases  under  three 
years  of  age  it  is  not  un- 
common for  the  temper- 
ature to  be  of  a  more  or 
less  remittent  type  (Fig. 
87). 

These  wide  fluctua- 
tions often  lead  to  great 
difficulty  in  diagnosis, 
particularly  if  the  physi- 
cal signs  appear  late,  as 
they  not  infrequently  do. 
It  is  probable  that  some 
of  them  are  to  be  ex- 
plained as  mixed  infec- 
tions. 

The  accompanying 
chart  (Fig.  88)  illustrates  three  features  which  are  often  seen  in  pneumo- 
nia: (1)  A  temperature  which  early  in  the  disease  is  steadily  high  and  as 


107° 

1 

2 

3 

i 

5 

6 

7 

8     9    10   1 

1  12  13  11 

15 

16 

17 

18 

19 

20 

106° 
106° 
101° 
103° 
102° 
101° 
100° 
99° 

Ht^ 

4 

A 

^ 

Ml 

--.4 

/ 

r 

/ 

\ 

t-Ul 

^A 

J 

V 

\ 

-t 

-t' 

\ 

j]: 

.1 

98° 
97° 
96° 
95° 
91° 

N 

A 

^- 

-s^ 

— 

-     I 

sf 

ffl 

nI 

FiQ.  88. — Lobar  Pneumonia  with  Subnormal  Tem- 
perature AFTER  THE  CRISIS.  History. —  Female, 
nineteen  months  old;  fairly  healthy;  sudden  onset; 
sjTnptoms  typical  but  physical  signs  delayed;  con- 
solidation in  left  mammary  region  on  the  eighth  day; 
on  the  ninth  in  right  lung  middle  lobe ;  on  the  elev- 
enth day  a  pseudo-critical  drop  followed  after  twenty- 
four  hours  of  apyrexia  by  a  further  rise,  which  was 
accompanied  by  signs  of  extension  of  the  disease  in 
the  right  lung.     Resolution  rapid  after  crisis. 


LOBAR  PNEUMONIA. 


527 


106° 
105° 
10i° 
103° 
102° 
101° 
100' 
99° 

1 

2 

S 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

U 

16 

16 

17 

K 

/^ 

A 

A 

/ 

Si 

V 

/ 

/ 

l/ 

w 

A 

/ 

y 

A 

\l 

\ 

\. 

L 

\^ 

,/^ 

^/' 

98° 

^ 

Vw 

*" 

the  day  of  crisis  approaches  becomes  remittent;  (2)  a  secondary  rise 
after  being  normal  for  twenty-four  hours,  wliich  was  due  in  this  in- 
stance to  an  extension  of  the  disease  to  a  new  part  of  the  lung;  (3)  a 
fall  to  a  point  considerably  below  normal  at  the  time  of  the  crisis.  In 
this  case  the  temperature  fell  in  the  course  of  eighteen  hours  from  105° 
to  95°  F.,  and  later  still 
lower;  it  was  two  days  before 
it  finally  remained  at  the 
normal  point.  A  fall  to 
96.5°  or  97°  F.  at  the  time 
of  crisis  is  not  uncommon. 

In  the  foregoing  cases  the 
fever  terminated  by  crisis. 
In  Fig.  89  is  shown  one  end- 
ing by  lysis.  This  is  a  mode 
of  termination  much  more 
frequent  in  ■  young  children 
than  in  those  who  are  older. 
Thus,  in  93  of  my  own  cases, 
nearly  all  of  which  were  un- 
der three  years  of  age,  the 
fever  ended  by  crisis  in  49, 
and  by  lysis  in  44;  while  in 

553  collected  cases,  the  majority  of  which  were  in  older  children,  396 
ended  by  crisis,  and  126  by  lysis. 

The  following  table  shows  the  day  of  crisis  in  567  cases  of  lobar 
pneumonia  in  children  who  recovered: 


Fig.  89.  —  Abortive  Pneumonia  in  Left  Lung, 

FOLLOWED   BY   TyPICAL    PnEUMONIA   IN    RiGHT 

Lung,  Terminating  by  Lysis.  History.  — 
Male,  seventeen  months  old,  healthy;  sudden 
onset ;  on  the  second  day  disseminated  fine  rales 
in  both  lungs  behind,  and  over  left  lower  lobe 
very  feeble  respiration,  high-pitched — i.  e.,  some 
bronchitis,  with  congestion  (?)  of  left  base.  On 
the  third,  fourth,  and  fifth  days,  general  symp- 
toms gone  and  signs  nearly  disappeared.  On 
the  sixth  day  all  symptoms  of  pneumonia,  and 
on  the  seventh  distinct  consolidation  of  right 
base,  rest  of  chest  clear.  Subsequent  course 
typical ;  resolution  rapid  and  complete. 


The  Day  of  Crisis. 


Second  day 3  cases. 

Third      "  

Fourth    "  

Fifth       "  

Sixth       "  

Seventh  " 

Eighth    "  

Ninth      "  

Tenth     "  


22 
43 
88 
83 
132 
73 
55 
22 


Eleventh  day 18  cases. 

Twelfth      "    7      " 

Thirteenth  day 8      " 

Fourteenth   "    7      " 

Fifteenth       "    1  case. 

Eighteenth    "    3  cases. 

Twenty-first  day 1  ease. 

Twenty-sixth  "    1     " 

567 


From  this  table  it  will  be  seen  that  the  most  frequent  critical  day  is 
the  seventh,  and  that  in  sixty-six  per  cent  of  the  cases  it  was  from  the 
fifth  to  the  eighth  day.  The  causes  of  a  post-critical  rise  in  the  tempera- 
ture are  chiefly  two — extension  of  the  disease  to  a  new  area,  or  the  devel- 
opment of  pleurisy,  which  is  apt  to  be  purulent.  Less  frequently  it  is 
due  to  otitis,  meningitis,  pericarditis,  or  gastro-enteritis.    In  fatal  cases 


528  DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

the  temperature  is  generally  high  until  the  end.  In  general,  it  may  be 
said  that  the  temperature  is  considerably  higher  in  children  than  in 
adults;  in  the  majority  of  cases  it  reaches  105°  F.,  the  usual  range  being 
from  102°  to  105°  F.  In  15  of  137  cases,  or  eleven  per  cent,  it  reached 
106°  F.  or  over. 

Gastro-enteric  Symptoms. — These  are  more  common  in  infants  than 
in  older  children.  At  the  onset  there  is  frequently  vomiting,  some- 
times also  diarrhoea.  A  continuance  of  the  vomiting  is  rare,  and  is 
generally  due  to  improper  feeding  or  medication.  It  may  be  a  very 
serious  complication.  Diarrlicea  is  also  rare,  except  at  the  onset  and 
in  summer  cas5^.  Great  tympanites  is  a  distressing  symptom,  and 
when  present,  it  is  a  bad  prognostic  sign.  Throughout  the  disease 
there  are  anorexia,  coated  tongue,  and  the  usual  symptoms  of  high 
fever. 

Nervous  Symptoms. — Cerebral  symptoms  are  frequent  and  very  often 
misleading.  Pneumonia  is  often  ushered  in  by  convulsions,  which  may 
be  repeated  two  or  three  times  in  the  course  of  the  first  twenty-four 
hours.  They  are  sometimes  followed  by  drowsiness  or  stupor,  sometimes 
by  active  delirium.  Cerebral  symptoms  may  predominate  for  several 
days.  There  may  be  opisthotonus,  dilated  or  contracted  pupils,  irregular 
pulse,  retracted  abdomen,  and,  in  fact,  almost  every  symptom  of  menin- 
gitis. Lumbar  puncture  in  these  cases  usually  shows  an  excess  of  cerebro- 
spinal fluid  under  high  tension  and  it  may  contain  a  few  pneumococci. 
Occasionally  the  decubitus  en  chien  de  fusil,  or  gun-hammer  position,  is 
assumed.  These  are  often  described  as  cases  of  cerebral  pneumonia,  and 
in  many  of  them  pneumonia  is  not  suspected  until  the  fourth  or  fifth 
day  of  the  disease,  sometimes  not  until  the  crisis  occurs,  when  the  rapid 
disappearance  of  all  these  nervous  symptoms  indicates  their  origin. 
Early  convulsions  are  not  generally  followed  by  an  especially  severe  type 
of  the  disease,  only  one  of  seven  such  cases  proving  fatal.  On  the  other 
hand,  cases  with  late  convulsions  are  usually  fatal,  as  they  indicate  either 
a  very  severe  form  of  the  disease  or  the  development  of  a  serious  compli- 
cation^ usiially  meningitis. 

Belgium  is  much  more  frequent  than  convulsions,  and  is  seen  in 
nearly  one-fourth  of  the  cases.  Generally  it  is  slight  and  noticed  only 
at  night  or  when  the  temperature  is  very  high.  It  is  most  pronounced 
at  the  height  of  the  disease.  Other  nervous  symptoms  belonging  to  the 
typhoid  state  are  occasionally  seen,  but  only  in  the  worst  forms  of  the 
disease. 

I  have  been  unable  to  discover  any  relation  between  the  seat  of  the 
disease  in  the  lungs  and  the  occurrence  of  cerebral  symptoms.  They 
are  more  frequent  in  children  under  five  years  than  in  those  who 
are  older,  and  depend  upon  the  suddenness  of  the  invasion,  the  in- 
tensity of  the  infection,  and  the  susceptibility  of  the  child.     Late  in 


LOBAR  PNEUMONIA.  529 

the  disease  they  may  indicate  exliaustion,  toxaemia,  or  complicating 
meningitis.  The  usual  nervous  symptoms — restlessness,  headache,  sleep- 
lessness, etc. — are  nearly  always  proportionate  to  tiie  height  of  the 
temperature. 

Urine. — Throughout  the  febrile  period  of  the  disease  the  urine  is 
scanty,  high-coloured,  with  a  high  specific  gravity,  usually  loaded  with 
urates  and  with  marked  diminution  of  the  chlorides.  In  a  small  number 
of  cases  a  trace  of  albumin  may  be  found,  and  occasionally  a  few  hyaline 
casts.  Evidences  of  serious  renal  disease  I  have  seldom  found  in  lobar 
pneumonia,  and  in  the  experience  of  all  observers  it  is  extremely  rare  in 
early  life. 

Skin. — The  face,  in  pneumonia,  is  usually  flushed,  sometimes  on  both 
sides  and  sometimes  only  on  one;  in  other  cases  it  is  pale,  but  not  in- 
dicative of  pain.  Cyanosis  is  rare  except  toward  the  close  of  the  disease 
and  is  usually  a  sign  of  respiratory  failure.  Herpes  of  the  lips  or  face  is 
quite  frequent. 

Blood. — There  is  regularly  a  leucocytosis  of  from  20,000  to  50,000; 
the  increase  is  chiefly  in  the  polymorphonuclear  cells  which  usually  form 
from  seventy  to  eighty-five  per  cent  of  the  leucocytes.  (See  also  chapter 
on  Diseases  of  the  Blood.) 

Physical  Signs. — The  earliest  signs  in  pneumonia  are  due  to  the 
acute  congestion  of  the  affected  lung  or  lobe,  in  consequence  of  which 
less  air  enters  this  portion  and  more  air  the  rest  of  the  lungs.  Percus- 
sion gives  diminished  resonance  or  slight  dulness,  oftQn  of  a  somewhat 
tympanitic  character  over  the  affected  area,  and  exaggerated  resonance 
over  the  remainder  of  this  lung  and  over  the  opposite  lung.  Ausculta- 
tion over  the  affected  lobe  gives  feeble  respiratory  murmur,  rather  high 
in  pitch;  sometimes  there  may  be  absence  of  all  breath-sounds  so  com- 
plete as  to  suggest  fluid.  The  normal  respiratory  murmur  over  the 
healthy  portions  of  the  lungs  is  intensified.  In  children  this  exag- 
gerated breathing  is  not  infrequently  mistaken  for  Ijroncliial  breathing, 
and  the  physician  may  be  led  into  the  error  of  locating  the  pneumonia 
upon  the  wrong  side.  Exaggerated  breathing  does  not  differ  from  nor- 
mal breathing  except  in  intensity.  Bronchial  breathing  is  hi^ig:  in 
pitch,  tubular  in  character,  and  is  heard  with  nearly  equal  inW^^y, 
both  on  expiration  and  inspiration.  If  the  chest  is  frequently  a^^l- 
tated,  crepitant  or  fine  subcrepitant  rales  (Figs.  90  and  91)  may 
usually  be  heard  at  some  period  at  the  end  of  full  inspiration,  but 
often  they  are  present  but  for  a  few  hours,  and  they  may  be  missed 
altogether. 

In  the  second  stage,  that  of  consolidation  (Fig.  92),  no  air  enters 

the  air  vesicles  of  the  affected  portion  of  the  lung.    Upon  palpation  there 

is  found  here  exaggerated  vocal  fremitus,  and  on  percussion  there  is 

marked  dulness,  but  very  rarely  flatness.     Over  the  rest  of  this  lung 

85 


I 


FiQ.  90.  —  First  Stage.  Congestion  of  left 
lower  lobe,  with  crepitant  rdles.  Feeble 
breathing  of  a  rude  character,  with  slight 
dulness. 


Fig.  91.  —  In  the  centre  of  the  area,  a  small 
spot  of  pure  bronchial  breathing  and  voice; 
surrounding  this  an  occasional  crepitant  rale, 
with  broncho-vesicular  breathing  and  slight 
dulness. 


I 


Fig.  92WSecond  Stage.  Complete  consolidation  of  left  lower  lobe.  Pure  bronchial  breathing 
and  bronchial  voice;  marked  dulness;  increased  vocal  fremitus,  and  at  the  lower  part  a  few 
friction  sounds. 


Note. — During  resolution  the  signs  take  the  inverse  order:  those  of  Fig.  92  give  place  to 
those  of  Fig.  91,  and  these  in  turn  to  those  of  Fig.  90.     In  addition,  many  coarse  rales  may 


be  heard. 


530 


LOBAR   PNEUMONIA.  531 

there  is  exaggerated,  sometimes  even  tympanitic,  resonance ;  this  is  espe- 
cially frequent  at  the  apex  of  the  lung  in  front,  when  there  is  consolida- 
tion at  the  base  behind.  Under  these  conditions  cracked-pot  resonance 
may  sometimes  be  obtained.  Over  the  healthy  lung  there  is  exaggerated 
resonance.  On  auscultation  over  the  consolidated  portion  there  are  bron- 
chial breathing  and  bronchial  voice,  the  area  over  which  they  are  heard 
being  sharply  defined.  Rales  are  usually  al)sent,  but  there  may  be  pleu- 
ritic friction  sounds. 

In  the  stage  of  resolution  there  is  a  gradual  disappearance  of  the 
signs  of  consolidation.  The  pure  bronchial  is  replaced  by  broncho-vesic- 
ular breathing,  the  vesicular  element  gradually  predominating.  Moist 
rales  of  all  varieties  are  heard.  Usually  the  most  persistent  signs  are 
slight  dulness  or  diminished  resonance,  with  a  respiratory  murmur  which 
is  feebler  than  normal  and  a  little  higher  in  pitch;  sometimes  there  are 
also  dry  friction  sounds.  These  signs  may  persist  for  two  or  three 
weeks. 

Exceptional  Physical  Signs. — While  in  the  majority  of  cases  the  signs 
of  consolidation  are  distinct  on  or  before  the  fourth  day,  in  not  a  few 
they  may  be  delayed  much  longer.  Of  eighty-two  cases  in  which  the  day 
was  noted  on  which  consolidation  was  found,  it  was  not  until  the  fifth 
day  or  later  in  one-fourth  the  number.  In  six  of  them,  although  care- 
fully and  repeatedly  examined,  no  consolidation  was  found  until  the 
seventh  day  or  later  and  in  one  case  not  until  the  twelfth  day.  It  has 
been  customary  to  look  upon  these  cases  of  delayed  or  concealed  physical 
signs  as  cases  of  central  pneumonia.  That  pneumonia  may  exist  in  the 
centre  of  a  lung  for  a  number  of  days  is,  to  my  mind,  extremely  improb- 
able. At  autopsy,  superficial  pneumonia  I  have  very  frequently  seen, 
but  central  pneumonia  never.  There  are  two  regions  in  which  pneumonia 
may  exist  and  yet  not  be  accessible  by  our  means  of  physical  examination, 
viz.,  at  the  apex  of  the  lung  in  the  part  covered  by  the  shoulder,  and 
along  the  posterior  border  of  the  lung  where  it  lies  against  the  vertebrae. 
In  either  of  these  situations  pneumonia  may  be  present  without  our  being 
able  to  find  it.  It  is  quite  common  in  cases  with  late  physical  signs  that 
the  first  distinctive  evidences  of  disease  are  found  high  in  the  axilla,  or 
beneath  the  clavicle  in  front,  and  these  regions  should  be  closely  watched 
in  doubtful  cases.  Sometimes  the  delay  is  best  explained  by  assuming 
that  constitutional  symptoms  due  to  a  pneumococcus  infection  may  be 
present  for  several  days  before  the  development  of  the  local  lesion  in 
the  lung. 

Complications. — The  occurrence  of  dry  pleurisy  over  the  consolidated 
portion  of  the  lung  is  so  constant  that  it  can  hardly  be  considered  a  com- 
plication. A  slight  serous  exudation  of  two  or  three  ounces  is  not  un- 
common, but  more  than  this  is  rare  in  young  children.  In  the  most 
severe  cases  of  pleurisy  there  is  an  excessive  exudation  of  fibrin  and  pus. 


532  DISEASES   OF  THE  RESPIRATORY   SYSTEM. 

This  occurred  in  eight  per  cent  of  my  cases.  This  variety  is  known  clin- 
ically as  pleuro-pneumonia,  and  will  be  considered  separately.  Pericar- 
ditis is  uncommon.  It  is  seen  more  often  in  infants  than  in  older  eliil- 
dren.  It  most  frequently  develops  at  the  height  of  the  pneumonia  and 
occurs  rather  oftener  when  this  affects  the  left  lung  than  the  right ;  it 
occurs  in  pleuro-pneumonia  more  often  than  in  the  simple  form.  The 
pericarditis  is  usually  of  the  fibrino-purulent  type.  It  may  sometimes 
be  discovered  by  physical  signs;  but  rarely  gives  rise  to  any  new  symp- 
toms. Endocarditis  was  not  seen  in  my  cases,  though  it  occasionally 
occurs.  Meningitis  is  rare,  and  generally  develops  late  in  the  disease. 
It  is  nearly  always  ushered  in  by  repeated  attacks  of  vomiting  or  con- 
vulsions. Its  course  is  short  and  progressive.  Peritonitis  causes  few  new 
symptoms  except  abdominal  distention,  pain,  and  tenderness.  Parotitis 
and  arthritis  are  very  rare  and  are  easily  recognised. 

Course  and  Termination. — In  the  great  majority  of  cases  lobar  pneu- 
monia terminates  eitlier  in  perfect  recovery  or  in  death.  When  ending 
in  recovery,  resolution  commonly  begins  immediately  upon  the  cessation 
of  the  fever,  and  is  complete  in  about  a  week.  Delayed  resolution  is  not 
common  in  children;  chronic  pneumonia  and  tuberculosis  are  rare 
sequelae,  but  empyema  is  very  frequent.  Its  symptoms  sometimes  develop 
immediately  after  the  pneumonia,  tlie  temperature  continuing  high;  or 
there  may  be  an  interval  of  a  few  days  before  the  development  of  the 
pleural  symptoms.  Some  pleuritic  adhesions  probably  remain  in  every 
case  in  which  there  has  been  mucli  dry  pleurisy,  and  when  severe  and  ex- 
tensive, these  may  be  the  cause  of  subsequent  symptoms,  like  any  other 
dry  pleurisy. 

Death  from  uncomplicated  pneumonia  may  be  due  to  exhaustion,  or 
to  heart  failure,  with  or  without  failure  of  the  respiration.  The  signs  of 
heart  failure  sometimes  develop  quite  rapidly  in  cases  which  are  appar- 
ently doing  well.  The  symptoms  are :  coldness  of  the  hands  and  feet, 
then  of  the  legs  and  arms ;  a  rapid,  compressible,  and  sometimes  irregular 
pulse ;  muscular  weakness  and  pallor,  but  usually  no  cyanosis.  The  symp- 
toms of  respiratory  failure  are:  very  rapid  superficial  respirations,  some- 
times 100  a  minute;  blueness  of  the  lips  and  finger  nails;  often  a  leaden 
hue  of  the  whole  body ;  there  are  loud  tracheal  rales,  and  recession  of  all 
the  soft  parts  of  the  chest  on  inspiration. 

Death  may  occur  early  in  the  disease,  where  the  pneumonia  has 
spread  rapidly,  involving  both  lungs.  In  most  of  the  uncomplicated 
fatal  cases,  deatli  results  from  failure  of  the  circulation  at  about  the  end 
of  the  first  week.  In  the  complicated  cases  death  usually  occurs  in  the 
second  week;  but  I  once  knew  fatal  meningitis  to  develop  at  the  end  of 
the  four  til  week. 

Diagnosis. — The  most  characteristic  differences  between  broncho-  and 
lobar  pneumonia  are  shown  in  the  following  table : 


LOBAR  PNEUMONIA. 


533 


BBONCHO-PNEUMONIA . 

1.  Often  secondary. 

2.  Under  two,  cmefly  under  one  year. 

3.  Occurs  more  frequently  in  delicate 
and  debilitated  children. 

4.  Bacteria — in  primary  cases,  usu- 
ally the  pneumococcus;  in  secondary 
cases,  usually  mixed  infection. 

5.  Products  of  inflammation  chiefly 
cellular;  process  often  diffuse. 

6.  Onset  often  gradual,  sometimes  in- 
sidious, especially  when  secondary. 

7.  No  typical  course;  fever  often  lasts 
three  or  four  weeks;  rarely  terminates  by 
crisis. 

8.  Involves  both  lungs  as  a  rule,  most 
frequently  lower  lobes  posteriorly. 

9.  Signs  of  bronchitis  mingled  with 
those  of  consolidation;  rales  in  other 
parts  of  the  same  lung,  or  in  the  opposite 
lung,  throughout  the  disease. 

10.  Consolidation  later — fourth  to 
seventh  day:  there  may  be  none;  apt  to 
be  incomplete;  shades  off  gradually. 

11.  Resolution  slow,  one  week  to  two 
months;  often  incomplete;  strong  tend- 
ency to  become  chronic. 

12.  Relapses  and  second  attacks  fre- 
quent. 

13.  Sequelae:  Empyema,  chronic  in- 
terstitial pneumonia,  sometimes  tuber- 
culosis. 

14.  Prognosis  always  serious  from  the 
age  and  the  circimistances  under  which 
disease  occurs. 

15.  Hospital  mortality  50  per  cent  of 
primary  cases,  65  per  cent  of  all  cases. 


LOBAR   PNEUMONIA. 

1.  Almost  always  primary. 

2.  Most  common  between  three  and 
eight  years. 

3.  More  often  in  those  previously 
healthy. 

4.  The  pneumococcus,  very  often 
alone. 

5.  Chiefly  fibrin;  process  circum- 
scribed. 

6.  Onset  sudden,  with  well-marked 
symptoms. 

7.  Typical  course;  crisis  usually  from 
fifth  to  eighth  day. 

8.  Usually  one  lobe  or  a  part  of  a  lobe; 
left  base  most  frequently',  right  apex  next. 

9.  Rale.s  only  early,  and  during  reso- 
lution; frequently  no  signs  in  opposite 
lung. 

10.  Consolidation  earlier;  second  or 
third  day.  Consolidation  complete;  area 
usually  sharply  defined. 

11.  Resolution  rapid,  usually  com- 
plete within  a  week. 

12.  Both  are  rare. 

13.  No  sequelae  except  empyema. 


14.  Prognosis  good;  rarely  fatal  ex- 
cept from  complications  —  empyema, 
meningitis,  pericarditis. 

15.  Mortality  4  per  cent  of  all  cases. 


In  the  majority  of  cases  tlie  symptoms  are  plain  and  the  physical 
signs  so  typical  that  it  is  difficult  to  overlook  pneumonia  if  any  degree 
of  care  is  used  in  the  examination  of  the  patient.  The  difficulties  in  diag- 
nosis are  due  to  the  great  variation  in  the  general  symptoms,  and  to  the 
late  appearance  of  the  physical  signs.  The  error  usually  made  is  to  mis- 
take pneumonia  for  some  other  disease,  rather  than  to  mistake  some 
other  disease  for  pneumonia.  On  account  of  its  frequency  in  children, 
pneumonia  should  always  be  excluded  before  accepting  any  other  ex- 
planation of  a  continuously  high  temperature.  The  rule  should  be  fol- 
lowed, in  all  cases  of  acute  illness,  of  making  a  thorough  examination  of 
the  chest  daily  until  the  diagnosis  is  clear.     If,  to  high  temperature. 


534  DISEASES  or  THE  RESPIRATORY  SYSTEM. 

rapid  respiration  and  marked  leucocytosis  are  added,  one  should  always 
suspect  pneumonia,  no  matter  what  the  other  symptoms  may  be.  It 
not  infrequently  happens  that  the  general  symptoms  are  quite  charac- 
teristic and  yet  the  physical  signs  appear  late.  In  such  cases  pneumonia 
should  always  be  looked  for  high  in  the  axilla  or  just  beneath  the  clavi- 
cle, since  it  is  particularly  in  the  cases  of  apex  pneumonia  that  this 
obscurity  is  likely  to  exist. 

In  their  onset,  scarlet  fever,  tonsillitis,  and  gastro-enteritis  may  all 
resemble  pneumonia.  Scarlet  fever  is  recognised  by  the  sore  throat  and 
the  characteristic  eruption  on  the  second  day;  tonsillitis,  by  the  local 
symptoms.  In  infancy,  pneumonia  often  begins  with  vomiting  and 
sometimes  there  is  also  diarrhoea,  which  may  lead  one  to  mistake  the 
disease  for  gastro-enteritis.  The  constitutional  symptoms  of  influenza 
often  closely  resemble  those  of  pneumonia ;  the  diagnosis  is  frequently 
in  doubt  for  several  days  until  definite  physical  signs  of  pneumonia 
make  their  appearance.  From  all  other  general  diseases,  pneumonia  is 
to  be  differentiated  by  the  physical  signs. 

Pneumonia  with  marked  cerebral  symptoms  sometimes  resembles 
cerebro-spinal  meningitis.  In  both  we  may  have  the  abrupt  onset,  con- 
vulsions, delirium  or  stupor,  opisthotonus,  prostration,  and  marked  leu- 
cocytosis. The  only  positive  means  of  differential  diagnosis  are  by  the 
physical  signs  in  pneumonia,  and  the  findings  of  lumbar  puncture  in 
cerebro-spinal  meningitis. 

The  question  sometimes  arises  in  pneumonia  with  cerebral  symptoms, 
whether  or  not  pneumococcus  meningitis  also  exists.  If  the  nervous 
symptoms  are  present  from  the  beginning,  there  is  probably  no  menin- 
gitis. If  they  develop  suddenly  during  the  course  or  toward  the  close 
of  the  disease,  meningitis  should  be  suspected.  The  only  positive  means 
of  differentiation  is  by  lumbar  puncture. 

Lobar  pneumonia  is  to  be  differentiated  from  a  pleuritic  effusion. 
The  most  common  mistake  is  to  confound  empyema  with  unresolved 
pneumonia.  In  pneumonia  rarely  if  ever  do  the  signs  point  to  involve- 
ment of  an  entire  lung.  There  is  increased  vocal  fremitus,  dulness, 
bronchial  voice  and  breathing,  and  occasional  rales  or  friction  sounds. 
In  empyema  the  whole  lung  is  often  affected,  there  is  displacement  of 
the  heart,  flatness  on  percussion,  diminished  or  absent  vocal  fremitus, 
and  although  bronchial  voice  and  breathing  are  present,  they  are  usually 
distant  and  feeble.  There  are  no  rales  or  friction  sounds.  In  doubtful 
cases  an  exploratory  puncture  should  always  be  made.  Serous  effusions 
give  the  same  physical  signs  as  empyema. 

Prognosis. — There  is  probably  no  disease  in  which  the  patient  ap- 
pears so  ill,  and  yet  so  often  recovers  completely,  as  in  lobar  pneumonia 
in  a  child  over  three  years  old.  Of  1,295  collected  cases,  chiefly  from 
hospital  practice,  there  were  but  39  deaths,  a  mortality  of  three  per  cent. 


LOBAR  PNEUMONIA.  535 

In  187  cases  of  my  own  there  were  21  deaths,  a  mortality  of  eleven  per 
cent.  Only  one  of  the  fatal  cases  was  over  two  years  old.  The  differ- 
ence between  the  mortality  among  my  cases  and  the  general  mortality 
given,  is  due  to  the  fact  that  a  large  proportion  of  the  first  group  were 
observed  in  children  under  two  years,  while  of  the  collected  cases,  the 
vast  majority  were  in  older  children.  Combining  the  above  figures,  we 
have  a  total  of  1,482  cases  with  60  deaths,  a  mortality  of  four  per  cent. 
In  nearly  all  my  cases  death  was  due  either  to  complications  or  to  very 
extensive  disease,  as  when  both  lungs  were  involved,  or  nearly  the  whole 
of  one  lung.  In  only  one  case  was  an  uncomplicated  pneumonia  of  a 
single  lobe  fatal. 

The  prognosis  depends  upon  the  age  of  the  patient,  the  intensity  of 
the  infection,  as  shown  by  the  temperature,  the  nervous  symptoms  and 
the  pulse,  the  presence  or  absence  of  complications,  and  the  extent  of  the 
local  disease.  These  factors  are  to  be  taken  into  consideration  rather 
than  any  special  symptoms.  Early  convulsions  do  not  materially  affect 
the  prognosis.    Late  convulsions  are  always  very  unfavourable. 

The  occurrence  of  vomiting,  diarrhoea,  or  marked  tympanites  late,  in 
the  disease  is  always  unfavourable. 

A  temperature  range  between  102°  and  105°  F.  is  the  rule,  and 
within  these  limits  the  fever  does  not  affect  the  prognosis.  Even  very 
high  temperature  does  not  increase  the  danger  from  the  disease  as  much 
as  might  be  expected.  Of  fifteen  cases  in  which  the  temperature  reached 
106°  F.  or  over,  all  but  three  recovered ;  while  of  six  cases  in  which  it 
was  106.5°  or  over,  only  one  died.  The  highest  recorded  temperature  in 
my  cases — 107.5°  F. — was  in  a  patient  who  recovered.  A  transient  rise, 
even  though  the  temperature  may  go  very  high,  is  seldom  serious. 
Much  more  serious  is  a  fever  which  remains  steadily  above  105°  F.,  as 
in  most  cases  this  accompanies  either  very  extensive  disease  or  pleuro- 
pneumonia. The  continuance  of  the  fever  after  the  tenth  day  is  a  bad 
symptom;  for,  although  the  crisis  may  be  postponed  until  the  twelfth 
day  and  occur  normally,  such  a  prolonged  temperature  is  an  indication 
of  a  new  focus  of  disease  or  the  development  of  complications.  In  a 
severe  attack,  the  extension  of  the  disease  to  another  lobe  after  the  fifth 
day  is  unfavourable.  If  resolution  does  not  begin  soon  after  the  tem- 
perature becomes  normal,  the  development  of  empyema,  or  some  other 
pulmonary  complication,  should  be  apprehended. 

Treatment. — In  the  treatment  of  lobar  pneumonia  in  children,  sev- 
eral cardinal  facts  are  to  be  kept  in  mind.  It  is  a  self-limited  disease, 
having  a  strong  tendency  to  recovery  in  the  great  majority  of  cases  re- 
gardless of  the  treatment  adopted.  The  fatal  cases  are  almost  always  in 
children  under  two  years  of  age ;  the  rare  deaths  in  older  ones  are  usu- 
ally due  to  complications.  There  is  no  means  of  treatment  by  which 
pneumonia  can  be  aborted  or  its  course  shortened.    It  follows,  therefore. 


536  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

that  the  indications  are,  so  far  as  possible,  to  make  the  patient  comfort- 
able during  his  illness,  to  watch  for  complications,  and  to  treat  the  in- 
dividual symptoms  as  they  arise. 

In  the  majority  of  cases,  hygienic  treatment  is  all  that  is  required. 
The  patient  should  be  kept  in  bed,  no  matter  how  mild  the  attack;  he 
should  be  disturbed  as  little  as  possible.  Most  children  with  pneumonia 
get  too  much  treatment.  There  seems  to  be  a  decided  advantage  not 
only  in  fresh  air,  but  in  cold  air.  Patients  in  cold  rooms  sleep  better, 
and  cough  less,  and  altogether  seem  more  comfortable  than  when  care- 
fully housed  to  prevent  their  "  taking  cold."  Wide-open  windows  are 
desirable  even  though  the  room  temperature  is  constantly  as  low  as  50° 
F.  The  patient  should  be  properly  protected  by  blankets,  flannel  wrap- 
pers, woolen  stockings,  and  at  times  a  hot-water  bag  at  his  feet.  Food 
should  be  given  at  regular  intervals,  not  oftener  than  every  tliree  hours. 
It  should  not  be  forced  when  the  patient  is  suffering  only  from  thirst, 
especially  early  in  the  attack,  when  the  appetite  is  often  completely  lost. 
Water  should  be  allowed  freely  at  all  times. 

These  measures,  careful  nursing,  an  occasional  dose  of  codeine  (gr. 
iV  to  a  child  of  three  years)  when  the  patient  is  very  restless,  fretful,  or 
sleepless,  an  ice-cap  to  the  head,  and  cold  sponging  when  the  tempera- 
ture makes  him  uncomfortable,  are  usually  all  that  is  necessary,  except 
to  keep  a  sharp  lookout  for  complications. 

Special  symptoms  may  require  treatment.  When  not  severe,  the 
nervous  symptoms  may  be  controlled  by  codeine  alone  or  in  combination 
with  small  doses  of  phenacetine  or  the  bromides.  Sometimes  sponging 
with  tepid  water  is  better  than  drugs.  Severe  nervous  symptoms,  such 
as  delirium,  stupor,  great  restlessness  with  impending  convulsions,  when 
associated  with  high  temperature,  call  for  ice  to  the  head,  cold  sponging, 
or  the  cold  pack  or  bath.  Pain,  if  moderate,  may  be  relieved  by  counter- 
irritation,  by  a  mustard  paste,  by  dry  cups,  an  ice-bag,  or  by  a  hot  poul- 
tice; if  severe,  codeine  may  be  used  in  addition.  The  cough  is  rarely 
severe  enough  to  require  treatment.  When  it  is  so  severe  as  to  prevent 
sleep,  small  doses  of  Dover's  powder  or  codeine  should  be  given.  Anti- 
pyretic measures  are  not  necessarily  called  for  even  if  the  temperature 
is  very  high.  Some  nervous  children  are  less  disturbed  by  the  tempera- 
ture than  by  the  means  used  to  reduce  it.  Under  such  conditions  the 
temperature  should  be  closely  watched,  but  not  necessarily  interfered 
with  unless  other  symptoms  develop.  The  nervous  symptoms  are  a  bet- 
ter guide  than  the  thermometer  to  the  use  of  antipyretics.  Cold  I  be- 
lieve to  be  the  safest  and  most  certain  antipyretic  we  possess.  It  may 
be  used  as  a  cold  sponge  bath,  the  cold  pack  or  an  ice-bag  to  the  chest. 
There  is  no  objection  to  the  bath  except  the  prejudice  of  the  laity. 
While  cold  is  applied  to  the  trunk  the  extremities  should  be  closely 
watched,  and  heat  applied  if  necessary.     The  duration. of  the  pack  or 


PLEURO-PNEUMONIA.  537 

bath,  and  the  frequency  of  their  use,  will  depend  upon  the  individual  case. 
In  the  majority  of  cases  stimulants  are  not  required.  They  are  called 
for  when  the  pulse  is  weak,  compressible,  and  rapid,  when  the  face  is 
pale  and  the  extremities  are  cold.  The  same  stimulants  are  to  be  em- 
ployed, and  in  the  same  way,  as  in  broncho-pneumonia.  Circulatory  and 
respiratory  stimulants  are  usually  required  in  larger  quantity  at  the 
time  of  and  just  after  the  crisis;  they  are  to  be  used  as  in  broncho- 
pneumonia. 

PLEURO-PNEUMONIA. 

Under  this  term  are  included  cases  of  pneumonia  with  an  excessive 
amount  of  pleurisy,  the  two  processes  uniting  to  produce  a  single  clinical 
type  of  disease. 

In  nearly  all  cases  of  lobar  pneumonia  there  is  a  certain  amount  of 
inflammation  of  the  pulmonary  pleura,  and  also  in  those  cases  of  broncho- 
pneumonia which  are  accompanied  by  any  marked  degree  of  consolida- 
tion. In  both  of  these  conditions  the  pleurisy  is  usually  co-extensive  with 
the  consolidation.  But  in  certain  cases,  in  both  forms  of  pneumonia, 
the  amount  of  pleurisy  is  excessive,  and  this  so  modifies  the  symptoms 
and  course  of  the  disease  as  to  require  for  them  a  separate  consideration. 
In  some  it  appears  that  the  inflammatory  process  begins  almost  simul- 
taneously in  the  lung  and  in  the  pleura;  while  in  others  the  pleurisy 
follows  the  pneumonia.  These  cases  are,  I  believe,  almost  invariably 
due  to  the  pneumococcus,  although  in  some  there  is  a  mixed  infection. 

In  398  hospital  cases  of  pneumonia  there  were  27,  or  6.8  per  cent, 
which  could  be  classed  as  pleuro-pneumonia,  the  diagnosis  being  con- 
firmed either  by  autopsy  or  operation.  Of  190  fatal  cases,  13.5  per  cent 
were  cases  of  pleuro-pneumonia.  Most  of  these  hospital  patients  were 
under  three  years  of  age,  and  the  disease  is,  I  think,  more  frequent  at 
this  period  than  in  older  children. 

Lesions. — Of  these  27  cases,  17  were  classed  as  broncho-pneumonia 
and  10  as  lobar  pneumonia.  The  left  lung  was  more  frequently  aifected 
than  the  right  in  the  proportion  of  three  to  two.  In  most  of  the  cases 
the  pleura  covering  the  entire  lung  was  involved,  even  though  the  pneu- 
monia affected  but  a  single  lobe,  or  only  a  part  of  a  lobe.  In  nearly  half 
the  cases  both  lungs  were  involved,  but  one  to  a  very  much  less  extent 
than  the  other.  In  a  small  number  of  cases  the  pleurisy  was  limited  to 
the  posterior  surface  of  the  lung. 

In  pleuro-pneumonia  both  the  visceral  and  the  parietal  pleura  are 
coated  with  a  layer  of  yellowish-green  fibrin,  in  thick,  shaggy  masses, 
causing  adhesions  of  the  lung  to  the  chest  wall,  the  diaphragm,  and  the 
pericardium  (Plate  XII).  The  exudation  varies  between  one-eighth 
and  one-half  of  an  inch  in  thickness.  It  can  often  be  stripped  from  the 
lung  or  scraped  from  the  chest  wall  by  the  handful.    In  its  meshes  small 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

pockets  may  form,  which  contain  only  a  few  drops,  or  sometimes  a 
drachm,  of  pus,  or  less  frequently  serum.  This  is  the  condition  in  which 
the  lung  is  usually  found  where  death  has  occurred  at  the  height  of  the 
disease.  If  the  process  has  lasted  longer,  larger  collections  of  pus  may 
be  present.  The  lung  itself  shows  the  usual  changes  of  pneumonia,  and 
if  there  has  been  any  considerable  accumulation  of  fluid,  there  are  in 
addition  the  evidences  of  compression. 

With  pleuro-pneumonia  of  the  left  side,  the  pericardium  is  occasion- 
ally involved.  This  was  seen  in  two  of  my  cases,  the  lesions  closely 
resembling  those  of  the  pleura.  In  two  cases  there  was  also  meningitis, 
and  in  one  peritonitis,  the  exudation  in  all  cases  having  the  same  char- 
acteristics. 

An  inflammation  of  the  intensity  described  is  very  often  fatal  in  the 
acute  stage,  if  the  patient  is  a  child  under  two  years  old.  Occasionally 
at  this  age,  and  very  frequently  in  older  children,  we  see  the  later  stages 
of  the  process.  The  most  frequent  course  is  for  more  and  more  pus  to 
be  poured  out  from  the  inflamed  pleura  until  the  chest  is  filled,  the  case 
becoming  thus  one  of  empyema.  Sometimes  the  fluid  is  serous  instead 
of  purulent,  but  this  is  very  rare  in  infancy.  Under  other  circumstances 
the  exudation  is  partly  absorbed,  but  the  greater  part  becomes  organised 
so  as  to  form  a  thick  jacket  of  fibrous  tissue  which  binds  the  lobe  or  lung 
to  the .  chest  wall,  and  interferes  seriously  with  its  subsequent  full  ex- 
pansion.    Chronic  interstitial  pneumonia  may  follow. 

Symptoms. — There  is  little  which  distinguishes  a  case  of  pleuro-pneu- 
monia except  the  severity  of  all  the  constitutional  symptoms;  the  tem- 
perature is  often  higher,  the  prostration  greater,  and  the  patient  in  every 
way  impresses  one  as  being  more  seriously  ill  than  with  ordinary  pneu- 
monia. Sometimes  the  thoracic  pain  is  more  severe  and  more  constant 
than  is  usual  in  pneumonia.  The  diagnosis,  however,  is  to  be  made  by 
the  physical  signs. 

In  the  early  stage  the  pleuritic  friction  sounds  are  unusually  promi- 
nent; after  two  or  three  days  the  signs  of  consolidation  come  out  clearly 
in  most  cases,  but  still  accompanied  by  loud  friction  sounds.  After  the 
fibrinous  exudation  is  very  abundant,  the  signs  are  often  obscure  and 
confusing,  and  there  may  be  at  no  time  well-defined  signs  of  consolida- 
tion. There  is  usually  a  mingling  of  the  signs  of  consolidation  with  those 
of  effusion.  There  is  marked  dulness,  and  sometimes  flatness.  The 
vocal  fremitus  is  apt  to  be  diminished,  and  it  may  be  absent.  Bronchial 
voice  and  breathing  are  heard,  but  they  are  not  distinct  as  in  consolida- 
tion ;  they  are,  however,  feeble  and  distant,  as  over  fluid.  There  are 
usually  coarse,  moist,  crackling  pleuritic  sounds,  but  these  may  be  absent. 
The  signs  may  be  found  over  one  entire  lung,  or  they  may  be  limited  to 
the  posterior  region,  and  even  to  a  single  lobe.  They  resemble  those 
present  over  fluid,  with  one  exception — viz.,  the  heart  is  not  displaced. 


PLATE    XII. 


« 

o 

J=X! 

-tJ 

^ 

^ 

h 

'? 

_o 

tr 

*J 

3 

aj 

^H 


^.= 


'5  a 

7;    SI 

P  S 


C.2      -^ 

•r:    -      o 

*-  t:  «  to 

C  o  ^  ® 

*•-  «5 
c-2  >»  = 

»"  e8  a)  "S 

11-2 -I 

®  M  ° 

-c  <s  •-= 

fee's  g  " 
•2  S  83  a 
2'5  ®  2 


^1 


HYPOSTATIC  PNEUMONIA.  539 

If  an  exploratory  puncture  is  made,  nothing  is  found ;  occasionally  the 
exploring  needle  happens  to  strike  one  of  the  small  pockets  of  pus  in 
the  meshes  of  the  fibrin,  and  a  few  drops  of  pus  are  withdrawn.  If  an 
incision  is  made  under  the  supposition  that  the  case  is  one  of  empyema, 
no  more  pus  may  be  found,  the  surgeon  coming  upon  the  pulmonary 
adhesions  as  soon  as  the  chest  is  opened.  There  is  scarcely  any  condi- 
tion in  the  chest  giving  signs  more  puzzling  than  those  just  enumerated. 
They  are,  however,  easily  explained  by  the  pathological  conditions 
present. 

Prognosis. — The  prognosis  in  pleuro-pneumonia  is  much  worse  than 
in  simple  pneumonia.  In  infants  tlie  outlook  is  very  bad.  the  majority 
of  cases  dying  during  the  acute  stage.  Aery  young  children  may  be 
overwhelmed  with  the  extent  and  the  intensity  of  the  inflammation,  and 
die  in  four  or  five  days.  In  children  over  two  years  old  the  most  frequent 
result  is  for  the  case  to  go  on  to  empyema,  which  with  proper  treat- 
ment usually  terminates  in  recovery.  Where  there  is  organisation  of  the 
fibrin  with  the  production  of  extensive  adhesions,  the  ultimate  result  is 
often  not  so  favourable  as  when  empyema  develops.  Convalescence  is 
usually  slow,  and  the  patients  are  liable  to  exacerbations  of  pleurisy; 
they  may  suffer  for  years  from  the  partial  crippling  of  one  lung. 

Treatment. — Cases  of  pleuro-pneumonia  are  to  be  managed  like  the 
ordinary  cases  of  pneumonia  of  the  severe  type.  In  some,  the  excessive 
pain  may  call  for  more  active  counter-irritation  and  a  freer  use  of  opium 
than  in  other  forms  of  pneumonia,  and  the  greater  prostration  may  re- 
quire that  stimulants  be  given  earlier  and  in  larger  quantities. 

HYPOSTATIC  PNEUMONIA. 

This  can  not  often  be  recognised  clinically,  but  it  is  very  frequently 
seen  upon  the  post-mortem  table.  It  represents  an  inflammatory  process 
of  a  low  grade  and  is  seen  to  some  degree  in  almost  every  case  where  an 
infant  has  died  of  chronic  disease.  It  is  particularly  frequent  in  those 
who  have  died  of  marasmus.  It  invariably  occupies  a  strip  along  the 
posterior  border  of  both  lungs,  and  usually  of  both  the  upper  and 
lower  lobes.  This  is  from  one  to  two  inches  wide,  of  a  uniform  dark- 
red  colour,  and  is  sharply  outlined.  The  pleura  is  not  involved,  and 
the  remainder  of  the  lung  may  be  normal,  congested,  or  slightly 
emphysematous.  On  section,  it  is  seen  that  the  pneumonic  area  is 
quite  superficial,  rarely  involving  the  lung  to  a  greater  depth  than 
half  an  inch.  Under  the  microscope  there  is  found  a  distention  of  the 
small  blood-vessels  in  the  affected  area,  and  the  air  vesicles  are  filled 
with  many  red  blood  cells,  epithelial  cells,  and  a  few  leucocytes.  Be- 
tween the  areas  of  consolidation  are  groups  of  air  vesicles  which  are 
normal,  congested,  or  collapsed.     It  is  a  lobular  rather  than  a  broncho- 


540  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

pneumonia.  The  lesions  in  this  form  of  pneumpnia  are  probabl)'  the 
result  of  venous  stasis,  owing  to  the  child's  recumbent  position. 

At  autopsy  the  condition  may  be  confounded  with  atelectasis.  Lit- 
tle significance  is  to  be  attached  to  the  finding  of  hypostatic  pneumonia 
at  autopsy,  and  it  alone  should  never  be  regarded  as  a  sufficient  cause  of 
death,  although  it  is  perhaps  the  only  lesion  present.  During  life  it 
may  give  rise  to  fine  moist  rales,  which  are  heard  along  the  spine, 
usually  upon  both  sides;  but  there  is  neither  duluess  nor  bronchial 
breathing. 

The  treatment  is  that  of  the  primary  disease. 

CHRONIC  BRONCHO-PNEUMONIA— CHRONIC  INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS. 

Chronic  broncho-pneumonia  is  an  inflammation  of  the  connective- 
tissue  framework  of  the  lung,  involving  the  stroma,  the  alveolar  septa, 
the  walls  of  the  bronchi,  and  the  pleura.  It  is  usually  accompanied  by 
cylindrical  dilatation  of  the  bronchi — bronchiectasis. 

Etiology. — In  children,  as  in  adults,  this  process  is  most  frequently 
associated  with  pulmonary  tuberculosis;  but  in  early  life  it  is  not  an  in- 
frequent condition  apart  from  tuberculosis.  The  non-tuberculous  cases, 
as  a  rule,  are  preceded  by  an  attack  of  acute  broncho-pneumonia,  some- 
times by  several  such  attacks,  separated  by  longer  or  shorter  intervals. 

Lesions. — The  part  of  the  lung  affected  may  be  an  entire  lobe,  but 
usualh'  it  is  a  portion  of  one  lobe,  or  there  are  areas  in  more  than  one 
lobe.  There  are  dense  connective-tissue  adhesions  binding  the  diseased 
part  to  the  chest  wall,  to  the  diaphragm  and  to  the  pericardium,  often 
so  firmly  that  the  lung  is  torn  on  removal.  The  affected  lung  is  smaller 
than  in  health;  it  is  hard,  tough,  and  fibrous.  Surrounding  the  fibrous 
portions  are  emphysematous  areas.  On  section,  the  process  is  seen  to 
be  somewhat  irregularly  distributed  through  the  lung,  the  lesion  being 
usually  most  marked  in  the  vicinity  of  the  smaller  bronchi,  and  some- 
times seen  only  there,  the  intervening  lung  being  nearly  normal  (Plate 
XIII).  In  some  portions,  where  the  process  is  most  advanced,  almost 
all  trace  of  lung  tissue  may  have  disappeared,  the  part  resembling  a  solid 
fibrous  tumour,  through  which  run  the  bronchial  tubes,  usually  much 
dilated.  In  places  this  dilatation  may  be  sufficient  to  form  cavities  of 
considerable  size.  The  bronchial  glands  are  often  enlarged  to  the  size 
of  a  hazelnut,  and  they  may  be  tuberculous. 

Upon  examination  with  the  microscope,  the  pleura  is  found  greatly 
thickened,  with  bands  of  new  fibrous  tissue  passing  from  it  into  the  lung. 
The  walls  of  the  small  bronchi  are  in  most  places  thicker  than  normal, 
but  elsewhere  they  have  undergone  cylindrical  dilatation,  and  are  filled 
with  pus.     The  walls  of  the  alveoli  show  a  marked  proliferation  of  the 


PLATE    XIII. 


Chronic  Broncho-Pneumonia. 

In  the  greater  part  of  the  specimen  the  disease  is  limited  to  the  vicinity  of  the 
small  bronchi,  AAA,  each  of  which  is  surrounded  by  a  zone  of  new  connective 
tissue,  the  result  of  the  inflammatory  process,  the  intervening  lung  tissue,  B  B,  being 
normal.  In  the  lower  left-hand  portion,  the  disease  is  more  diffuse ;  the  air  vesicles, 
C,  between  the  areas  of  new  connective  tissue  are  greatly  compressed,  and  in  some 
places  entirely  obliterated,  (After  Delafield.) 


CHRONIC   BRONCHO-PNEUMONIA.  541 

connective-tissue  elements,  and  the  alveoli  are  filled  with  organised  in- 
flammatory products,  so  that  they  are  nearly  or  quite  obliterated.  The 
stroma  is  much  increased  in  amount  throughout  the  affected  lung. 

Symptoms. — In  most  of  the  cases  there  is  a  history  of  an  attack  of 
acute  broncho-pneumonia,  from  which  the  child  made  a  slow  convales- 
«ence,  remaining  pale,  anaemic,  and  sometimes  wasted  for  several  months. 
Improvement  then  took  place  in  the  general  symptoms,  the  appetite  and 
strength  returned,  and  in  many  cases  the  lost  weight  was  nearly  or  quite 
regained.  However,  neither  the  pulmonary  symptoms  nor  the  physical 
signs  entirely  disappeared.  There  remained  a  dry,  hard  cough,  which  at 
times  was  severe.  Pains  in  the  chest  were  occasionally  complained  of, 
and  perhaps  shortness  of  breath  on  exertion  was  noticed. 

Examination  shows  a  persistence  of  the  dulness  on  percussion,  with 
a  rude  or  broncho-vesicular  respiratory  murmur  of  very  feeble  intensity. 
Little  change  may  take  place  in  these  signs  for  months;  then  an  acute 
attack  of  bronchitis  or  broncho-pneumonia  may  occur.  If  the  latter,  the 
same  lung  is  affected,  and  a  fresh  consolidation  is  added  to  the  previous 
disease.  This  attack  may  not  be  very  severe,  but  it  drags  on  for  several 
weeks,  with  slight  fever  and  little  or  no  change  in  the  physical  signs. 
Partial  resolution  may  then  take  place,  but  the  lung  is  left  much  more 
seriously  crippled  than  before.  Often  there  is  a  history  of  several  such 
attacks,  each  one  leaving  the  lung  a  little  worse  than  it  found  it. 

The  characteristic  physical  signs  of  chronic  broncho-pneumonia  are 
not  usually  present  until  the  process  has  continued  for  many  months. 
They  may.l?e  found  over  part  of  a  lobe,  or  over  an  entire  lobe,  or  even  the 
greater  part  of  one  lung.  On  inspection,  there  may  be  seen,  in  a  well- 
marked  case,  retraction  of  the  chest,  which  is  especially  noticeable  when 
the  disease  is  situate^  at  the  apex  of  the  lung.  The  vocal  fremitus  is 
usually  increased,  but  it  may  not  be  abnormal.  There  is  marked  dulness, 
often  flatness,  over  the  affected  area,  with  exaggerated  resonance  over 
the  rest  of  the  lung.  The  area  of  flatness  shades  off  gradually.  The  most 
striking  thing  on  auscultation  is  the  very  feeble  respiratory  murmur;  in 
many  cases  the  lung  is  almost  silent.  More  rarely  there  is  marked  bron- 
chial voice  and  breathing.  Rales  and  friction  sounds  are  usually  absent 
except  during  an  acute  exacerbation  of  the  symptoms,  when  they  may 
be  heard  as  in  any  attack  of  broncho-pneumonia.  In  recent  cases  there 
is  no  displacement  of  the  heart;  in  those  of  long  standing  it  may  be 
drawn  far  to  the  affected  side  by  contraction  of  the  adhesions. 

When  the  lesions  are  once  present  complete  recovery  is  impossible, 
and  there  is  always  a  tendency  for  them  to  increase  rapidly  or  slowly, 
according  to  the  child's  vigour  of  constitution,  its  surroundings,  and  the 
frequency  with  which  exacerbations  occur.  If  the  disease  is  extensive 
the  patient  often  succumbs  to  some  intercurrent  disease  or  to  an  acute 
attack  of  pneumonia ;  if  limited  in  area,  the  process  may  be  arrested  and 


542  DISEASES  OF   THE   RESPIRATORY   SYSTEM. 

the  patient  recover,  always,  however,  to  be  more  or  less  embarrassed 
because  of  the  crippling  of  a  part  of  one  lung.  Not  a  small  number  of 
these  children  ultimately  die  of  tuberculosis,  and  in  such  cases  it  is  al- 
ways a  difficult  matter  to  decide  whether  tuberculosis  was  present  from 
the  beginning,  or  wliether  it  was  due  to  subsequent  infection. 

The  cases  in  which  bronchiectasis  is  the  most  important  condition 
are  not  common.  The  only  characteristic  additional  symptom  is  a 
copious  muco-purulent  expectoration,  which  is  usually  very  foetid.  It 
may  amount  to  several  ounces  a  day,  and  is  expelled  after  paroxysms  of 
coughing,  which  usually  occur  in  the  morning.  This  may  continue  for 
months,  or  even  years,  and  yet  these  patients  are  generally  without  fever, 
seldom  lose  weight,  and  may  have  the  appearance  of  being  in  very  good 
health.    It  is  rare  that  the  physical  signs  of  a  cavity  are  present. 

Prognosis. — This  depends  on  the  extent  of  the  disease,  the  patient's 
age  and  constitution,  and  on  our  ability  to  prevent  by  treatment,  climatic 
and  otherwise,  the  occurrence  of  acute  exacerbations.  Under  the  most 
favourable  conditions,  a  few  patients  may  recover  completely  so  far  as 
symptoms  are  concerned;  but  the  majority  remain  at  best  delicate  dur- 
ing childhood,  or  even  throughout  life. 

Diagnosis. — The  most  important  thing  is  to  distinguish  between  the 
simple  and  the  tuberculous  cases,  and  this,  by  symptoms  and  physical 
signs,  is  in  the  majority  impossible.  If  the  family  history  is  good,  if 
the  patient  lives  in  the  country,  if  his  symptoms  begin  with  a  well-de- 
fined acute  attack  of  pneumonia,  if  the  seat  of  disease  is  the  base  pos- 
teriorly, and  if  the  examination  of  the  sputum  is  negative,  the  process 
is  probably  simple.  If  the  family  history  is  doubtful  or  is  positively 
tuberculous,  if  the  patient  lives  in  the  city,  and  especially  if  he  is  an 
inmate  of  an  institution  or  if  his  home  is  among  the  tenements,  if  the 
initial  symptoms  are  indefinite,  if  the  disease  is  situated  anteriorly,  the 
process  is  probably  tuberculous.  The  cutaneous  tuberculin  test  aids 
much  in  diagnosis.  With  a  negative  reaction  tuberculosis  can  be  ex- 
cluded almost  with  certainty ;  but  a  positive  reaction  does  not  prove  that 
the  pulmonary  process  is  tuberculous,  although  it  is  strongly  suggestive. 
The  discovery  of  tubercle  bacilli  in  the  sputum  is,  of  course,  conclusive. 

Foreign  bodies  in  the  lung  may  give  symptoms  of  chronic  broncho- 
pneumonia ;  metallic  and  most  solid  substances  may  be  detected  by  the 
X-ray. 

Treatment. — Nothing  has  any  essential  influence  upon  the  disease 
except  change  of  climate.  This  should  be  the  same  as  for  tuberculous 
cases.  The  treatment  of  the  patient  has  for  its  object  the  maintenance 
of  the  general  nutrition  at  its  highest  point,  by  careful  feeding,  judicious 
exercise,  and  by  most  of  the  measures  enumerated  in  the  chapter  on  Mal- 
nutrition. Cod-liver  oil  should  be  given  throughout  every  winter  season. 
The  cough  may  be  treated  as  in  cases  of  chronic  bronchitis. 


ABSCESS  OF  THE   LUNG.  543 

Cases  of  bronchiectasis  may  obtain  considerable  relief  from  inhala- 
tions of  creosote.    They  should  not  be  operated  upon. 

ABSCESS  OF  THE  LUXG. 

Multiple  small  abscesses  are  not  uncommon  as  a  termination  of  acute 
broncho-pneumonia,  in  which  connection  they  have  already  been  consid- 
ered. Larger  non-tuberculous  abscesses  of  the  lung  are  rare,  very  obscure 
in  their  symptoms,  and  apt  to  be  mistaken  for  localised  empyema,  some- 
times for  interstitial  pneumonia  with  bronchiectasis.  Three  such  cases 
have  come  under  my  observation.^  One  was  discovered  at  autopsy,  the 
other  two  were  recognised  during  life  and  successfully  treated  by  opera- 
tion. Other  examples  in  young  children  have  been  reported  by  Huber 
and  by  Hedges.  The  cause  of  these  single  abscesses  is  usually  a  previous 
attack  of  acute  primary  pneumonia,  less  frequently  an  inflammation  ex- 
cited by  a  foreign  body  in  the  lung. 

An  abscess  due  to  a  foreign  body  is  usually  accompanied  by  wasting, 
and  a  widely  fluctuating  temperature  of  a  hectic  type — symptoms  sug- 
gestive of  a  rapidly  advancing  tuberculous  process.  If  the  abscess  fol- 
lows an  ordinary  pneumonia  the  course  is  generally  less  intense.  The 
constitutional  symptoms  differ  little  from  those  of  empyema.  There  is 
an  irregular  type  of  fever,  sometimes  quite  high,  but  more  often  only 
from  99°  to  101°  or  102°  F.,  a  moderate  cough,  not  much  wasting,  and 
generally  not  very  marked  prostration.  A  leucocytosis  of  30,000  to  50,- 
000  is  usually  present.  The  physical  signs  are  somewhat  confusing  and 
are  a  combination  of  those  present  in  effusion  and  consolidation.  There 
is  an  area  of  flatness  shading  off  into  dulness.  The  vocal  fremitus  may 
be  increased  or  it  may  be  diminished.  The  respiratory  murmur  is  very 
feeble  or  absent  over  the  abscess,  often  it  is  broncho-vesicular  in  charac- 
ter. Friction  sounds  and  rales  are  usually  present.  The  heart  is  slightly 
or  not  at  all  displaced.  If  an  exploratory  needle  is  introduced,  pus  may 
not  be  found  even  by  repeated  punctures;  or  it  may  be  obtained  at  one 
time  and  not  at  another,  although  introduced  in  the  same  intercostal 
space,  the  difference  in  result  being  due  to  the  direction  in  which  the 
needle  is  passed  into  the  lung.  When  pus  is  found,  the  diagnosis  of  a 
localised  empyema  is  generally  regarded  as  established,  and  it  is  not 
until  the  chest  is  opened  that  the  mistake  is  discovered.  The  operator 
then  comes  upon  the  lung,  which  may  or  may  not  be  adherent.  If  the 
abscess  follows  an  acute  pneumonia  the  pus  may  show  a  pure  culture  of 
the  pneumococcus.  If  it  is  due  to  a  foreign  body,  there  is  invariably 
a  mixed  infection,  and  the  pus  is  apt  to  be  foetid. 

When  not  treated  surgically,  abscess  of  the  lung  may  rupture  into 
the   pleural   cavity,   producing   a   secondary   empyema,   or   spontaneous 

1  Archives  of  Pa?diatrics,  January,  1904. 


544  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

evacuation  may  take  place  through  a  bronchus  and  recovery  follow. 
When  the  cause  is  a  foreign  body  rapid  recovery  often  follows  its  expul- 
sion by  coughing.  If  the  diagnosis  is  made  and  proper  surgical  treat- 
ment is  instituted,  recovery  occurs  in  probably  the  majority  of  cases. 

The  general  plan  of  treatment  should  be  the  same  as  in  empyema. 
In  a  small  proportion  of  cases  aspiration  may  suffice  for  a  cure.  How- 
ever, incision  is  usually  necessary.  If  the  pleura  is  not  adherent,  adhe- 
sions should  be  excited  by  packing  the  thoracic  wound  with  gauze,  and 
after  a  few  days  a  second  operation  may  be  done.  The  lung  should  be 
opened  with  a  blunt  instrument,  following  the  line  of  the  exploring 
needle,  and  a  drainage-tube  inserted  as  in  empyema,  the  subsequent  treat- 
ment being  the  same  as  for  that  disease. 

GANGRENE  OF  THE  LUNG. 

Pulmonary  gangrene  is  rare  in  children,  although  probably  more  com- 
mon than  in  adults.  It  is  most  frequently  associated  with  pneumonia. 
It  is  usually  circumscribed,  and  seldom  diagnosticated  during  life. 

Etiology. — All  my  cases  have  been  in  children  under  three  years  old, 
the  youngest  an  infant  of  four  months.  Gangrene  occurs  for  the  most 
part  in  children  who  are  ill-conditioned,  feeble,  or  cachectic,  and  often 
follows  one  of  the  infectious  diseases,  particularly  measles.  Of  nine 
cases  which  have  come  under  my  personal  observation,  six  complicated 
acute  broncho-pneumonia  and  one  lobar  pneumonia.  Pulmonary  gan- 
grene has  been  present  in  three  per  cent  of  my  autopsies  upon  cases  of 
pneumonia.  The  immediate  cause  of  the  necrotic  process  is  interference 
with  the  circulation  in  a  part  of  the  lung,  which  is  usually  due  to  throm- 
bosis or  embolism  of  some  of  the  branches  of  the  pulmonary  artery.  To 
this  there  is  added  the  entrance  of  putrefactive  bacteria.  In  some  eases 
pulmonary  gangrene  may  begin  as  a  septic  thrombosis,  this  infection 
originating  in  some  process  in  a  distant  part  of  the  body. 

Lesions. — The  lower  lobes  are  more  frequently  affected  than  the  up- 
per, and  the  surface  of  the  lung  rather  than  the  central  portions. 

Two  forms  of  gangrene  may  be  seen :  the  diffuse  form,  which  affects 
a  whole  lobe,  or  even  a  whole  lung;  and  the  circumscribed  form,  which 
occurs  in  a  number  of  small  scattered  areas.  The  latter  is  the  variety 
usually  seen  in  children.  In  the  diffuse  form  the  lung  is  of  a  dirty 
green  or  brown  colour,  moist,  and  emits  a  gangrenous  odour.  In  the 
circumscribed  form,  when  occurring  in  pneumonia,  the  parts  affected 
are  of  a  gray  or  green  colour,  usually  wedge-shaped,  with  the  base  at  the 
surface  of  the  lung.  In  the  early  stage  they  are  not  softened,  and  have 
no  gangrenous  odour;  later,  both  these  conditions  may  be  present,  and 
masses  of  necrotic  lung  tissue  may  be  found  in  a  cavity  with  ragged  walls, 
partly  filled  with  foetid  pus.     Careful  dissection  will  reveal,  in  many 


ACQUIRED  ATELECTASIS— PULMONARY  COLLAPSE.  545 

cases,  the  presence  of  thrombi  in  the  vessels  leading  to  the  gangrenous 
parts. 

Symptoms. — There  are  but  two  distinctive  symptoms  of  pulmonary 
gangrene :  the  gangrenous  odour  of  the  breath,  and  the  expectoration  of 
masses  of  necrotic  lung  tissue.  In  the  cases  associated  with  acute  pneu- 
monia, which  include  the  majority  of  those  seen,  death  nearly  always 
takes  place  before  there  is  any  separation  of  the  sloughs,  and  even  before 
very  active  decomposition  in  the  necrotic  areas  lias  occurred.  Both  the 
peculiar  symptoms  are  therefore  wanting,  and  the  diagnosis  is  made 
only  at  the  autopsy.  This  has  been  true  of  nearly  all  the  cases  which 
have  come  under  my  own  observation.  But  these  patients,  with  one  ex- 
ception, were  infants.  In  older  children,  particularly  in  cases  secondary 
to  the  entrance  of  a  foreign  body,  the  characteristic  symptoms  are  more 
frequently  seen,  and  there  may  be  a  third  symptom — haemorrhage.  This 
is  present  in  about  one-fourth  of  the  cases  (Rilliet  and  Barthez),  and 
may  be  fatal.  The  general  symptoms  associated  with  gangrene  are  those 
of  profound  asthenia,  resembling  the  typhoid  condition. 

From  what  has  been  said,  it  will  be  evident  that  the  diagnosis  is  very 
difficult.  If  the  characteristic  odour  of  the  breath  is  present,  conditions 
in  the  mouth  from  which  it  might  arise  must  be  excluded.  The  physical 
signs  differ  in  no  respect  from  those  of  ordinary  cases  of  pneumonia. 
The  termination  is  almost  always  in  death.  This  is  due  not  only  to  the 
condition  itself,  but  to  the  circumstances  in  which  it  is  seen. 

Treatment. — The  general  treatment  should  be  supporting  and  stimu- 
lating, as  in  all  severe  cases  of  pneumonia.  For  the  local  process  but 
little  can  be  done,  except  the  inhalation  of  antiseptics,  of  which  creosote 
and  turpentine  are  undoubtedly  the  best. 

ACQUIRED  ATELECTASIS— PULMONARY  COLLAPSE. 

These  terms  are  applied  to  a  state  of  the  lung  resembling  the  foetal 
condition,  but  occurring  in  a  lung  which  has  once  been  expanded.  It 
may  be  due  to  compression  or  to  obstruction. 

Collapse  from  Compression. — The  principal  cause  of  this  form  is  pleu- 
ritic effusion.  It  may  also  be  produced  by  pneumothorax,  enlargement 
of  the  heart,  pericardial  effusion,  deformities  of  the  chest  from  rickets 
or  Pott's  disease,  and  tumours  of  the  mediastinum  or  the  thoracic  wall. 
In  these  conditions,  on  account  of  the  external  pressure,  the  air  vesicles 
are  not  filled,  although  the  bronchi  are  pervious.  After  collapse  has 
existed  for  a  considerable  time,  changes  may  take  place  in  the  lung 
which  render  expansion  difficult  or  impossible.  Unless,  however,  there 
are  pleuritic  adhesions,  expansion  often  takes  place  readily  after  many 
weeks  and  even  months.  The  symptoms  and  signs  are  those  of  the  orig- 
inal disease. 
36 


546  DISE.\SES  OF  THE  RESPIRATORY  SYSTEM. 

Treatment  is  available  chiefly  in  that  form  which  follows  pleuritic 
effusion,  and  will  be  considered  in  the  chapter  on  Empyema. 

Collapse  from  Obstruction. — This  is  due  to  two  factors:  blocking  of 
either  the  large  or  small  bronchial  tubes,  and  feeble  inspiratory  force. 
The  importance  of  collapse  from  obstruction  in  the  acute  diseases  of 
the  lung  in  infancy  has,  I  think,  been  exaggerated.  Whenever  a  large 
or  small  bronchus  is  completely  obstructed  by  a  foreign  body,  the  portion 
of  the  lung  to  which  the  bronchus  is  distributed  gradually  becomes  col- 
lapsed. If  it  is  one  of  the  primary  bronchi  which  is  occluded,  a  whole 
lung  may  be  collapsed;  if  one  of  the  lobar  divisions,  an  entire  lobe;  if 
one  of  the  smaller  divisions,  only  a  small  area.  The  collapse  does  not 
take  place  immediately,  but  the  contents  of  the  air  vesicles  are  gradually 
absorbed  by  the  blood.  The  collapsed  portion  is  slightly  depressed  below 
the  surface  of  the  lung.  It  is  of  a  dark-red  colour,  very  vascular,  and 
to  the  naked  eye  resembles  a  pneumonic  area,  which  it  may  subsequently 
become. 

Many  writers  explain  the  development  of  broncho-pneumonia  from 
bronchitis  of  the  smaller  tubes,  through  the  intervention  of  pulmonary 
collapse,  assuming  that  the  obstruction  of  the  small  bronchi,  from  swelling 
of  their  walls  and  the  accumulation  of  secretion,  produces  the  same  re- 
sult as  the  plugging  of  a  bronchus  by  a  foreign  body.  In  my  own  autop- 
sies I  have  found  little  support  for  this  theory.  In  acute  bronchitis  of 
the  smaller  tubes  the  lumen  is  narrowed,  but  seldom  enough  to  prevent 
the  entrance  of  air.  The  result  is  usually  emphysema,  not  atelectasis. 
Such,  at  least,  has  been  the  condition  I  have  most  frequently  found  in 
autopsies  in  the  earliest  stage  of  broncho-pneumonia  following  bronchitis 
of  the  fine  tubes.  There  are  very  often  groups  of  collapsed  air  vesicles 
surrounding  pneumonic  areas,  but  these  are  neither  an  essential  nor  a 
very  important  part  of  the  lesion.  Collapse  of  a  large  part  of  the  lung, 
or  even  of  a  lobe,  I  have  never  seen,  either  in  pertussis  or  in  acute 
bronchitis. 

There  is  seen  in  delicate  or  rachitic  infants  a  form  of  collapse  which 
comes  on  very  gradually.  It  is  accompanied  by  bronchitis  affecting  the 
tubes  in  the  dependent  part  of  the  lung.  It  may  resemble  the  congenital 
form  of  atelectasis.  Under  the  microscope  there  is  almost  invariably 
found,  accompanying  the  collapse,  lobular  pneumonia  and  bronchitis  of 
the  tubes  in  the  affected  regions. 

The  symptoms  of  acquired  atelectasis  are  much  the  same  as  in  the 
persistent  congenital  form.  The  respiration  is  rapid,  and  there  may  be 
inspiratory  dyspnoea  with  deep  recession  of  the  chest  walls,  especially  if 
there  is  rickets.  There  is  also  cyanosis  of  variable  intensity.  The  tem- 
perature is  not  elevated,  but  frequently  is  subnormal.  The  physical  signs 
are  very  uncertain.  There  is  usually  feeble  respiratory  murmur  over  the 
affected  areas,  occasionally  accompanied  by  moist  rales.     The  essential 


EMPHYSEMA.  547 

point  of  difference  between  these  cases  and  those  of  congenital  atelectasis 
is  that  in  the  former  the  patients  are  often  strong  at  birth,  crying  and 
breathing  well,  giving  no  signs  of  anything  wrong  in  the  lungs  until  the 
general  nutrition  has  suffered  from  some  other  cause. 

The  following  is  a  fairly  typical  case:  A  female  infant  thirteen 
months  old  had  been  under  observation  for  several  months  before  death. 
During  this  period  she  suffered  a  great  part  of  the  time  from  mild  bron- 
chitis. The  chest  was  extremely  rachitic.  The  respiration  was  always 
accelerated,  and  on  inspiration  the  lateral  recession  of  the  chest  was  at 
times  extreme.  There  was  occasionally  seen  slight  cyanosis,  and  during 
the  last  few  weeks  it  was  constant.  Death  occurred  quite  suddenly.  At 
autopsy  there  was  found  very  marked  vesicular  emphysema  of  both  lungs 
in  front.  Nearly  the  whole  of  both  lower  lobes  were  in  a  condition  of 
collapse,  and  of  a  uniform  grayish-purple  colour.  The  posterior  portion 
of  the  upper  lobes  was  similarly  affected,  but  to  a  less  degree.  With 
moderate  force  all  of  the  collapsed  areas  could  be  completely  inflated. 
Bronchitis  was  present,  but  the  pleura  was  normal. 

The  treatment  of  these  cases  is  the  same  as  that  outlined  in  the 
chapter  upon  Congenital  Atelectasis. 

EMPHYSEMA. 

Pulmonary  emphysema  consists  primarily  in  overdistention  of  the  air 
vesicles.  It  may  result  in  their  rupture  and  the  escape  of  air  into  the 
interlobular  connective  tissue  of  the  lung.  In  infancy  and  childhood 
emphysema  is  usually  associated  with  acute  processes. 

Etiology. — Cases  of  emphysema  are  divided  into  two  groups  which  are 
due  to  quite  different  causes.  In  one  group  it  is  compensatory,  and  con- 
sists in  overdistention  of  the  air  vesicles  in  certain  parts  of  the  lungs 
because  the  full  expansion  of  other  parts  is  prevented  either  because  they 
are  consolidated,  as  in  pneumonia  or  tuberculosis,  bound  down  by  ad- 
hesions from  old  pleurisy,  or  subjected  to  external  pressure,  as  from  chest 
deformities  due  to  Pott's  disease  or  rickets.  In  these  conditions  it  is 
probable  that  the  emphysema  is  produced  during  inspiration.  It  may 
also  be  produced  by  the  artificial  inflation  of  the  lungs  of  the  newly  born. 

In  the  second  group  of  cases  emphysema  is  produced  by  obstructive 
expiratory  dyspnoea  or  cough.  It  is  seen  in  all  forms  of  laryngeal  stenosis, 
in  acute  bronchitis  and  broncho-pneumonia,  in  asthma,  pertussis,  and 
occasionally  it  is  produced  by  any  condition  which  requires  deep  inspira- 
tion and'holding  the  breath.  In  bronchitis  the  obstruction  may  be  caused 
by  a  swelling  of  the  mucous  membrane  or  by  an  accumulation  of  secretion. 
In  this  group  of  cases  air  enters  the  lung,  but  as  it  can  not  readily  escape, 
the  air  vesicles  are  distended,  sometimes  to  such  a  degree  that  their 
resiliency  is  almost  entirely  lost. 


648  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Lesions. — The  most  common  form  in  early  life  is  acute  vesicular 
emphysema,  which  occurs  when  the  force  distending  the  air  cells  is  only 
moderate.  In  this  form  there  is  dilatation  of  the  vesicles  with  very 
slight  structural  changes,  there  being  usually  rupture  of  a  few  alveolar 
septa  only  (Fig.  73).  Although  the  dilatation  may  be  quite  marked, 
the  emphysema  is  not  permanent.  The  parts  most  affected  are  the  upper 
lobes,  particularly  the  anterior  borders.  In  appearance  the  emphysema- 
tous lung  is  pale,  sometimes  almost  white.  The  areas  are  prominent,  and 
do  not  collapse  upon  opening  the  chest.  With  a  lens,  or  even  with  the 
naked  eye,  the  individual  air  vesicles  can  often  be  distinguished  as  minute 
pearly  bodies,  at  times  resembling  miliary  tubercles.  When  the  disease 
is  secondary  to  acute  bronchitis  or  larjTigeal  stenosis  it  may  affect  nearly 
the  whole  of  both  lungs. 

With  a  greater  distending  force  rupture  of  many  of  the  air  vesicles 
results,  and  this  may  give  rise  to  interstitial  or  interlobular  emphysema. 
At  times  blebs  are  formed,  varying  in  size  from  a  pin's  head  to  a  cherry 
or  even  larger.  These  are  usually  seen  at  the  anterior  border  or  at  the 
root  of  the  lung  on  its  inner  surface.  Again,  the  air  finds  its  way  between 
the  lobules,  dissecting  them  apart  in  all  directions  throughout  the  lung. 
Sometimes  a  large  part  of  the  surface  of  both  lungs  is  seamed  with  ir- 
regular deep  crevasses  containing  air,  the  largest  being  an  inch  or  more 
in  length  and  nearly  one-fourth  of  an  inch  wide.  The  most  severe  cases 
occur  in  pertussis.  On  two  or  three  occasions  I  have  seen  this  form  of 
emphysema,  once  to  an  extreme  degree,  where  children  had  died  from 
diseases  unconnected  with  the  respiratory  tract,  and  where  no  history 
could  be  obtained  which  threw  any  light  upon  the  etiology  of  the  em- 
physema. Eupture  of  the  blebs  which  form  at  the  root  of  the  lung  may 
lead  to  emphysema  of  the  mediastinum,  or  even  of  the  subcutaneous  con- 
nective tissue  of  the  body.  This  is  occasionally  seen  in  whooping-cough 
and  in  laryngeal  stenosis.  The  primary  or  substantive  form  of  em- 
physema seen  in  adult  life  rarely  if  ever  occurs  in  childhood. 

Symptoms. — Emphysema  occurring  in  acute  pulmonary  diseases  gives 
rise  to  no  peculiar  symptoms  and  to  no  physical  signs  except  exaggerated 
resonance  upon  percussion.  This  masks  dulness  from  consolidation  and 
also  that  from  the  liver  and  spleen.  If  the  patients  recover  from  the 
original  disease,  the  emphysema  greatly  diminishes  or  disappears  com- 
pletely in  the  course  of  a  few  weeks  or  months.  Acute  interlobular 
emphysema  can  not  be  diagnosticated  during  life,  unless,  as  is  sometimes 
the  case,  general  subcutaneous  emphysema  is  seen,  which  may  come  on 
quickly,  last  for  several  hours  or  days  and  then  gradually  disappear. 

The  treatment  of  emphysema  is  that  of  the  disease  with  which  it  is 
associated. 


DRY  PLEURISY.  549 

CHAPTER    VI. 
PLEURISY. 

All  the  common  forms  of  inflammation  of  the  pleura  are  seen  in 
childhood.  In  the  great  majority  of  cases  they  are  secondary  to  disease 
of  the  lung  itself.  Serous  effusions  are  much  less  frequent  than  in  adults, 
and  under  three  years  they  are  rare.  Purulent  effusion  (empyema)  is, 
however,  much  more  often  seen  than  in  adult  life,  and  it  is  the  most 
important  variety  of  pleurisy  with  which  the  physician  has  to  deal. 

Whether  inflammation  of  the  pleura  ever  occurs  as  a  strictly  primary 
disease  is  still  a  mooted  point.  Cases  are  occasionally  observed  clinically 
in  which  both  the  serous  and  purulent  forms  of  the  disease  appear  to  be 
primary,  but  these  are  extremely  rare.  Acute  pleurisy  may,  however, 
follow  inflammation  of  the  lung  so  rapidly  that  it  is  not  easy  to  de- 
termine that  the  lung  was  first  affected.  In  infants,  extension  from  the 
lung  is  almost  the  sole  cause.  It  occurs  both  with  lobar  and  broncho- 
pneumonia, existing  to  some  degree  in  nearly  every  case  in  which  there 
is  consolidation  of  the  lung.  Next  in  frequency  to  simple  pneumonia  as 
a  cause  of  pleurisy  are  the  tuberculous  processes  of  the  lung.  Tuber- 
culous pleurisy  without  tuberculosis  of  the  lungs  or  the  bronchial  glands 
is  of  doubtful  occurrence.  Acute  pleurisy  is  not  an  infrequent  complica- 
tion of  the  infectious  diseases,  particularly  scarlet  and  typhoid  fevers, 
measles,  and  influenza.  In  most  of  these  cases  also  it  is  secondary  to 
disease  of  the  lung.  Pleurisy  in  older  children  occasionally  follows 
cold  and  exposure,  although  it  is  doubtful  whether  in  any  case  this 
is  the  only  cause.  In  them  also  it  may  occur  as  a  complication  of  rheu- 
matism. 

The  most  important  cause  of  acute  pleurisy  being  extension  from 
pneumonia,  it  follows  that  it  is  most  frequent  in  the  cold  season,  that  it 
occurs  more  often  in  males  than  in  females,  and  between  the  ages  of  one 
and  five  years.  It  may,  however,  be  seen  at  all  ages,  and  may  even  occur 
in  intra-uterine  life.  The  youngest  case  in  which  I  have  found  ex- 
tensive pleuritic  adhesions  as  an  evidence  of  previous  inflammation  was 
in  an  infant  of  three  months.  In  this  case  firm  connective  tissue  ad- 
hesions were  found  over  the  whole  of  both  lungs. 

DRY  PLEURISY. 

In  infants  and  young  children  this  usually  accompanies  pneumonia  or 
tuberculous  processes  in  the  lung.    In  older  children  it  may  be  primary. 

Lesions.— On  account  of  the  frequency  with  which  this  occurs  in 
pneumonia  we  have  an  opportunity  of  observing  it  in  all  stages.  In  the 
mildest  varieties  it  affects  only  the  pulmonary  pleura,  and  occurs  over  the 


550  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

pneumonic  areas.  The  pleura  is  injected,  has  lost  its  lustre,  and  appears 
dull  or  roughened.  This  is  due  to  an  exudation  of  fibrin  upon  its  sur- 
face. If  the  process  continues,  more  fibrin  is  poured  out,  and  there  are 
in  addition  swelling  and  a  proliferation  of  the  connective-tissue  cells,  and 
an  exudation  of  leucocytes  from  the  blood-vessels.  The  pleura  is  then 
coated  with  a  layer  of  fibrin  of  variable  thickness,  in  which  are  entangled 
pus  cells  and  new  connective-tissue  cells.  The  layer  of  fibrin  varies  from 
the  thickness  of  tissue  paper  to  that  of  an  ordinary  book  cover.  In  re- 
cent cases  it  may  easily  be  stripped  off,  while  in  older  ones  it  becomes 
organised  and  is  firmly  adherent.  The  colour  of  the  exudate  varies  with 
the  number  of  pus  cells.  It  is  gray,  grayish-yellow,  or  yellowish-green, 
according  as  these  cells  are  few  or  numerous.  As  a  rule,  dry  pleurisy 
is  localised,  but  the  two  opposing  surfaces  are  affected.  Part  of  the 
exudate  is  usually  absorbed,  but  it  is  doubtful  if  complete  recovery  oc- 
curs, there  being  left  behind  some  adhesions  between  the  visceral  and 
parietal  layers. 

In  the  dry  form  of  tuberculous  pleurisy  there  may  be  only  an  ex- 
udation of  fibrin,  or  the  pleura  may  be  covered  with  gray  tubercles  and 
yellow  tuberculous  nodules.  These  are  not  only  seen  upon  the  pleura, 
but  develop  in  the  exudation.  In  this  form,  which  is  usually  chronic, 
great  thickening  of  the  pleura  may  take  place.  Both  the  serous  and 
purulent  effusions  occurring  in  conjunction  with  tuberculosis  are  likely 
to  be  sacculated  because  of  the  previous  existence  of  adhesions. 

After  nearly  every  case  of  dry  pleurisy  there  probably  remains  some 
slight  thickening  of  the  pleura.  In  certain  cases  there  follows  a  chronic 
inflammation  of  the  pleura  with  the  production  of  new  connective  tissue, 
which  results  in  thickening  and  adhesions,  which  may  be  so  extensive  as 
to  entirely  obliterate  the  pleural  cavity.  Either  one  or  both  sides  may 
be  affected.  It  is  usually  accompanied  by  external  pericarditis.  This 
form  is  extremely  rare  in  childhood. 

Symptoms. — As  an  independent  clinical  disease,  acute  dry  pleurisy 
has  no  existence  in  infancy  or  early  childhood.  The  cases  which  are  occa- 
sionally so  diagnosticated  have  in  my  experience  invariably  proven  to  be 
broncho-pneumonia.  In  children  from  ten  to  fourteen  years  old,  dry 
pleurisy  may  occur  under  the  same  conditions  as  in  adults. 

The  symptoms  are  sharp,  localised  pain,  increased  by  full  inspiration, 
sometimes  tenderness  upon  pressure,  and  a  short,  teasing  cough.  The 
pain  is  not  always  felt  upon  the  affected  side,  and  it  may  be  referred  to 
the  abdomen.  Upon  physical  examination,  dry  pleurisy  is  recognised 
by  the  presence  of  a  pleuritic  friction  sound.  This  is  usually  of  a  moist, 
crackling  character,  generally  localised,  and  heard  both  on  inspiration 
and  expiration.  It  is  quite  superficial,  and  not  changed  by  coughing. 
This  form  of  pleurisy,  as  a  rule,  runs  a  course  of  a  few  days  or  a  week, 
without  constitutional  symptoms.    When  dry  pleurisy  occurs  as  a  com- 


PLEURISY  WITH   SEROITg  EFFUSION.  551 

plication  of  pneumonia  it  is  recognised  by  the  signs  just  mentioned ;  but 
it  usually  causes  no  new  symptoms  except  pain. 

Treatment. — The  treatment  consists  in  counter-irritation  by  mustard, 
iodine,  or  blisters,  according  to  the  severity  of  the  inflammation,  and  in 
the  use  of  opium.  Severe  pain  can  sometimes  be  relieved  by  firmly  en- 
circling the  chest  with  a  broad  band  of  adhesive  plaster. 

PLEURISY  WITH  SEROUS  EFFUSION! 

This  form  of  pleurisy  is  not  common  in  young  children,  and  in  in- 
fants it  is  rare.  It  usually  occurs  as  a  complication  of  pneumonia,  but 
may  be  seen  in  nephritis,  acute  rheumatism,  scarlet  fever,  or  any  of  the 
other  acute  infectious  diseases.  It  may  be  tuberculous.  In  rare  cases  it 
appears  to  be  primary.  Bacteria  are  occasionally  present  in  the  exuda- 
tion, even  in  cases  which  do  not  become  purulent,  but  their  number  is 
usually  small.  The  pneumococcus,  the  streptococcus,  and  the  tubercle 
bacillus  are  the  forms  most  often  seen. 

Lesions. — The  early  changes  are  much  the  same  as  in  dry  pleurisy, 
but  in  addition  serum  is  poured  out  from  the  blood-vessels,  in  some  cases 
almost  from  the  beginning  of  the  inflammation.  This  may  be  small  in 
amount,  or  it  may  fill  the  pleural  cavity.  The  lesions  are  similar  to  those 
seen  in  adults,  except  that  in  children  there  is  apt  to  be  more  fibrin.  The 
process  usually  terminates  in  absorption  of  the  serum,  but,  as  in  dry 
pleurisy,  more  or  less  extensive  adhesions  are  left  behind  from  the  fibri- 
nous exudation.  In  other  cases  there  is  at  first  a  clear  serum,  often  con- 
taining pneumococci,  then  it  becomes  somewhat  turbid,  and  finally 
purulent.    This  is  especially  common  in  infants. 

Symptoms. — The  small  serous  effusions  of  one  or  two  ounces,  occur- 
ring with  the  pleurisy  that  complicates  pneumonia,  rarely  cause  either 
symptoms  or  physical  signs  by  which  they  can  be  recognised.  In  the 
present  connection  only  those  cases  will  be  discussed  in  which  the  amount 
of  effusion  is  considerable.  This  form  of  pleurisy  sometimes  follows  a 
well-defined  attack  of  pneumonia.  Other  cases  come  on  with  acute  febrile 
symptoms  somewhat  resembling  those  of  pneumonia,  but  with  all  the 
symptoms  less  severe,  except  the  pain.  After  an  illness  of  only  two  or 
three  days  the  chest  may  be  found  full  of  fluid.  In  a  third  class  the 
disease  comes  on  insidiously,  with  little  or  no  fever,  and  often  with  no 
distinct  pulmonary  symptoms  except  shortness  of  breath.  There  are  gen- 
eral weakness,  sometimes  loss  of  flesh,  anaemia,  and  moderate  prostration ; 
but  usually  the  patients  are  not  sick  enough  to  go  to  bed.  The  symp- 
toms of  pleurisy  with  effusion  vary  greatly.  When  it  occurs  as  a  com- 
plication of  some  acute  infectious  disease,  it  is  often  latent,  and  the 
diagnosis  is  to  be  made  only  by  the  physical  examination  of  the  chest. 

In  cases  in  which  the  fluid  does  not  become  purulent,  the  usual  course 


552  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  the  disease  is  for  the  fluid  to  disappear  gradually  by  absorption,  the 
case  going  on  to  spontaneous  recovery.  Serious  symptoms  resulting 
from  pressure  upon  the  heart  and  lungs  are  not  common,  but  may  occur 
when  the  fluid  accumulates  rapidly;  hence  they  are  most  likely  to  be 
seen  early  in  the  attack.  There  may  be  great  dyspnoea,  sometimes 
orthopnoea,  cyanosis,  weak  pulse,  and  even  attacks  of  syncope.  Death 
may  occur  with  these  symptoms.  In  certain  cases  there  is  seen  no 
tendency  to  spontaneous  absorption,  and  the  exudation  may  remain  sta- 
tionary for  months.  There  may  then  be  fever,  usually  slight  but  some- 
times quite  regular,  with  a  decline  in  the  general  health,  pallor  and 
anaemia,  which  may  strongly  suggest  the  existence  of  pus,  although  this 
is  not  present.    Others  are  regarded  as  cases  of  tuberculosis. 

Physical  Signs. — The  signs  in  the  chest  are  essentially  the  same 
whether  the  fluid  is  serous  or  purulent.  On  inspection,  there  is  dimin- 
ished movement  of  the  affected  side,  sometimes  bulging  of  the  intercostal 
spaces,  and  if  the  effusion  is  large,  an  increase  in  the  measurement  of 
the  affected  side  of  the  chest.  The  apex  beat  of  the  heart  will  usually 
be  considerably  displaced  if  the  effusion  is  upon  the  left  side.  It  may 
be  found  at  the  epigastrium,  at  the  right  border  of  the  sternum,  or  even 
in  the  right  mammary  line.  In  disease  of  the  right  side  the  displacement 
is  less,  and  occurs  only  with  a  large  effusion.  It  may  then  be  found  in 
or  near  the  left  axillary  line.  On  palpation,  the  vocal  fremitus  is  usually 
diminished  or  absent,  but  it  may  be  but  little  changed.  Percussion  gives 
marked  dulness  or  flatness.  In  a  large  effusion  this  is  over  the  entire 
lung.  There  is  also  a  sensation  of  increased  resistance  appreciable  by  the 
percussing  finger.  With  a  smaller  effusion  there  is  usually  flatness  over 
the  lower  part  of  the  chest  and  dulness  or  tympanitic  resonance  above; 
sometimes  dulness  is  found  behind  and  tympanitic  resonance  at  the  apex 
in  front.  The  line  of  flatness  may  change  with  the  position  of  the  patient. 
Grocco's  sign  is  found  in  the  majority  of  cases.  This  is  a  triangular 
area  of  dulness  posteriorly,  with  its  base  to  the  spine,  on  the  side  opposite 
to  the  effusion.  The  signs  on  auscultation  are  variable,  and  probably 
lead  to  more  frequent  mistakes  in  diagnosis  than  in  any  other  pulmonary 
affection.  Bronchial  breathing  and  bronchial  voice  over  the  fluid  are 
common  in  children.  Absence  of  both  voice  and  breathing  is  sometimes 
met  with,  but  it  is  exceptional.  The  bronchial  breathing  over  fluid  usu- 
ally differs  from  that  over  consolidation,  in  that  it  is  feebler  and  dis- 
tant ;  in  some  cases,  however,  it  is  indistinguishable  from  that  heard  over 
consolidation.  Friction  sounds  may  be  heard  above  the  level  of  the  fluid, 
or  when  the  fluid  is  subsiding,  and  there  may  be  bronchial  rales. 

Diagnosis. — The  most  reliable  signs  for  diagnosis  are  displacement 
of  the  heart,  flatness  on  percussion,  absence  of  rales  and  friction  sounds, 
and  (usually  distant)  bronchial  breathing.  In  an  infant,  flatness  should 
always  lead  one  to  suspect  fluid.     If  there  is  flatness  over  one  entire 


PLEURISY  WITH  SEROUS  EFFUSION.  553 

lung,  the  existence  of  fluid  is  almost  certain.  Between  serous  and  puru- 
lent effusions  a  positive  diagnosis  is  possible  only  by  the  use  of  the  ex- 
ploring needle.  This  should  be  employed  in  every  case,  as  for  treat- 
ment it  is  important  to  know  at  once  whether  or  not  we  have  a  purulent 
effusion  to  deal  with.  The  amount  of  fluid  in  serous  pleurisy  is  generally 
less  than  in  the  purulent  variety. 

Pleurisy  is  further  to  be  differentiated  from  pneumonia,  and  from 
tuberculosis.  From  pneumonia,  the  acute  cases  are  distinguished  by  the 
lower  temperature,  the  less  severe  prostration,  and  the  fact  that  all 
the  general  symptoms  are  milder,  but  especially  by  the  physical  signs.  The 
differential  diagnosis  by  the  physical  signs  between  effusion  and  the 
various  forms  of  consolidation  is  considered  under  the  head  of  Empyema. 

Prognosis. — In  the  acute  cases  complicating  pneumonia,  a  serous 
pleurisy  is  very  apt  to  become  purulent.  Other  forms  of  pleurisy  with 
effusion,  as  a  rule,  terminate  in  recovery.  In  cases  coming  on  without 
definite  cause  there  should  always  exist  a  suspicion  of  tuberculosis,  and 
hence  every  patient  should  be  closely  watched  for  the  development  of 
the  other  signs  of  that  disease. 

Treatment. — In  the  great  majority  of  cases,  only  symptomatic  treat- 
ment is  required  during  the  acute  period.  The  patient  should  be  kept 
in  bed,  and  pain  relieved  by  opium,  counter-irritation,  or  dry  cups.  After 
the  fever  has  ceased  the  patient  may  be  allowed  to  sit  up,  but  all  exer- 
tion should  be  carefully  avoided  if  the  effusion  is  large.  Sudden  death 
has  occurred  when  this  rule  has  been  violated.  The  patient  should  in 
suitable  weather  be  kept  in  the  open  air  as  much  as  possible.  In  the 
course  of  a  few  weeks  the  effusion  usually  subsides  under  simple  tonic 
treatment.  Absorption  may  sometimes  be  hastened  by  counter-irritation 
and  diuretics;  but  convalescence  is  apt  to  be  slow,  and  it  may  be  several 
months  before  the  health  is  entirely  restored. 

The  removal  of  the  fluid  by  operation  is  indicated  in  the  acute  form 
when  it  is  accumulating  so  rapidly  as  to  endanger  life  from  the  pressure 
upon  the  heart  and  lungs;  also  when  there  is  no  tendency  to  absorption 
after  from  two  to  three  weeks  of  constitutional  treatment.  In  such  cases 
nothing  is  to  be  gained  by  waiting,  and  harm  may  be  done  to  the  lung 
by  the  delay.  The  usual  method  is  by  aspiration.  In  the  acute  stage 
enough  should  be  removed  to  relieve  the  patient's  symptoms,  aspiration 
being  repeated  if  necessary  in  twelve  or  twenty-four  hours.  In  infants, 
particularly,  there  is  great  danger  of  wounding  the  lung  when  aspiration 
is  repeated  several  times.  This  usually  results  in  the  production  of 
pneumo-thorax  which  may  mask  the  re-accumulation  of  the  fluid.  In 
the  subacute  stage  the  removal  of  a  portion  of  the  fluid  may  be  all  that 
is  required,  spontaneous  absorption  of  the  remainder  often  taking  place 
quite  promptly.  A  few  cases  of  serous  pleurisy  have  been  incised  and 
drained  as  cases  of  empyema. 


554  DISEASES  OF  THE   RESPIRATORY   SYSTEM. 

EMPYEMA. 

Fully  nine-tenths  of  the  cases  of  empyema  in  children  under  five  y^ars 
either  occur  with  or  follow  pneumonia,  being  usually  the  sequel  of  the 
form  described  as  pleuro-pneumonia.  In  some  of  these  cases,  however, 
the  pleurisy  masks  the  pneumonia,  so  that  the  former  appears  to  be  the 
primary  disease.  Tuberculosis  is  a  rare  cause  in  early  childhood,  but 
becomes  more  frequent  after  the  seventh  year.  Empyema  may  com- 
plicate scarlet  fever,  measles,  or  any  of  the  other  acute  infectious  dis- 
eases. It  is  met  with  in  pyaemia  from  all  causes.  It  may  occur  in  the 
newly  born  as  the  result  of  infection  through  the  umbilical  wound  or 
the  skin.  It  is  seen  with  suppurative  inflammations  of  the  joints  and 
in  osteo-myelitis.  It  may  complicate  suppurative  processes  in  the  ab- 
domen, such  as  appendicitis  or  purulent  peritonitis.  Among  the  local 
causes  may  be  mentioned  traumatism,  necrosis  of  a  rib,  and  the  rupture 
into  the  pleural  cavity  of  abscesses  originating  in  the  mediastinum,  in 
the  thoracic  wall,  or  below  the  diaphragm. 

Etiology. — Since  empyema  is  generally  secondary  to  pneumonia,  its 
causes  are  mainly  those  of  that  disease.  Bacteriologically,  the  cases  may 
be  divided  into  several  groups : 

1.  Those  containing  the  pneumococcus  (micrococcus  lanceolatus) , 
usually  in  pure  culture.  This  is  the  largest  group,  and  includes  nearly 
all  the  cases  secondary  to  pneumonia. 

2.  Those  containing  other  pyogenic  germs,  particularly  the  strepto- 
coccus and  the  staphylococcus  aureus.  These  organisms  may  be  found 
alone,  or  associated  with  the  pneumococcus.  This  combination  is  likely 
to  be  found  in  cases  secondary  to  the  pneumonia  which  occurs  with  the 
infectious  diseases.  The  streptococcus  and  staphylococcus  occur  in  the 
pleurisy  of  pyaemia,  and  generally  also  when  the  disease  is  due  to  the 
rupture  of  abscesses  into  the  pleural  cavity.  I  have  once  found  the  in- 
fluenza bacillus  as  the  sole  organism  in  empyema. 

3.  The  cases  due  to  tuberculosis.  These  are  rare  in  children  and 
almost  unknown  in  infants.  The  tubercle  bacillus  is  often  difficult  to 
demonstrate,  and  it  may  be  absent.  But  it  is  not  safe  to  assume  that 
tuberculosis  is  present  because  no  organisms  are  found. 

Lesions. — Empyema  is  an  inflammation  with  the  production  of 
serum,  fibrin,  and  pus.  In  most  of  the  cases — and  the  younger  the 
child  the  more  frequent  its  occurrence — it  succeeds  pleuro-pneumonia. 
There  is  first  an  exudation  of  fibrin  with  an  excess  of  pus  cells.  As  the 
process  continues,  more  and  more  pus  is  poured  out,  with  serum.  At 
first  the  fluid  collects  in  small  pockets  formed  by  the  slight  adhesions. 
As  it  accumulates  these  are  broken  down,  and  the  pleural  cavity  may  be 
filled  with  pus.  If  the  original  inflammation  involved  but  a  portion  of 
the  pleura  the  empyema  may  be  sacculated.     This  is  often  seen  even  in 


EMPYEMA. 


555 


infants.  Sacculated  empyema  is  usiially  posterior  and  over  one  lower 
lobe,  but  may  be  in  any  part  of  the  chest.  In  very  rare  cases  there  may 
be  several  sacs  containing  pus,  separated  by  septa.  This  I  have  never 
seen  in  empyema  following  pneumonia.  The  cases  just  described  are 
those  in  which,  in  infants  and  young  children,  the  pneumococcus  is  reg- 
ularly found.  The  amount  of  fibrin  is  large,  covers  both  surfaces  of  the 
pleura,  and  many  large  masses  float  in  the  fluid.  The  pus  is  usually 
thick,  creamy,  and  odourless.  In  another  group  of  cases  the  evidences 
of  inflammation  of  the  pleura  are  much  less  marked,  and  in  some  they 
may  be  slight.  There  is  but  little  fibrin  in  the  exudate,  and  adhesions 
are  rare.  In  this  form  the  streptococcus  or  the  staphylococcus  are  the 
organisms  usually  found.  In  these  cases  the  inflammation  may  be 
purulent  from  the  outset,  and  the  pus  is  thinner  than  in  the  preceding 
variety.  Empyema  following  pneumonia  is  occasionally  preceded  by  a 
serous  effusion  which,  although  almost  clear,  is  usually  found  to  contain 
great  numbers  of  bacteria, 
usually  pneumococci. 

Even  when  the  fluid 
is  moderate  in  quantity  it 
is  not  all  at  the  bottom  of 
the  chest,  but  is  generally 
distributed  over  a  consid- 
erable part  of  its  surface, 
and  its  depth  at  the  mid- 
dle and  upper  part  of  the 
chest  may  be  only  half  an 
inch,  or  even  less.  When 
the  accumulation  is  larg- 
er, the  lung  does  not  float 
on  the  surface  of  the 
fluid,  but  the  fluid  sur- 
rounds the  lung,  which  is 
compressed  on  all  sides 
(Fig.  93).  The  heart  is 
displaced;  the  diaphragm 
and  the  abdominal  viscera 
are  somewhat  depressed, 
and  there  may  be  bulg- 
ing of  the  chest  on  the  af- 
fected side.  The  amount 
of  fluid  in  ordinary  cases  is  from  four  to  twenty  ounces,  although  in  neg- 
lected cases  it  may  accumulate  until  it  amounts  to  four  or  five  pints, 
the  effect  upon  the  lung  will  depend  upon  the  amount  of  fluid  and  the 
duration  of  the  compression.    When  the  quantity  is  small,  or  when  the 


Fig.  93. — Section  of  a  Lung.  To  Ulustrate  the  dis- 
tribution of  the  fluid  in  the  chest  in  a  moderately- 
large  effusion  (diagrammatic). 


556 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


pressure  is  removed  early,  the  lung  in  most  cases  readily  expands,  air 
being  forced  into  it  from  the  opposite  lung,  especially  during  the  act  of 
coughing.  With  the  exception  of  adhesions,  recovery  may  be  complete. 
Although  wide  in  extent,  the  adhesions  are  not  usually  strong  enough 
to  interfere  seriously  with  the  function  of  the  lung.  If  the  pressure  is 
great  and  has  been  long  continued,  the  adhesions  over  the  lung  may 
become  so  dense  and  firm  that  expansion  is  difficult,  and  can  at  best  be 
only  partial.  In  such  cases  recession  of  the  chest  wall  occurs.  In  old 
cases,  expansion  is  still  further  interfered  with  by  the  changes  taking 
place  in  the  lung  itself,  usually  a  low  grade  of  interstitial  pneumonia. 

In  cases  receiving  no  treatment,  absorption  of  the  pus  is  possible,  but 
is  not  to  be  expected.  It  generally  seeks  an  external  outlet;  the  lung 
may  be  perforated  and  the  pus  evacuated  through  the  bronchi,  or  external 
rupture  may  occur,  generally  in  the  neighbourhood  of  the  nipple.  In 
still  other  cases  the  pus  may  burrow  along  the  spine,  or  through  the 
diaphragm  reaching  the  peritonaeum. 

Empyema  is  more  often  of  the  left  than  of  the  right  side,  the  propor- 
tion being  about  three  to  two.  It  is  double  in  about  three  per  cent  of  all 
cases,  but  much  oftener  in  infants.  The  most  serious  complication  in 
young  children  is  pericarditis,  usually  with  empyema  of  the  left  side ;  in 
older  children  the  most  frequent  complication  is  pulmonary  tuberculosis. 


DAY 

1 

8 

3 

4 

5 

6 

1 

8 

9 

10 

11 

12 

13 

u 

15 

10 

17 

18 

1» 

20 

21 

22 

23 

10« 
106° 
101 
103 
108 
101 
100^ 
90^ 

M   E 

M  E 

M   E 

M   E 

M   E 

M   E 

M    E 

M   E 

M   E 

M   E 

M    E 

M    E 

M  E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M   E 

M  r. 

A 

A 

A 

/ 

iA 

/ 

/ 

r 

/ 

J 

Y 

V 

V 

l^ 

A 

A 

A 

V* 

\l 

A 

h 

f 

r 

j\ 

v 

\I 

/^ 

v\ 

A 

V 

Y 

' 

V 

Y 

V^ 

/ 

/ 

I 

l^ 

u/\ 

A 

t 

V 

V     ' 

^ 

/ 

^\ 

J 

V 

Fig.  94. — Empyema  following  Pneumonia.  Private  patient,  girl,  eight  years  old;  se- 
vere pneumonia  terminating  by  lysis;  development  of  empyema  indicated  by  second- 
ary temperature;  operation  on  seventeenth  day;  recovery. 


Symptoms. — When  it  occurs  as  a  sequel  of  pneumonia,  the  symptoms 
of  empyema  may  follow  those  of  the  original  disease  without  any  inter- 
mission; or  after  the  temperature  has  been  normal  or  nearly  so  for  sev- 
eral days  it  may  rise  again,  sometimes  quite  suddenly,  but  more  often 
gradually.  With  this  accession  of  fever  there  are  other  symptoms  point- 
ing to  an  increase  in  the  thoracic  disease.  (See  Figs.  94  and  95.) 
After  scarlet  fever  or  other  infectious  diseases,  the  onset  of  empyema  13 
often  signalised  by  cough,  rapid  breathing,  and  the  other  usual  symptoms 
of  pulmonary   disease.     In   the   cases   where  empyema   appears   to  be 


EMPYEMA. 


657 


Fig.  95. — Empyema  following  Pneumonia.  Hospital  pa- 
tient, two  years  old ;  single-lobe  pneumonia  with  crisis  on 
ninth  day;  no  resolution,  but  instead  gradual  develop- 
ment of  signs  of  empyema  closely  following  the  temper- 
ature curve. 


primary,  the  onset  is  sudden,  with  higli  temperature  and  general  and 
local  symptoms  resembling  those  of  pneumonia.  After  such  a  be- 
ginning, the  chest  may  be  found  full  of  pus  by  the  third  or  fourth 
day.  In  older  children  empyema  may  come  on  with  gradual,  and  even 
insidious  symptoms,  there  being  only  slight  fever,  dyspnoea,  and 
cachexia.  Marked  leu- 
cocytosis,  30,000  to  50,- 
000,  is  almost  invari- 
ably present.  The 
proportion  of  poly- 
morphonuclear cells  is 
usually  from  seventy 
to  eighty  per  cent. 

Whatever  may  have 
been  the  mode  of  on- 
set, when  the  pus  has 
been  in  the  chest  for 
some  time  the  symp- 
toms are  fairly  uni- 
form. During  the 
acute  stage  there  are  present  pallor,  anaemia,  and  prostration.  The  respi- 
rations are  always  accelerated,  being  usually  from  forty  to  seventy  a 
minute.  Cough  is  present;  there  is  dyspnoea,  sometimes  marked,  but 
more  often  it  is  scarcely  noticeable.  The  temperature  is  exceedingly 
variable;  usually  it  ranges  from  101°  to  103°  F.  A  typical  hectic  tem- 
perature with  sweating,  is  in  my  experience  very  rare.  The  pulse  is 
rapid  but  of  fair  strength.  There  is  loss  of  flesh,  sometimes  even  emacia- 
tion and  anorexia;  occasionally  there  is  diarrhoea.  The  stage  of  acute 
symptoms  may  last  from  two  to  four  weeks.  This  may  be  succeeded  by 
a  subacute  stage  which  may  last  for  months.  In  this  there  is  little  or  no 
fever;  the  patient  seems  convalescent  so  far  as  regaining  strength  and 
colour  are  concerned;  but  cough,  dyspncea,  and  rapid  respiration  con- 
tinue. The  chest  shows  no  change  in  signs  from  those  of  the  acute  stage. 
In  chronic  cases  the  general  symptoms  closely  resemble  those  of  tuber- 
culosis. There  may  be  clubbing  of  the  fingers,  albuminuria,  swelling  of 
the  feet,  and  often  marked  lateral  curvature  of  the  spine. 

Diagnosis. — The  physical  signs  do  not  differ  essentially  from  those 
present  in  serous  effusion.  If  there  are  signs  of  fluid  in  the  chest  and 
the  patient  is  under  three  years  of  age,  the  fluid  is  usually  purulent ;  and 
from  the  third  to  the  seventh  year,  pus  is  much  more  often  found  than 
serum.  A  marked  leucocytosis  always  makes  pus  more  probable.  In 
every  case  in  which  fluid  is  suspected  the  exploring  needle  should  be 
used,  because  of  the  great  importance  of  an  early  diagnosis.  The  skin 
should  be  surgically  clean  and  the  needle  sterilised.     Pus  may  not  be 


558  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

found  because  the  needle  is  too  small,  too  short,  or  because  it  is  intro- 
duced too  far  into  the  chest;  for  when  the  layer  of  pus  is  thin,  the 
needle  may  be  pushed  through  this  into  the  lung. 

The  physical  signs  upon  which  most  reliance  is  to  be  placed  are, 
marked  dulness  or  flatness  on  percussion,  feeble  breathing,  and  displace- 
ment of  the  heart.  When  in  a  young  child  these  signs  are  present, 
whether  general  or  localised,  a  needle  should  be  inserted,  and  if  pus  is 
not  found  at  the  first  trial,  repeated  punctures  should  be  made  until 
the  presence  or  absence  of  fluid  is  definitely  settled. 

Empyema  is  most  frequently  confounded  with  unresolved  pneumonia. 
The  differential  points  are  that  in  unresolved  pneumonia  the  dulness  is 
usually  over  a  single  lobe,  rales  or  friction  sounds  are  heard,  and  there  is 
no  displacement  of  the  heart ;  empyema  may  give  flatness  over  the  whole 
lung,  or  over  the  lower  half  of  the  chest  in  front  and  behind,  rales  and 
friction  sounds  are  absent  over  this  area,  and  the  heart  is  usually  dis- 
placed. In  both  conditions  we  may  get  bronchial  breathing  and  voice. 
The  confusion  of  acute  pneumonia  or  tuberculosis  with  empyema,  gen- 
erally arises  from  placing  too  much  reliance  upon  auscultation.  In 
pleuro-pneumonia,  with  an  excessive  exudation  of  fibrin,  the  signs  may 
be  identical  with  those  of  empyema,  except  that  the  heart  is  not  dis- 
placed. I  have  twice  seen  pulmonary  tuberculosis,  with  caseation  of  an 
entire  lobe,  which  gave  signs  that  were  identical  with  those  of  a  sac- 
culated empyema.  It  is  by  the  exploring  needle,  and  by  that  alone,  that 
empyema  is  positively  differentiated  from  these  pulmonary  conditions. 

There  are  some  other  thoracic  diseases  from  which  the  diagnosis  may 
be  even  more  difficult.  A  large  pericardial  effusion  gives  signs  which 
are  in  some  cases  identical  with  those  of  empyema  of  the  left  side. 
Marked  displacement  of  the  heart  to  the  right  is  always  a  strong  point 
in  favour  of  empyema;  besides,  such  pericardial  effusions  are  extremely 
rare  in  young  children.  A  pulmonary  abscess  of  considerable  size — also 
a  rare  condition — gives  signs  identical  with  those  of  localised  empyema, 
and  is  only  distinguished  from  it  by  autopsy  or  operation.  Abscesses 
from  broken-down  tuberculous  glands  may  give  signs  resembling  those 
of  localised  empyema,  and  like  an  empyema  may  point  between  the  ribs 
in  the  upper  part  of  the  chest.  The  constitutional  symptoms  of  empy- 
ema may  at  times  resemble  typhoid  fever  or  malaria;  but  it  is  dis- 
tinguished from  them  by  the  physical  signs  and  by  the  examination  of 
the  blood. 

Prognosis. — The  outcome  of  a  case  of  emp3^ema  depends  chiefly  upon 
the  age  and  general  condition  of  the  patient,  the  exciting  cause,  the  dura- 
tion of  the  symptoms,  the  presence  or  absence  of  serious  complications, 
and  the  treatment.  The  mortality  in  infants  under  one  year,  partic- 
ularly hospital  cases,  is  very  high— fully  ninety  per  cent.  It  is  dif- 
ficult to  understand  why  these  cases  do  so  badly ;  many  of  these  children 


EMPYEMA.  559 

on  admission  are  in  excellent  condition  and  do  well  for  a  week  or  more 
after  operation.  Then  the  temperature  rises,  the  patients  lose  ground 
rapidly  and  die  of  exhaustion  at  the  end  of  the  second  or  third  week. 
Their  inability  to  expand  properly  the  compressed  lung  has  always 
seemed  to  me  an  important  factor,  as  this  condition  is  almost  invariably 
found  at  autopsy.  Very  seldom  is  there  trouble  with  drainage.  Em- 
pyema in  children  over  two  years  old  seen  reasonably  early  and  receiv- 
ing proper  treatment,  almost  invariably  terminates  in  recovery,  unless 
the  disease  is  double  or  serious  complications  exist.  The  best  results  are 
seen  in  the  cases  that  follow  pneumonia.  Pneumococcus  and  staphylo- 
coccus cases  have  a  better  outlook  than  those  due  to  the  streptococcus. 
Tuberculosis  before  the  seventh  year  is  an  exceedingly  infrequent  cause, 
and  gangrene  of  the  lung  and  general  pyaemia  are  both  rare  causes  in 
early  life.  It  is  these  three  conditions  that  make  the  prognosis  of  the 
disease  in  adults  so  serious.  Great  delay  in  operation  makes  the  prog- 
nosis worse,  because  the  more  difficult  the  expansion  of  the  lung  the  more 
tedious  is  the  disease,  and  the  greater  the  likelihood  of  a  sinus  remain- 
ing. With  proper  early  treatment  these  patients  not  only  recover,  but 
in  most  cases  the  recovery  is  surprisingly  complete.  Retraction  of  the 
chest  and  its  resulting  lateral  curvature  of  the  spine  are  rare,  and  seen 
only  in  neglected  cases.  In  very  many  cases,  in  which  a  reasonably  early 
operation  was  done,  it  is  impossible,  after  the  lapse  of  two  or  three 
years,  to  detect  any  difference  whatever  in  the  physical  signs  of  the  two 
sides  of  the  chest.  There  are  few  serious  diseases  the  treatment  of  which 
is  more  satisfactory  than  that  of  acute  empyema  in  older  children. 

Spontaneous  recovery  in  empyema  may  take  place  by  absorption ;  but 
this  is  so  rare  that  it  is  not  to  be  expected.  The  pus  may  be  evacuated 
spontaneously  through  a  bronchus,  rupture  having  taken  place  through 
the  visceral  pleura.  When  this  occurs,  a  large  amount  of  pus  may  be 
coughed  up  in  a  few  hours,  usually  followed  by  immediate,  but  not 
always  lasting,  improvement.  This  is  the  most  favourable  of  the  natural 
terminations.  External  opening  may  take  place,  usually  in  the  region  of 
the  nipple.  There  is  an  area  of  redness,  then  a  fluctuating  tumour,  and 
finally  the  pointing  of  an  abscess.  The  discharge  may  continue  for 
months,  or  even  for  years.  External  opening  rarely  occurs  until  the  dis- 
ease has  lasted  several  months.  Of  19  cases  of  empyema  in  children  col- 
lected by  Schmidt,  in  which  a  spontaneous  discharge  of  pus  occurred 
either  externally  or  through  a  bronchus,  there  were  17  deaths  and  2 
recoveries.  Empyema  may  burrow  behind  the  diaphragm  into  the  ab- 
dominal cavity,  appearing  as  a  psoas  abscess;  it  may  burrow  posteriorly 
into  the  lumbar  region ;  it  may  rupture  into  the  oesophagus,  or  through 
the  diaphragm  into  the  peritoneal  cavity.  All  these  conditions,  how- 
ever, are  very  rare.  The  chances  of  spontaneous  cure  in  empyema  are 
small.     Of  32  cases,  reported  by  Eilliet  and  Barthez,  which  received 


560  DISEASES  OF  THE  RESPIRATORY   SYSTEM. 

no  surgical  treatment,  21  proved  fatal.  The  statistics  of  empyema  be- 
fore the  general  adoption  of  surgical  treatment  are  appalling.  Patients 
were  either  worn  out  by  the  protracted  suppuration,  or  died  from  amy- 
loid degeneration,  pneumonia,  or  tuberculosis. 

Treatment. — The  medical  treatment  relates  to  the  patient  only;  the 
disease  is  always  to  be  treated  surgically.  Like  any  other  acute  abscess, 
empyema  requires  free  incision  and  drainage  with  proper  aseptic  pre- 
cautions. 

Aspiration  as  a  means  of  cure  is  now  seldom  used.  Unquestionably 
it  sometimes  suffices  to  cure  empyema,  most  frequently  when  it  is  local- 
ised, and  when  the  cause  is  the  stapliylococcus.  How  often  this  occurs 
is  shown  by  the  following  statistics :  Of  139  cases  which  I  collected  that 
were  treated  by  aspiration,  25  were  cured,  8  of  these  by  a  single  aspira- 
tion; 13  died,  and  the  remaining  101  were  afterward  subjected  to  other 
treatment.  The  objections  to  aspiration  are,  that  it  is  not  possible  to 
remove  all  the  pus;  that  it  affords  no  opportunity  for  the  removal  of  the 
large  fibrinous  masses;  besides,  there  is  the  danger,  especially  with  re- 
peated aspirations,  of  puncturing  the  lung  and  producing  pneumothorax. 
Simple  aspiration,  therefore,  is  to  be  advised  in  children  only  for  tem- 
porary relief  when  the  amount  of  fluid  is  large  and  the  symptoms  are 
urgent.  Aspiration,  followed  by  the  injection  of  formalin  and  glycerine, 
is  not,  from  my  experience,  to  be  recommended.  Likewise,  the  proced- 
ure of  continuous  aspiration,  as  proposed  by  Bryant,  I  have  found  in  in- 
fants equally  unsatisfactory. 

Incision  and  Drainage. — In  many  cases  it  is  preferable  to  delay 
incision  until  the  period  of  most  acute  inflammation  has  subsided, 
as  shown  by  lower  temperature  and  stationary  physical  signs.  This 
is  usually  seen  two  or  three  weeks  after  the  pleural  invasion.  Such 
delay  is  not  admissible  if  either  the  local  condition  or  the  temperature 
points  to  a  steady  increase  in  the  disease;  nor  when  the  general  symp- 
toms indicate  increasing  prostration  or  sepsis.  The  dangers  attendant 
upon  general  anaesthesia  are  considerable,  and  in  most  cases  it  is  better 
not  to  employ  it.  I  have  known  of  four  deaths  on  the  table  during 
operation,  and  in  several  other  cases  have  seen  very  alarming  symptoms 
occur.  Chloroform  is  more  to  be  feared  than  ether.  It  is  well,  when 
possible,  to  employ  local  anaesthesia.  The  most  favourable  point  for 
incision  is  the  posterior  axillary  line  in  the  seventh  intercostal  space 
upon  the  right  side,  the  eighth  upon  the  left.  In  a  case  of  localised 
empyema,  the  lowest  point  at  which  pus  can  be  obtained  by  puncture 
should  be  chosen.  The  incision  is  made  in  the  middle  of  the  intercostal 
space.  No  matter  what  has  been  found  by  puncture  on  previous  occa- 
sions, the  exploring  needle  should  always  be  used  at  the  time  of  opera- 
tion and  at  the  site  of  the  incision  before  the  latter  is  made.  The  in- 
cision should  be  only  large  enough  to  allow  the  introduction  of  two  tubes 


EMPYEMA.  561 

side  by  side  into  the  pleural  cavity.  The  haemorrhage  is  very  rarely 
sufficient  to  require  a  ligature.  It  is,  I  believe,  undesiral)le  to  attempt 
to  empty  the  chest  at  the  time  of  operation.  A  better  plan  is  to  insert 
the  tubes  at  once  and  apply  the  dressings,  allowing  tlie  pus  to  escape 
slowly.  The  drainage  tubes  should  be  of  rubber,  fenestrated,  one-fourth 
to  three-eighths  of  an  inch  in  diameter  and  about  three  inches  long. 
To  secure  them  from  slipping  into  the  cavity,  the  outer  end  should  be 
transfixed  by  a  large  safety-pin  before  introduction. 

Both  the  original  operation  and  the  subsequent  dressings  should  be 
done  with  strict  aseptic  precautions  on  account  of  the  danger  of  sec- 
ondary infection,  the  occurrence  of  which  adds  to  the  severity  and  pro- 
longs the  course  of  the  disease.  After  the  third  or  fourth  day  the  second 
tube  may  be  omitted  and  the  remaining  one  gradually  shortened.  Often, 
by  the  end  of  the  fourth  week,  and  sometimes  before,  the  tube  may  be 
dispensed  with  altogether.  The  time  of  redressing  and  the  removal  of 
the  tube  is  determined  by  the  amount  of  discharge  and  the  temperature. 

Simple  incision  with  drainage  I  believe  to  be  the  preferable  opera- 
tion for  recent  cases  in  infants.  One  advantage  over  rib  resection  is 
that  it  is  shorter  and  altogether  less  of  an  operation,  these  factors  being 
at  times  of  considerable  importance  in  very  young  and  feeble  children. 
Again,  it  can  be  done  without  an  ana3sthetic,  and  it  has  seemed  to  me 
that  pulmonary  expansion  took  place  with  greater  facility  than  when 
the  much  larger  opening  into  the  chest  was  made.  Finally,  in  a  large 
number  of  cases,  it  gives  all  the  room  needed  for  drainage.  There  are, 
however,  some  disadvantages.  The  smaller  opening  may  not  give  ade- 
quate room  for  the  removal  of  large  masses  of  fibrin.  In  old  cases,  par- 
ticularly, it  not  infrequently  happens  that  after  the  chest  has  been 
emptied  the  ribs  become  so  closely  approximated  that  but  little  space  is 
left,  and  the  drainage  tubes  are  pinched.  Furthermore,  the  contact  of 
the  tubes  may  lead  to  erosion  and  superficial  necrosis  of  the  adjacent 
ribs,  sometimes  to  exostoses.  While,  therefore,  simple  incision  with 
drainage  is  to  be  preferred  in  the  case  of  infants,  for  all  other  patients 
the  resection  of  a  rib  seems  desirable  and  advantageous.  The  removal 
of  an  inch  of  rib  is  usually  all  that  is  necessary. 

Kenyon's  method  of  continuous  drainage  into  a  wash-bottle  below 
the  water  level,  has  much  to  commend  it  especially  for  infants.  The 
opening  made  into  the  chest  is  a  small  one  admitting  only  a  single  tube. 
The  wound  is  tightly  packed  about  the  tube  so  as  to  admit  no  air.  The 
thoracic  tube  is  connected  by  several  feet  of  rubber  tubing  with  the 
wash-bottle  which  contains  a  sterile  salt  solution.  This  bottle  is  sus- 
pended beneath  the  patient's  bed  or  placed  upon  the  floor.  The  char- 
acter and  the  amount  of  discharge  can  thus  readily  be  seen.  As  the 
tube  need  not  be  changed  for  several  days  the  child  is  spared  the  fatigue 
and  distress  of  frequent  dressings.  The  small  opening  into  the  chest  is 
37 


562 


DISEASES  OF  THE   RESPIRATORY   SYSTEM. 


of  considerable  advantage  in  preventing  the  admission  of  air;  it  thus 
diminishes  the  danger  of  secondary  infection  and  favours  the  expansion 
of  the  lung.  Should  the  tube  become  blocked  it  can  be  cleared  by  rais- 
ing the  bottle  and  allowing  the  fluid  to  flow  into  the  chest  and  then 
siphoning  it  out.  The  bottle  is  emptied  once  or  twice  a  day  and  the 
air  is  excluded  by  clamping  the  tube  meanwliile. 

Washing   out   the   pleural    cavity   is   indicated    in   cases   in   which 
the  pus  is  foul,    A  single  washing  for  the  purpose  of  removing  fibrin  is 

the  routine  practice  of  some  sur- 
geons. For  this  a  warm,  sterilised 
salt  solution  should  be  used.  Per- 
sonally, I  have  seldom  found  this 
necessary.  Eepeated  irrigations 
should  not,  I  think,  be  employed. 
The  usual  duration  of  the  dis- 
charge in  cases  treated  by  simple 
incision  is  from  three  to  six 
weeks,  the  average  being  about 
five  weeks. 

A  persistence  of  temperature 
or  a  fresh  rise  after  operation  most 
frequently  indicates  defective 
drainage,  generally  due  to  block- 
ing of  the  tube;  but  this  is  not 
always  the  case.  It  may  be  due 
to  pneumonia,  either  a  continu- 
ance of  the  old  process  or  the 
lighting  up  of  a  new  one,  to  ab- 
scess of  the  lung,  to  empyema  of 
t^^_    B  the  opposite  side,  to  pericarditis, 

Hw  K  k  °^  *^  some  cause  outside  the  chest, 

f^      1  very  frequently  otitis.     The  mis- 

take is  often  made  of  allowing 
the  tube  to  remain  for  too  long  a 
time,  so  that  a  sinus  is  kept  open 
which  would  otherwise  close. 

In  chronic  cases,  or  those 
which  have  been  long  neglected, 
some  further  operative  treatment 
is  often  necessary.  The  lung  is  so 
bound  down  by  firm  adhesions 
that  further  expansion  is  impos- 
sible, and  even  after  the  chest  has  receded  to  its  utmost,  so  that  the  ribs 
are  in  contact,  there  still  remains  a  cavity  which  can  not  close.    For  such 


Fio.  96. — Deformitt  apter  an  Old  Em- 
pyema OF  THE  Left  Side  for  which 
Estlander's  Operation  was  Per- 
formed. Portions  of  five  ribs  were  re- 
moved. (From  a  photograph  seven  years 
after  operation.) 


EMPYEMA. 


563 


cases  the  only  hope  is  an  operation  by  wliieh  portions  of  several  ribs  are 

removed,  thus  allowing  a  greater  collapse  of  the  cbest  wall.     This  is 

known  as  thoracoplasty,  or  Estlander's  operation.     The  operation  is  of 

itself   a    serious    one,    and 

only  to  be  advised  as  a  last 

resort  in  inveterate  cases. 

Such   an    operation   is,    of 

course,  always  followed  by 

very  great  deformity  (Fig. 

96). 

Methods  of  Inducing 
Expansion  of  the  Lung. — 
In  most  of  the  cases,  partic- 
ularly the  recent  ones,  com- 
plete expansion  of  the  lung 
takes  place  without  any 
difficulty,  the  chief  agent 
being  the  cough.  In  some 
cases  this  may  be  insuffi- 
cient. The  apparatus,  de- 
vised by  James,  shown  in 
the  accompanying  cut  ( Fig. 
97),  serves  at  the  same 
time  as  a  toy  for  the  child's  amusement  and  as  a  most  efficient  means  of 
inducing  forced  expiration.  One  bottle  is  placed  a  few  inches  higher  than 
the  other,  and  the  child  blows  a  coloured  fluid  from  the  lower  into  the 
higher  bottle,  allowing  it  to  siphon  back.  Blowing  soap  bubbles  often 
answers  the  same  purpose. 


FiQ.  97.- 


-James's  Apparatus  for  Expanding  the 
Lung  after  EmpteiiIa. 


SECTION  V. 
DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

CHAPTER    I. 
PECULIARITIES  OF  THE  HEART  AND  CIRCULATION  IN  EARLY  LIFE. 

The  Foetal  Circulation. — During  the  latter  part  of  fcetal  life  the  cir- 
culation may  be  briefly  described  as  follows :  The  purified  blood  comes 
from  the  placenta  through  the  umbilical  vein.  Entering  the  body,  it 
divides  at  the  under  surface  of  the  liver  into  two  branches,  the  smaller 
one,  the  ductus  venosus,  communicating  directly  with  the  inferior  vena 
cava;  the  larger  branch  joining  the  portal  vein,  so  that  its  blood  trav- 
erses the  liver,  and  then  enters  the  inferior  vena  cava  through  the  hepatic 
vein.  From  the  inferior  vena  cava  the  blood  enters  the  right  auricle,  like 
that  returned  from  the  head  and  upper  extremities  by  the  superior  vena 
cava.  A  part  of  the  blood  now  passes  directly  into  the  left  auricle  through 
the  foramen  ovale;  the  remainder,  through  the  tricuspid  orifice  into  the 
right  ventricle.  As  the  requirements  of  the  pulmonary  circulation  are  not 
great,  only  a  small  part  of  the  blood  is  sent  through  the  pulmonary  artery 
to  the  lungs ;  the  greater  portion  passes  from  the  pulmonary  artery  through 
the  ductus  arteriosus  into  the  aorta,  joining  here  the  blood  from  the  left 
ventricle.  The  blood  thus  finds  its  way  from  the  right  heart  to  the  left, 
only  in  small  part  by  way  of  the  lungs,  the  greater  part  passing  directly 
from  the  right  auricle  to  the  left,  or  from  the  right  ventricle  into  the  aorta 
through  the  ductus  arteriosus.  From  the  aorta,  the  blood  reaches  the 
placenta  through  the  umbilical  arteries,  which  are  a  continuation  of  the 
hypogastric  arteries,  which  in  turn  are  given  off  from  the  internal  iliacs. 

Changes  in  the  Circulation  at  Birth. — With  the  ligation  of  the  um- 
bilical cord,  the  circulation  through  the  umbilical  vein  and  arteries  and 
the  ductus  venosus  ceases.  With  the  establishment  of  respiration  and 
the  consequent  increased  demands  made  by  the  pulmonary  circula- 
tion, the  blood  ceases  almost  at  once  to  pass  through  the  ductus  arterio- 
sus, and  very  soon  through  the  foramen  ovale.  The  umbilical  vessels 
during  the  first  few  days  of  life  are  filled  with  small  thrombi,  which  be- 
come organised.  By  the  end  of  the 'first  week,  these  vessels,  as  well  as  the 
ductus  venosus,  are  usually  closed  at  their  extremities,  although  they  may 
remain  patulous  throughout  the  greater  part  of  their  extent  for  several 
weeks.  They  subsequently  atrophy  to  the  condition  of  small  fibrous 
564 


HEART  AND  CIRCULATION  IN  EARLY  LIFE. 


565 


cords.  For  some  weeks  before  birth  the  circulation  through  the  foramen 
ovale  is  slight,  it  being  gradually  obstructed  by  the  growth  of  a  septum 
which  nearly  fills  the  space  at  birth.  After  the  first  week  of  e.xtra-uterine 
life  very  little,  if  any,  blood  passes  through  it,  altliough  complete  closure 
of  the  foramen  often  does  not  take  place  until  tlie  middle  of  the  first  year. 
In  fully  one- fourth  of  the  autopsies  I  have  made  upon  infants  under  six 
months  old,  there  have  been  found  minute  openings  at  the  margin  of  the 
foramen  ovale,  but  they  are  usually  oblique,  and  closed  by  the  valvular 
curtain  so  as  effectually  to  obstruct  the  current  of  blood.  The  ductus  arte- 
riosus is  first  closed  by  a  clot,  which  becomes  organised  and  blends  with 
the  products  of  a  proliferating  arteritis.  It  is  rarely  found  open  after  the 
tenth  day,  and  by  the  twentieth  it  is  almost  invariably  obliterated. 

The  Pulse. — The  pulse  in  early  life  is  not  only  more  frequent,  but  it 
is  very  much  more  variable  than  in  adults.  The  following  is  the  average 
pulse-rate  in  healthy  children  during  sleep  or  ])erfect  quiet : 

Six  to  twelve  months 105  to  11.5  per  minute. 

Two  to  six  j^ears 90  "  105    " 

Seven  to  ten  years 80  "     90    "         " 

Eleven  to  fourteen  yeans 75  "     85    "         " 


The  pulse  is  a  little  more  frequent  in  females  than  in  males,  and  more 
frequent  when  sitting  than  when  lying  down.  Muscular  exercise  or  ex- 
citement ir.creases  the  pulse-rate  by  from  twenty  to  fifty  beats.  Very 
trivial  causes  disturb  not  only  the  frequency  but  the  force  of  the  pulse. 
The  pulse  in  young  infants  may  be  irregular  even  in  health  and  during 
sleep.  When  rapid,  it  is  frequently  irregular  without  special  significance. 
No  dicrotism  is  seen  in  the  pulse  wave  of  early  infancy. 

The  circulation  is  much  more  active  in  infancy  than  in  later  child- 
hood ;  thus,  according  to  Vierordt,  the  entire  round  of  the  circulation  is 
accomplished  in  the  newly  born  in  twelve  seconds;  at  three  years,  in 
fifteen  seconds;  in  the  adult,  in  twenty-two  seconds. 

Size  and  Growth. — The  relative  size  of  the  heart  is  slightly  greater  in 
infancy  than  in  later  life,  it  being  smallest  at  about  the  seventh  year. 
The  average  weight  at  the  different  periods  of  life  is  as  follows:  ^ 


Age. 

Ounces. 

Grammes. 

Ratio  to  body 
weight. 

Birth 

1  year 

2  years 

3  "     

0.50 
1.25 
1.87 
2.25 
2.80 
5.84 
8.50 

35 1 
531 
64 1 
80 

166 

241 

1  to  225 

7     "     

1  to  280 

14    "     

1  to  222 

Adult 

1  to  226 

1  The  figures  in  infancy  are  from  one  hundred  and  fifty-five  observations  made  in 
the  New  York  Infant  Asylum;  the  others  are  taken  from  Sahli. 


566  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

The  growth  of  the  heart  is  rapid  during  the  first  three  years,  and 
nearl}'  proportionate  to  that  of  the  body.  It  is  slowest  from  the  third 
to  the  tentli  year,  and  most  rapid  from  the  eleventh  to  the  fifteenth 
year.  At  birth,  the  thickness  of  the  riglit  ventricle  is  very  nearly  the 
same  as  that  of  the  left,  the  ratio  being  6 :  7.  The  left  ventricle,  how- 
ever, grows  very  much  more  rapidly  than  the  right,  so  that  at  the  end 
of  the  second  year  the  ratio  is  1:2,  which  is  nearly  that  of  the  rest  of 
childhood. 

Position  of  the  Apex  Beat. — In  the  infant  the  heart  is  placed  some- 
what higher,  and  occupies  a  position  a  little  nearer  the  horizontal  than 
in  the  adult.  This  is  partly  due  to  the  higher  position  of  the  dia- 
phragm. The  apex  beat  is  therefore  higher  and  farther  to  the  left  than 
in  adult  life.  According  to  the  observations  of  Wassilewski  and  Starck, 
whose  combined  examinations  with  reference  to  this  point  were  made 
upon  over  2,100  children,  the  apex  beat  is,  as  a  rule,  outside  the  mam- 
mary line  until  the  fourth  year;  if  it  is  less  than  one-third  of  an  inch 
beyond  the  nipple,  it  can  not  be  considered  abnormal.  From  the  fourth 
to  the  ninth  year,  the  apex  beat  is  in  or  near  the  mammary  line.  After 
the  thirteenth  year,  under  normal  conditions,  it  is  invariably  within 
that  line.  During  the  first  year  the  apex  beat  is  usually  found  in  the 
fourth  intercostal  space;  from  the  first  to  the  seventh  year,  it  is  found 
with  about  equal  frequency  in  the  fourth  and  the  fifth  spaces ;  after  the 
seventh  it  is  usually,  and  after  the  thirteenth  year  it  is  always,  when 
normal,  in  the  fifth  space.  The  position  of  the  apex  beat  may  be  con- 
siderably modified  by  severe  deformities  of  the  chest  resulting  from 
rickets.  Pott's  disease,  or  lateral  curvature  of  the  spine. 

Examination  of  the  Heart. — Inspection. — Bulging  of  the  praecordia  is 
a  frequent  and  important  sign  of  cardiac  disease  during  childhood.  The 
cardiac  impulse  is  generally  weaker  than  in  the  adult,  and  often  it  is 
difficult  to  locate  the  apex  beat  owing  to  the  thick  layer  of  adipose  tissue 
covering  the  chest. 

Palpation. — This  is  usually  a  much  more  satisfactory  method  than  is 
inspection  for  determining  the  position  of  the  apex  beat.  For  this  pur- 
pose the  child  should  be  in  the  sitting  posture,  with  the  body  inclined 
slightly  forward.  Great  displacement  of  the  apex  beat  is  always  signifi- 
cant, and  should  lead  one  to  suspect  pleuritic  effusion ;  lesser  degrees  of 
displacement  to  the  left  indicate  hypertrophy,  especially  of  the  left  ven- 
tricle; to  the  right,  hypertrophy  of  the  right  ventricle. 

Percussion. — This  is  best  done  by  means  of  the  percussion  hammer. 
A  light  blow  should  be  used,  on  account  of  the  thinness  and  elasticity  of 
the  chest  walls.  In  percussing  the  heart,  changes  in  the  percussion 
note  are  generally  better  appreciated  if  one  proceeds  from  the  lung 
toward  the  heart  rather  than  in  the  opposite  direction.  The  outline  of 
the  area  of  "  relative  "  or  "  deep  cardiac  dulness,"  especially  in  small  chil- 


CONGENTIAL  ANOMALIES  OF  THE  HEART.  567 

dren,  is  proportionately  larger  than  in  the  adult.  Tliis  may  lead  to  the 
mistaken  opinion  that  the  heart  is  enlarged,  when  it  is  really  of  normal 
size.  The  upper  boundary  of  this  area  is  at  the  second  interspace  or  the 
lower  border  of  the  second  costal  cartilage,  at  the  left  margin  of  the 
sternum;  from  this  point  the  line  of  dulness  extends  in  a  curved  direc- 
tion outward  and  downward,  the  extreme  left  limit  being  at  or  slightly 
beyond  the  mammary  line  at  the  fourth  interspace.  On  the  right  side 
the  line  of  dulness  extends  downward  from  the  second  interspace  in  a 
slightly  curved  direction  along  the  parasternal  line.  The  lower  border 
is  indeterminable  on  account  of  the  liver. 

The  area  of  "  absolute  "  or  "  superficial  cardiac  dulness,"  or  that  part 
of  the  heart  uncovered  by  the  lung,  resembles  in  shape  the  same  area  in 
the  adult,  but  it  is  relatively  larger. 

Auscultation. — This  is  of  little  value  unless  the  child  is  quiet.  For 
an  accurate  diagnosis  the  stethoscope  is  indispensable,  but  auscultation 
should  always  be  practised  with  the  naked  car  as  well.  The  rhythm  and 
rapidity  of  the  child's  heart  action  are  much  more  easily  disturbed  than 
are  the  adult's,  and  such  disturbances  are  consequently  much  less  sig- 
nificant. The  rapidity  of  the  heart  in  infancy  is  ordinarily  so  great  as 
to  make  it  difficult  to  distinguish  between  diastolic  and  presystolic 
murnmrs.  Normally,  the  loudest  sound  is  the  first  sound  at  the  apex; 
the  weakest  sound  is  the  second  sound  at  the  aortic  orifice. 

In  consequence  of  the  small  size  and  the  thin  walls  of  the  chest,  all 
sounds,  both  normal  and  pathological,  appear  relatively  louder  than  in 
the  adult,  and  the  area  of  diffusion  is  therefore  much  greater.  Thus  it  is 
a  frequent  occurrence  for  murmurs  to  be  heard  all  over  the  chest  both  in 
front  and  behind. 

Eeduplication  of  the  heart  sounds,  in  consequence  of  the  valves  of 
the  two  sides  not  closing  exactly  together,  is  not  uncommon  in  children, 
and  may  be  due  simply  to  excitement.  During  the  first  four  years  of 
life  nearly  all  the  abnormal  murmurs  heard  are  systolic. 

Accidental  murmurs  may  be  due  to  anaemia  and  other  blood  condi- 
tions, and,  although  not  so  common  as  in  older  patients,  they  are  by  no 
means  rare  even  in  infants. 


CHAPTEK    II. 

CONGENITAL  ANOMALIES  OF  THE  HEART. 

Etiology. — Of  the  causes  of  congenital  cardiac  disease  little  is  defi- 
nitely known.  It  occurs  more  often  in  first-born  children  than  later 
ones;  16  of  50  cases  being  in  first  children  (Still).  It  is  often  associated 
with  other  forms  of  imperfect  development,  notably  of  the  brain,  as 


568  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

in  Mongolian  idiocy.  An  attempt  has  been  made  to  connect  cardiac 
malformations  with  syphilis.  A  syphilitic  family  history  is  very  sel- 
dom found.  But  Warthin  has  lately  brought  forward  additional  reason 
for  suspecting  syphilis  since  he  has  found  that  some  of  these  cases  give 
a  positive  reaction  to  the  Wassermann  test.  Further  observations  are 
needed  on  this  point.  There  has  not  been  adduced  any  evidence  to  show 
that  rheumatism  plays  a  part. 

Lesions. — The  congenital  anomalies  of  the  heart  may  be  grouped 
under  three  general  heads: 

1.  Malformations  resulting  from  imperfect  development  of  certain 
parts  of  the  heart,  most  frequently  one  of  the  septa.  Either  the  ven- 
tricular or  the  auricular  septum  may  be  affected,  or  that  dividing  the 
pulmonary  artery  from  the  aorta.  Such  failure  in  development  per- 
petuates conditions  which  are  normal  in  the  early  months  of  fcetal  life. 
There  may  also  be  atresia  of  any  one  of  the  orifices,  absence  of  one  or 
more  of  the  valvular  leaflets,  or  of  any  one  of  the  large  vessels. 

2.  The  results  of  festal  endocarditis.  The  effects  of  this  condition 
vary  according  to  the  time  of  its  occurrence.  It  is  almost  invariably  of 
the  right  side,  most  frequently  affecting  the  pulmonic  valves.  Valvular 
disease  in  foetal  life  leads  not  only  to  hypertrophy  and  dilatation,  but 
also  interferes  with  the  normal  development  of  the  heart  by  preventing 
the  closure  of  the  auricular  or  ventricular  septum  or  the  ductus  arterio- 
sus, these  being  kept  open  by  way  of  compensation. 

3.  Persistence  of  foetal  conditions,  such  as  the  foramen  ovale  or  duc- 
tus arteriosus.  This  may  be  the  result  of  valvular  disease,  as  previously 
stated,  or  of  some  condition  of  the  lungs,  such  as  atelectasis. 

In  the  following  table  are  given  the  lesions  found  in  two  hundred 
and  forty-two  cases,  which  I  have  collected  from  medical  literature: 

Frequency  of  the  different  lesions  in  2^2  autopsies  upon  cases  of  congenital 

cardiac  anomaly. 

Defect  in  the  ventricular  septum 149  cases;  the  only  lesion  in  5  cases. 

Defect  in  the  auricular  septum,  or  patent  fora- 
men ovale 126  " 

Pulmonic  stenosis  or  atresia 108  " 

Patent  ductus  arteriosus 68  " 

Abnormalities  in  the  origin  of  the  great  vessels.  45  " 

Pulmonic  insufficiency 17  " 

Tricuspid  insufficiency 6  " 

Tricuspid  stenosis  or  atresia 3  " 

Mitral  insufficiency 1  " 

Mitral  stenosis  or  atresia 6  " 

Aortic  insufficiency 1  " 

Aortic  stenosis  or  atresia 6  " 

Transposition  of  the  heart 2  " 

Ectocardia 1  " 


"  9 

"  6 

"  3 

"  0 

"  0 

"  0 

"  0 

"  0 

"  0 

"  0 

"  0 

"  0 

"  0 

CONGENTIAL  ANOMALIES  OF  THE  HEART. 


569 


The  most  frequent  associated  lesions. 

Pulmonic  stenosis  with  defect  in  the  ventricu- 
lar septum 92  cases;  the  only  lesions  in  20  cases. 

Pulmonic  stenosis,  with  defect  in  the  auricular 

septum 52      "         "      "         "      "     8      " 

Defects  in  both  septa 82      ""        "      "         "      "17      " 

Pulmonic  stenosis  with  defects  in  both  septa. .  36      "         "      "         "      "  21      " 

From  this  table  it  will  be  seen  that,  in  the  great  majority  of  cases, 
several  lesions  are  present,  the  most  frequent  combinations  being  pul- 
monic stenosis  with  defective  ventricular  septum,  pulmonic  stenosis 
with  defective  auricular  septum,  the  three  lesions  associated,  or  the  first 
two  with  a  patent  ductus  arteriosus.  Stenosis  of  the  isthmus  of  the 
aorta,  although  not  noted  in  this  series,  is  not  a  very  uncommon  lesion; 
the  obstruction  is  in  the  arch  of  the  aorta  beyond  the  point  where  the 
large  vessels  are  given  off. 

Defect  in  the  Ventricular  Septum. — This  is  the  most  frequent  lesion 
in  congenital  cardiac  disease,  and  in  half  the  cases  was  associated  with 
pulmonic  stenosis.  The  defect  is 
generally  at  the  upper  part  of  the 
septum  (Fig.  98).  It  is  usually 
from  one-fourth  to  one-half  an 

inch  in  diameter,  but  not  infre-      ^^^^»^^      ^m\K 
queutly  there  is  a  large  defect,      ^K^^Ktm^Kf 
and  the  septum  may  be  entirely      ^^^^^l^^^Bf/^ 
absent,  the  heart  then  consisting 
of  but  three  cavities — two  auri- 
cles and   one  ventricle.     If  the      ^^V'^**^ 
auricular   septum   also   is   want-      ^^KtkI'W ''J"' 
ing,  as  may  be  the  case,  the  heart      ^HL'^fJI^r'.^W 
has  but  two  cavities.    Frequently      ^^HL^xl^^t^l^'L  t 
there  are   also   abnormalities   in      ^^HH^H^^I^^^Vti 
the  origin  of  the  great  vessels. 
The   pulmonary   artery   and   the 

aorta  may  be  given  off  from  the  ^  ^  r^ 

•'  .  Fig.  98.  —  Congenital  Cardiac   Disease. 

common    ventricle,    or    the    aorta  -phe  left  ventricle  is  shown  with  a  defect 

may   arise   partly   from   one   ven-  in  the  ventricular  septum,  the  opening  be- 

,    .  ,  J  .  1      i?  ii         ii  ing  just  beneath  the  aortic  valve.     (From 

tricle  and  partly  from  the  other.  ^  ^^^.^^^  ^^^^  -^  ^^^  Babies'  Hospital.) 

If  pulmonic  stenosis  or  atresia 

is  present,  the  opening  in  the  ventricular  septum  is  conservative,  afford- 
ing a  channel  for  the  passage  of  blood  from  the  right  to  the  left  side 
of  the  heart. 

Patent  Foramen  Ovale,  or  Defect  in  the  Auricular  Septum.-— AV 
though  this  is  one  of  the  most  common  congenital  malformations,  it  is 
not  one  of  the  most  important.    It  rarely  occurs  alone,  but  is  frequently 


570  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

found  with  pulmonic  stenosis  or  a  defect  in  the  ventricular  septum. 
Small  oblique  openings  in  the  auricular  septum — usually  at  the  foramen 
ovale — are  not  infrequently  met  with  in  autopsies  upon  young  infants, 
but  they  are  of  no  importance.  In  pathological  conditions  the  opening 
is  from  one-fourth  to  one  inch  in  diameter,  and  there  may  be  more  than 
one  opening.  A  defect  in  this  septum  is  frequently  secondary  to  pul- 
monic stenosis. 

Patent  Ductus  Arteriosus. — As  a  solitary  lesion  this  is  rare,  but  it  is 
frequently  associated  with  pulmonic  stenosis,  usually  with  a  defect  in  one 
or  both  septa.  It  is  then  one  of  the  channels  by  which  the  blood  may 
find  its  way  to  the  lungs  when  the  pulmonary  orifice  is  obstructed.  It 
is  not  a  malformation,  but  simply  the  persistence  of  a  foetal  condition 
usually  necessitated  by  other  changes  in  the  heart.  But  the  direction  of 
the  blood  current  is  the  opposite  of  that  which  exists  in  foetal  life. 

Pulmonic  Stenosis. — This  is  one  of  the  most  frequent  and  most  im- 
portant lesions.  It  may  be  due  to  foetal  endocarditis,  or  to  a  malfor- 
mation. If  the  former,  there  is  usually  stenosis;  if  the  latter,  there  may 
be  atresia.  It  is  often  a  primary  lesion,  and  when  marked  it  is  al- 
ways accompanied  by  other  changes,  most  frequently  by  a  defect  in  one 
or  both  septa  or  by  a  patent  ductus  arteriosus.  This  is  important,  as 
being  more  constantly  associated  with  cyanosis  than  is  any  other  con- 
genital lesion.  Most  of  the  children  who  live  beyond  six  or  seven  years 
with  cyanosis  have  this  lesion,  always  accompanied  by  others  of  a  com- 
pensatory character.  The  amount  of  obstruction  varies  from  a  slight 
narrowing  of  the  orifice  to  complete  atresia.  The  seat  of  obstruction 
may  be  at  the  pulmonic  orifice,  in  the  conus  arteriosus,  or  in  the  pul- 
monary artery  just  beyond  the  valves.  If  there  is  atresia,  the  pulmonary 
artery  is  very  small,  and  may  be  rudimentary. 

Pulmonic  Insufficiency. — This  lesion  is  relatively  rare.  It  is  usually 
the  result  of  foetal  endocarditis,  but  there  may  be  absence  of  the  pul- 
monary valve.  It  is  most  frequently  associated  with  a  defect  in  the  ven- 
tricular septum. 

Tricuspid,  mitral,  and  aortic  disease  are  relatively  infrequent  and 
usually  seen  in  cases  with  multiple  defects.  Atresia  or  stenosis  is  much 
more  common  than  insufficiency. 

Abnormalities  in  the  Origin  of  the  Large  Vessels. — These  are  quite 
frequent;  but,  as  will  be  seen  from  the  table,  they  are  always  associated 
with  other  lesions.  Three  forms  are  seen :  ( 1 )  Transposition  of  the  large 
vessels — the  pulmonary  artery  is  given  off  from  the  left,  and  the  aorta 
from  the  right,  ventricle.  (2)  Both  arteries  arise  from  a  common 
trunk.  This  is  usually  due  to  an  incomplete  development  of  the  lower 
part  of  the  septum  dividing  the  two  arteries.  Usually  the  pulmonary 
artery  appears  to  be  a  branch  of  the  aorta.  This  condition  is  fre- 
quently associated  with  other  abnormalities,  often  with  so  large  a  defect 


CONGENTIAL  ANOMALIES  OF  THE  HEART.       571 

in  the  ventricular  septum  that  there  is  really  but  one  ventricle.  (3)  The 
aorta  has  an  abnormal  origin,  arising  from  the  right  ventricle,  or  partly 
from  both  ventricles.  This  also  is  associated  witli  a  large  defect  in  the 
ventricular  septum.  When  described  as  arising  from  both  ventricles,  the 
aorta  is  usually  given  off  directly  above  the  line  .of  the  septum. 

An  abnormality  in  the  number  of  valvular  segments  is  quite  fre- 
quent, but  seldom  impairs  tlie  valve's  function.  In  rare  cases  a  valve  is 
rudimentary,  and  it  may  be  absent,  generally  at  the  pulmonic  or  tri- 
cuspid orifice.  Absence  of  the  right  auricle  and  absence  of  the  pericar- 
dium have  been  recorded;  also  opening  of  the  pulmonary  veins  into  the 
right  auricle,  and  a  single  pulmonary  artery.  In  one  case  in  the  series 
there  was  ectocardia,  this  being  associated  with  a  congenital  fissure  of 
the  sternum.  I  once  saw  a  very  remarkable  instance  of  congenital  car- 
diac displacement;  the  heart  was  situated  in  the  abdominal  cavity.  Its 
pulsations  could  be  plainly  seen  and  felt  just  above  the  umbilicus. 
There  was  a  large  umbilical  hernia,  a  congenital  defect  of  the  abdom- 
inal walls,  and  undoubtedly  also  an  opening  in  the  diaphragm.^ 

Transposition  of  the  heart,  or  true  dextro-cardia,  was  recorded  but 
twice  in  this  series  of  cases.  It  was,  however,  simulated  in  several 
others,  including  one  of  my  own,  where  the  apex  beat  was  to  the  right 
of  the  sternum.  There  was  in  this  case  great  hypertrophy  of  the  right 
ventricle  with  a  rudimentary  ventricular  septum. 

Secondary  Lesions. — In  congenital  malformations  the  right  heart  is 
usually  found  hypertrophied,  since  there  are  present  one  or  more  of  the 
fcetal  conditions  in  which  the  greater  part  of  the  work  is  thrown  upon 
the  right  ventricle.  Such  hypertrophy  is  in  most  cases  accompanied  by 
some  dilatation.  Changes  in  the  wall  of  the  left  heart  alone  are  exceed- 
ingly rare.  In  four  cases  there  was  evidence  of  malignant  endocarditis, 
which  was  the  cause  of  death,  all  but  one  of  these  patients  being  adults. 

Symptoms. — The  symptoms  of  congenital  cardiac  disease  are  usually 
manifested  soon  after  birth.  Of  128  cases  in  which  the  time  of  the  first 
symptoms  was  noted,  they  were  congenital,  or  appeared  during  the 
first  month,  in  85;  after  one  month  and  during  the  first  year,  in  18; 
from  one  to  sixteen  years,  in  15;  while  in  10  no  symptoms  were  observed 
until  after  puberty.  Congenital  cardiac  disease  is  one  of  the  causes,  but 
not  a  frequent  one,  of  death  during  the  first  days  of  life. 

The  most  striking  objective  symptom  is  cyanosis.  This  is  present 
in  most  of  the  severe  cases;  but,  considering  all  varieties,  cyanosis  is 
more  often  absent  than  present,  and  it  may  be  absent  even  with  serious 
lesions.  It  may  be  slight  and  noticed  only  upon  exertion,  as  upon 
coughing  or  crying,  or  it  may  be  intense  and  constant,  giving  the  skin 
a  dark,  leaden  colour,  and  the  mucous  membrane  of  the  mouth  a  rasp- 

» The  Medical  News,  December  11,  1897. 


S72  iDISEASES  OF  THiE  CIRCULATORY  SYSTEM. 

berry  hue.  The  view  that  cyanosis  depends  upon  an  admixture  of 
arterial  and  venous  blood  is  generally  discredited.  In  the  great  ma- 
jority of  the  cases  at  least,  the  explanation  is  a  deficient  oxidation  of 
the  blood  in  the  lungs,  owing  to  some  interference  with  the  pulmonary 
circulation.  In  sixty-three  per  cent  of  the  cases  with  cyanosis  in  the 
series,  there  was  found  pulmonic  stenosis  or  atresia,  or  a  small  pulmonary 
artery.  Cyanosis  is  of  much  value  in  diagnosis,  as  in  acquired  cardiac 
disease  it  is  rarely  persistent.  The  degree  of  cyanosis  and  its  con- 
stancy are  of  some  importance  in  determining  the  gravity  of  the  lesion, 
although  cyanosis  alone  is  not  to  be  depended  upon. 

Another    frequent    symptom    is   the   enlargement    of   the    terminal 
phalanges  known  as  clubbed  or  "  drum -stick "  fingers    (Fig.   99)   and 


Fio.  99. — Clubbing  of  the  Fingerh  in  Con(;enital  Heart  Disease. 
(From  a  boy  five  years  old.) 

toes.  This  almost  invariably  accompanies  cyanosis,  and  is  generally  pro- 
portionate to  it.  The  enlargement,  which  usually  involves  all  the 
phalanges,  is  probably  due  to  venous  obstruction.  Occasionally  there 
are  seen  dyspnaa,  oedema  of  the  face  or  lower  extremities,  dropsy  of 
the  serous  cavities,  and  haemorrhages,  particularly  hasmoptysis  and 
epistaxis. 

There  is  generally  marked  dyspnoea  on  exertion  in  the  cases  in  which 
cyanosis  is  present;  but  in  most  of  those  without  cyanosis  there  is  no 
dyspnoea,  and,  in  fact,  no  objective  or  subjective  symptoms,  even  though 
the  murmur  may  be  very  loud.    The  majority  of  the  cyanotic  cases  are 


CONGENTIAL  ANOMALIES  OF  THE  HEART.  573 

undersized  and  develop  slowly;  in  them  the  problem  of  nutrition  is  a 
difficult  one. 

In  cases  accompanied  by  cyanosis,  or  with  obstruction  to  the  pulmo- 
nary circulation,  a  polycythaemia  is  present.  The  increase  in  the  number 
of  red  cells  is  generally  proportionate  to  tlie  cyanosis;  the  average  of  fif- 
teen cases  studied  in  my  clinic  by  Dr.  I.  S.  Wile  was  7,495,000;  the 
highest  was  12,480,000.  The  haemoglohin  is  usually  correspondingly 
increased.  In  the  series  mentioned  the  average  was  1(J7  per  cent,  the 
highest  being  130.  The  number  of  white  cells  is  changed  very  slightly, 
if  at  all;  the  average  in  my  cases  was  10,200,  which  disproves  the  theory 
of  blood  concentration.  The  best  explanation  of  the  polycythaemia 
seems  to  be  that  it  is  compensatory,  and  that  the  blood  hypertrophies 
like  other  tissues.  The  blood-forming  organs  are  stimulated  to  greater 
activity  by  the  demands  of  the  tissues  for  oxygen.  The  quantity  of  blood 
remains  the  same,  but  the  number  of  red  cells  and  the  hemoglobin,  and 
consequently  the  oxygen-carrying  power,  are  \ery  greatly  increased.  This 
in  part  compensates  for  the  smaller  amount  of  blood  that  can  traverse 
the  lungs  and  there  become  oxygenated. 

Diagnosis. — The  most  important  diagnostic  features  are  cyanosis,  the 
presence  of  a  loud  murmur,  and  signs  of  enlargement  of  the  right  heart. 

Murmurs  are  present  in  fully  nine-tenths  of  the  cases,  the  most 
characteristic  being  a  systolic  murmur,  loudest  at  the  left  border  of  the 
sternum  in  the  second  or  third  intercostal  space,  and  widely  diffused, 
often  being  audible  all  over  the  chest.  The  point  of  maximum  intensity 
is  important  for  diagnosis.  In  the  great  majority  of  cases  only  a  single 
murmur  is  heard.  A  systolic  murmur  is  usually  due  to  pulmonic  stenosis, 
deficient  ventricular  septum  or  aortic  stenosis,  very  rarely  to  mitral  or 
tricuspid  regurgitation.  Since  these  conditions  are  very  often  associated, 
it  is  difficult  to  tell  upon  which  one  the  murmur  depends. 

A  patent  ductus  arteriosus  usually  gives  a  prolonged,  almost  con- 
tinuous, murmur  with  systolic  intensification,  which  is  loudest  in  the  sec- 
ond or  third  left  interspace.  In  a  young  child,  a  loud  murmur  at  the 
base  of  the  heart  with  cyanosis,  almost  always  means  congenital  disease. 
A  thrill  is  often  present  but  it  is  not  important  for  a  diagnosis. 

Enlargement  of  the  right  heart,  chiefly  from  ventricular  hypertrophy, 
is  present  in  most  of  the  cases. 

A  diagnosis  of  the  precise  nature  of  the  malformation  is  very  difficult, 
and  in  the  great  majority  of  cases  only  a  probable  diagnosis  is  possible. 
Nearly  all  the  cases  are  complex,  and  the  variety  of  combinations  is  very 
great.  A  study  of  the  histories  and  autopsies  of  the  cases  in  this  series 
reveals  many  apparently  contradictory  facts.  Loud  murmurs  are  some- 
times heard  which  are  difficult  to  explain  by  the  lesions,  and  murmurs 
may  be  absent  when  there  is  every  reason  from  the  post-mortem  findings 
for  expecting  their  presence. '  With  reference  to  the  other  conditions,  I 


574  DISEASES  OF  THE  CIRCULATORY   SYSTEM. 

can  not  do  better  than  give  the  more  frequent  clinical  symptoms  with 
the  results  of  the  autopsies  in  the  series  of  cases  which  I  have  collected. 

A  Systolic  Murmur  at  the  Base  with  Cyanosis. — This  was  the  most 
common  combination  met  with,  and  was  present  in  about  one-third  of 
the  entire  number.  In  over  eighty  per  cent  of  the  cases  with  these 
symptoms,  pulmonic  stenosis  was  found.  The  remainder  were  compli- 
cated cases  of  quite  a  wide  variety.  Pulmonic  stenosis  was  usually 
associated  with  a  defect  in  one  of  the  cardiac  septa,  or  a  patent  ductus 
arteriosus. 

A  Systolic  Murmur  without  Cyanosis. — In  this  series  of  autopsies 
this  was  not  a  frequent  combination,  being  noted  but  six  times.  It  is 
usually  dependent  upon  a  defect  in  the  ventricular  septum  without  pul- 
monic stenosis.  Clinically,  however,  this  is  more  often  seen,  in  fact  it 
is  one  of  the  most  common  types.  The  murmur  is  generally  loudest 
at  the  left  margin  of  the  sternum  at  the  third  space.  There  is  a  striking 
absence  of  all  other  symptoms.  I  have  watched  a  number  of  such  pa- 
tients grow  to  maturity  and  go  through  serious  attacks  of  illness  without 
showing  any  symptoms  referable  to  the  heart. 

A  Systolic  Murmur  at  the  Apex  with  Cyanosis. — Of  the  six  cases  with 
this  combination,  all  were  examples  of  complex  malformation,  the  most 
frequent  lesions  being  a  defect  in  the  auricular  septum,  transposition  of 
the  great  vessels,  and  patent  ductus  arteriosus. 

Cyanosis  without  murmurs  was  noted  fourteen  times.  It  usually  in- 
dicates either  pulmonic  atresia  or  the  transposition  or  irregular  origin 
of  the  great  vessels,  but  is  sometimes  seen  when  lesions,  such  as  usually 
give  murmurs,  are  found  at  autopsy. 

Diastolic  murmurs  were  heard  in  two  cases,  and  clepended  upon  pul- 
monic insufficiency. 

Absence  of  both  cyanosis  and  murmurs  was  recorded  in  five  cases. 
The  lesions  found  were:  atresia  of  the  aorta,  both  arteries  arising  from 
the  right  ventricle,  or  defective  septa. 

The  only  cases,  therefore,  in  which  a  fairly  certain  anatomical  diag- 
nosis can  be  made  are  those  of  pulmonic  stenosis  with  a  deficient  ven- 
tricular septum. 

Diagnosis  of  Congenital  from  Acquired  Disease. — Congenital  dis- 
ease may  be  suspected  if  the  patient  is  under  two  years  of  age ;  if  there 
is  no  history  of  previous  rheumatism;  if  the  murmur  is  atypical  in  its 
location,  character,  or  transmission;  if  there  is  a  very  loud  murmur  at 
the  base  or  over  the  body  of  the  heart,  and  if  there  is  evidence  of  enlarge- 
ment of  the  right  heart.  If  cyanosis  and  clubbing  of  the  fingers  are 
present  the  diagnosis  is  almost  certain. 

Especially  difficult  are  the  cases  without  cyanosis  seen  in  older  chil- 
dren. But  absence  of  hypertrophy  of  the  left  ventricle,  continued  absence 
of  subjective  symptoms,  even  with  a  very  loud  murmur,  and  a  lesion 


CONGENTIAL  ANOMALIES  OF  THE  HEART.  575 

which  does  not  increase,  all  point  strongly  to  a  congenital  malfor- 
mation. 

Diagnosis  of  Congenital  from  Accidental  Mannurs. — This  is  often  a 
more  difficult  matter  than  to  decide  between  congenital  and  acquired  dis- 
ease. From  a  murmur  alone  one  should  be  very  cautiovis  in  making  a  diag- 
nosis of  cardiac  malformation  in  a  very  antemic  infant.  Anaemic  nuirmurs 
are  systolic,  usually  basic,  unaccompanied  by  enlargement  of  the  heart ; 
usually  heard  in  the  carotids,  often  in  the  subclavian  arteries,  but  are 
seldom  so  loud  as  those  due  to  malformations.  In  some  cases  it  may  be 
necessary  to  watch  the  progress  of  the  case  before  deciding  the  question. 

In  children  from  three  to  ten  years  of  age  it  is  not  uncommon  to 
find  about  the  level  of  the  nipple  at  the  left  border  of  the  sternum  a 
soft  systolic  murmur  best  heard  on  lying  down,  which,  as  it  usually 
disappears,  must  be  considered  functional.  It  is  easily  mistaken  for  a 
congenital  murmur. 

Prognosis. — Of  225  cases,  60  per  cent  were  fatal  before  the  end  of 
the  fifth  year,,  and  nearly  one-half  of  these  during  the  first  two  months ; 
while  sixteen  per  cent  of  the  cases  lived  over  sixteen  years,  and  eight  per 
cent  over  thirty  years.  The  prognosis  in  cases  witliout  cyanosis  is  good; 
in  many  children  the  lesion  has  apparently  little  effect  on  the  health  or 
development.  The  prognosis  is  much  worse  in  cases  with  cyanosis,  and 
generally  it  is  bad  in  proportion  to  the  degree  of  cyanosis.  The  loudness 
of  the  murmur  has  no  prognostic  importance. 

In  the  cases  fatal  soon  after  birth  the  usual  lesions  are  large  defects 
in  the  septa,  transposition  of  the  great  vessels,  or  pulmonic  atresia.  In 
five  of  twenty-three  cases  dying  thus  early,  the  heart  had  but  two  cavities. 
Lesions  which  are  compatible  with  the  longest  life  are  minor  septum 
defects,  and  pulinonic  stenosis  which  can  be  compensated  for  by  hyper- 
trophy of  the  right  ventricle  and  in  other  ways.  Many  exceptional  in- 
stances are  recorded  in  which  patients  have  lived  a  long  time  in  spite  of 
extreme  deformities.  One  child  with  transposition  of  the  pulmonary 
artery  and  aorta  lived  two  and  a  half  years.  Tiedemann's  case  lived 
eleven  years  with  a  heart  consisting  of  three  cavities — two  auricles  and 
one  ventricle — and  with  constant  cyanosis.  In  three  cases  reported  by 
Eokitansky,  the  patients  lived  over  forty  years  with  rudimentary  auric- 
ular septa;  cyanosis  is  not  mentioned  as  being  present.  Gelpke's  case 
had  cyanosis,  and  lived  twenty-seven  years  with  rudimentary  auricular 
and  ventricular  septa,  and  with  no  tricuspid  opening.  Patients  with 
serious  congenital  cardiac  lesions  are  especially  susceptible  to  pulmonary 
diseases  of  all  kinds  and  occasionally  develop  malignant  endocarditis. 
Almost  any  acute  illness  may  prove  fatal. 

Treatment. — These  patients  are  prone  to  develop  at  times  attacks 
resembling  angina  pectoris,  which  are  best  relieved  by  amylnitrite  or 
by   the    use    of   morphine    hypodermically.      No    treatment    is    of    the 


676  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

slightest  avail  in  diminishing  the  amount  of  deformity  or  promoting  the 
closure  of  any  of  the  abnormal  openings.  All  cases  are  to  be  treated 
symptomatically. 


CHAPTER    III. 
PERICARDITIS. 

Inflammation  of  the  pericardium  is  uncommon  in  infancy  and 
early  childhood,  only  two  cases  being  seen  in  726  consecutive  autopsies 
at  the  New  York  Infant  Asylum.  But  in  later  childhood  pericarditis 
is  more  frequent  and  more  serious  than  the  same  disease  in  adults. 

Pericarditis  is  almost  invariably  a  secondary  disease,  following  (1) 
empyema  or  pleuro-pneumonia ;  (2)  acute  rheumatism;  (3)  acute  in- 
fectious diseases,  especially  scarlet  fever;  (4)  pyaemia;  (5)  tuberculosis; 
(6)  local  conditions.  The  relative  importance  of  these  causes  differs 
with  the  age  of  the  child.  In  infancy  and  early  childhood  nearly  all  the 
cases  complicate  disease  of  the  lung  or  pleura,  more  frequently  of  the 
left  side.  After  the  fourth  year  rheumatism  takes  the  first  place  as  an 
etiological  factor.  Pericarditis  is  then  generally  associated  with  endo- 
carditis, and  may  precede  or  follow  the  articular  manifestations  of  rheu- 
matism. Following  scarlet  fever,  pericarditis  often  occurs  in  connection 
with  nephritis  or  multiple  joint  inflammations.  In  typhoid  fever  also 
it  is  usually  associated  with  pneumonia  or  joint  lesions.  Pyaemia  may 
be  a  cause  in  the  newly  born,  or  it  may  occur  in  connection  with'  disease 
of  the  bones  or  joints  in  older  children;  in  both  it  is  usually  associated 
with  similar  lesions  of  other  serous  membranes.  Tuberculous  pericarditis 
is  more  frequent  after  the  third  year,  and  is  generally  secondary  to  pul- 
monary tuberculosis.  Among  the  local  causes  may  be  mentioned  trau- 
matism, ulceration  of  a  foreign  body  from  the  oesophagus  into  the  peri- 
cardium, disease  of  the  sternum,  ribs,  or  vertebrae,  and  abscesses  resulting 
from  cheesy  bronchial  lymph  nodes. 

Lesions. — Pericardial  transudations,  or  an  increase  in  the  normal 
pericardial  fluid,  are  met  with  in  many  conditions  in  which  there  is  a 
very  marked  degree  of  anaemia,  general  dropsy,  or  a  weak  heart,  partic- 
ularly of  the  right  side.  Generally  from  one  and  a  half  to  two  ounces 
of  clear  serum  are  found  in  the  pericardial  sac. 

Pneumococcus  pericarditis  is  always  acute  and  closely  resembles  in 
its  lesions  the  inflammation  of  the  pleura  due  to  the  same  cause.  In 
the  milder  cases  there  is  seen  only  a  fibrinous  exudate.  In  the  more 
common  and  more  severe  forms  the  visceral  and  parietal  pericardium  is 
covered  with  a  thick  coating  of  fibrin  and  pus  (compare  pleuro-pneu- 
monia), or  more  pus  cells  and  serum  may  be  poured  out  and  the  sac 


ACUTE   PERICARDITIS.  577 

contain  fluid  pns.  The  amount  is  usually  small,  one-half  to  one  ounce, 
but  it  may  be  as  much  as  a  pint.  When  the  inflaiimiation  is  excited  by 
other  pyogenic  organisms,  the  staphylococcus  or  the  streptococcus,  the 
lesions  are  similar  to  those  just  described. 

In  rheumatic  pericarditis  the  inflammation  may  be  a  plastic  one  with 
a  fibrino-cellular  exudate  (dry  pericarditis)  or  sero-fihrinous  (pericar- 
ditis with  effusion).  The  inflammation  generally  begins  at  the  baf-e  of 
the  heart  and  affects  both  the  visceral  and  parietal  layers.  The  (juantity 
of  fluid  present  is  usually  small,  not  exceeding  two  or  three  ounces;  ex- 
ceptionally as  much  as  a  pint  may  be  present.  It  may  be  clear  or 
slightly  turbid.  More  important  than  the  j^ericarditis  are  the  associated 
changes  in  the  heart  muscle.  These  are  present  in  every  severe  case. 
To  the  myocarditis  and  consequent  dilatation  the  most  serious  symptoms 
of  pericarditis  are  due. 

Purulent  pericarditis  may  be  set  up  by  a  foreign  body  ulcerating  into 
the  sac,  by  the  rupture  of  a  mediastinal  abscess,  or  by  general  pya?mia. 
Under  these- circumstances  the  process  may  be  purulent  from  the  outset. 
Any  of  the  pyogenic  bacteria  may  be  found. 

External  or  mediastinal  pericarditis  is  always  associated  with  medi- 
astinal pleurisy,  and  results  in  more  or  less  extensive  adhesions  of  the 
pericardial  and  pleural  surfaces,  wnth  an  increase  in  the  connective  tissue 
of  the  mediastinum.  This  is  often  a  tuberculous  process.  When  severe, 
it  may  cause  compression  of  the  large  blood-vessels,  but  seldom  in  any 
other  way  produce  symptoms.  With  this  form  there  is  usually  inflam- 
mation of  tlie  internal  layer  of  the  pericardium  as  well.  Only  inflamma- 
tion of  the  internal  layer  is  ordinarily  considered  as  pericarditis,  the 
other  form  being  preferably  classed  as  mediastinitis. 

Pericarditis  with  an  effusion  of  blood  is  very  rare  in  children.  It  may 
occur  from,  the  rupture  of  organised  adhesions  or  in  certain  blood  states 
such  as  purpura,  and  very  rarely  in  tuberculosis. 

With  acute  tuberculosis  there  is  usually  only  a  deposit  of  miliary 
tubercles,  or  there  may  be  a  small  serous  or  sero-sanguinolent  effusion. 
In  chronic  cases  there  may  be  a  tuberculous  inflammation  with  the  for- 
mation of  caseous  nodules,  new  connective  tissue,  and  extensive  adhesions. 
This  generally  occurs  in  connection  with  pulmonary  tuberculosis — some- 
times with  tuberculous  peritonitis. 

In  any  form  of  pericarditis  complete  recovery,  so  far  as  pathological 
conditions  are  concerned,  is  rare — if,  indeed,  it  ever  occurs.  After  a 
rheumatic  pericarditis  adhesions  remain,  which  may  be  slight,  but  are 
often  complete,  causing  entire  obliteration  of  the  pericardial  sac.  Such 
adhesions  are  followed  by  secondary  changes.  The  growth  and  devel- 
opment of  the  heart  are  interfered  with,  and  there  may  be  sufficient 
pressure  upon  the  coronary  vessels  to  lead  to  degeneration  of  the  mus- 
cular walls  and  chronic  dilatation  of  the  heart. 
38 


578  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Symptoms. — A  pericardial  transudation,  or  dropsy  of  the  pericar- 
dium, is  very  rarely  large  enough  to  make  a  diagnosis  possible. 

External  pericarditis  is  seldom  recognised  during  life,  there  being  no 
symptoms  except  those  of  the  pleurisy  with  which  it  is  associated.  Occa- 
sionally there  may  be  heard,  particularly  if  the  inflammation  is  anterior, 
a  pleuritic  friction  sound  which  is  increased  with  the  systole  of  the 
heart.  The  pulse  may  be  weak  during  inspiration,  and  there  may  be  an 
increased  area  of  cardiac  dulness.  If  the  inflammation  is  cliiefly  posterior, 
it  causes  only  the  symptoms  of  mediastinitis,  which  is  recognised  prin- 
cipally by  its  pressure  effects  upon  the  great  vessels.  It  may  produce 
cedema  of  the  face  or  of  the  lower  extremities,  ascites,  enlargement  of  the 
liver  and  spleen,  but  rarely  albuminuria.  It  is  usually  progressive,  and 
lasts  from  a  few  months  to  two  or  three  years,  according  to  its  cause. 

Pericarditis  in  infancy  is  usually  overlooked,  not  only  on  account  of 
its  rarity,  but  also  from  the  obscurity  of  its  symptoms.  When  pericarditis 
develops  at  the  height  of  an  attack  of  pneumonia,  as  it  usually  does, 
there  may  be  no  new  symptoms,  or  at  most  only  increased  prostration 
with  perhaps  a  more  rapid  or  slightly  irregular  pulse.  On  auscultation, 
if  practised  early,  one  may  get  pericardial  friction  sounds;  l)ut  these  are 
masked  by  the  pulmonary  signs  and  in  infants  seldom  made  out.  The 
most  striking  sign  is  that  the  cardiac  sounds  formerly  distinct  are  now 
feeble  and  distant,  at  times  almost  inaudible.  Later  there  may  be  in- 
creased dulness  from  pericardial  effusion,  or  from  dilatation.  The  phy- 
sician should  be  on  the  watch  for  it  in  infants  with  pleuro-pneumonia, 
especially  of  the  left  side. 

Rheumatic  pericarditis  affecting  as  it  generally  does  older  children 
is  easier  of  recognition.  Localised  pain  and  tenderness  are  usually  pres- 
ent and  also  a  certain  amount  of  embarrassment  of  the  heart's  action, 
manifested  by  precordial  distress,  palpitation,  or  a  tumultuous  heart 
action  with  a  rapid  and  at  times  an  irregular  pulse.  There  is  often  vom- 
iting, dyspnoea,  and  a  teasing,  dry  cough;  there  may  be  orthopncea  and 
some  cyanosis.    Sometimes  there  is  delirium. 

The  earliest  physical  signs  of  pericarditis  are  friction  sounds,  which 
can  generally  be  heard,  though  sometimes  over  only  a  small  area,  at 
the  base  of  the  heart.  The  sound  is  a  double  one;  it  is  synchronous 
with  the  heart's  movement,  it  is  generally  more  circumscribed  tlian 
an  endocardial  murmur  and  not  so  blowing  in  character.  Very  early 
there  is  an  increase  in  cardiac  dulness  which  may  be  considerable.  It 
may  extend  as  much  as  one  and  one-half  inches  beyond  the  right  border 
of  the  sternum,  and  to  the  left  one  or  two  inches  beyond  the  mammary 
line.  (See  Figs.  100  and  101.)  It  may  be  due  to  effusion  or  to  dilata- 
tion with  which  effusion  is  easily  and  frequently  confounded.  In  a  case 
with  early  and  rapidly  developing  dulness  it  is  safe  to  assume  that  some 
dilatation  is  present.    When  there  is  considerable  effusion  the  apex  beat 


ACUTE  PERICARDITIS. 


579 


is  feeble  and  may  be  displaced  upward.  The  cardiac  sounds  are  dimin- 
ished in  intensity  and  may  be  almost  inaudible.  The  area  of  dulness  is 
triangular  or  pear-shaped  with  the  base  below.  Witli  large  effusion  there 
may  also  be  dulness  to  the  left  of  the  spine  beliind.  Rotch's  sign  of 
effusion,  dulness  to  the  right  of  the  sternum  in  the  fiftli  space,  though 
often  present  is  not  entirely  reliable. 

In  cases  terminating  fatally  the  progress  of  the  disease  is  quite  rapid, 
the  entire  duration  Ixjing  seldom  longer  than  three  or  four  weeks,  and 


Fig.  100. — Pericarditis  with  Effusion. 
Anterior  view,  showing  moderate  disten- 
tion of  the  pericardium,  especially  to  the 
right  of  the  middle  line;  right  border 
at  A.    Boy  eight  years  old. 


Fig.  101. — Pericarditis  with  Effusion. 
Same  patient  as  Fig.  100,  but  taken  four 
days  later.  Great  distention  of  the  peri- 
cardium ;  right  border  at  B.  Complete 
recovery  by  absorption. 


it  may  be  much  less.  Pneumonia  often  develops  toward  the  close.  When 
ending  i^i  recovery  improvement  is  very  slow  and  it  may  be  two  or  three 
months  before  the  patient  is  out  of  bed,  and  a  much  longer  time  before 
even  a  moderate  degree  of  health  is  established. 

Prognosis. — Acute  pericarditis  due  to  the  pneumococcus  in  infancy 
almost  invariably  ends  fatally  and  in  older  children  this  is  the  usual 
termination.  Occasionally  at  the  later  age  resolution  may  take  place 
before  pus  forms,  or  the  pyo-pericardium  which  ensues  is  successfully 
opened  and  drained.  Purulent  pericarditis  from  other  causes  is  usually 
fatal.  In  rheumatic  pericarditis  the  outlook  for  life  is  better,  but  this 
with  its  associated  myocarditis  is  without  doubt  the  gravest  manifesta- 
tion of  rheumatism  in  early  life.  No  complication  is  more  to  be  dreaded, 
both  on  account  of  immediate  and  remote  dangers.  Of  forty-eight  cases 
of  acute  pericarditis  reported  by  Still  in  which  this  supervened  during 
endocarditis,  forty  proved  fatal  in  the  course  of  a  few  weeks.  In  patients 
who  do  not  die  from  the  disease  the  remote  consequences  by  reason  of 
adhesions  and  subsequent  dilatation  are  very  serious. 

Diagnosis. — Pericarditis  is  recognised  by  knowing  when  to  look  for 
it — in  infants  with  pneumonia,  in  older  children  with  rheumatism.    The 


580  DISEASES  OF  THE  CIRCULATORY   SYSTEM. 

difficulties  of  diagnosis  of  dry  pericarditis  are  very  much  greater  in  young 
children  owing  to  the  very  rapid  action  of  the  heart.  Dry  pericarditis 
is  recognised  by  the  friction  sounds,  which  are  best  heard  over  the  base 
and  are  to  be  differentiated  from  endocardial  murmurs.  Pericarditis  with 
effusion  is  to  be  diagnosticated  from  dilatation  of  the  heart  and  from  pleu- 
ritic effusions.  From  dilatation,  the  diagnosis  is  very  difficult  in  child- 
hood, but  the  recognition  of  small  effusions  is  not  essential,  since  the  im- 
portant condition  is  the  accompanying  dilatation.  Large  effusions  ma}'^  be 
mistaken  for  a  sacculated  empyema  of  the  left  side,  in  the  latter,  however, 
the  heart  is  generally  crowded  to  the  right.  When  empyema  and  pericar- 
ditis coexist,  it  may  be  impossible  to  recognise  the  condition.  The  diag- 
nosis l)etween  serous  and  purulent  effusions  can  be  made  only  by  aspiration. 
Treatment. — In  an  attack  of  acute  pericarditis  the  patient  should  be 
kept  in  bed,  absolutely  quiet,  and  an  ice-bag  used  over  the  heart.  A 
layer  of  thin  flannel  should  be  placed  beneath  the  bag.  During  the 
acute  stage  it  should  be  applied  constantly  with  perhaps  a  few  hours' 
omission  during  the  night.  To  be  effective  much  attention  to  detail  is 
necessary.  Some  children  will  not  tolerate  ice  and  for  them  dry  heat 
may  be  substituted.  It  often  mitigates  the  pain.  Counter-irritation  by 
mustard  from  time  to  time  is  useful,  but  blisters  should  not  be  employed 
in  children.  Leeching  is  much  used  in  England,  not  so  much  in  this 
country  as  its  merits  warrant.  Four  or  five  leeches  are  applied  over  the 
sternum  or  liver.  The  especial  indications  for  leeches  according  to  Still 
are  cyanosis,  marked  dyspnoea,  and  a  dilatation  as  shown  by  increase  in 
the  cardiac  dulness.  A  rapid  increase  in  dulness  is  to  be  regarded  as 
mainly  due  to  dilatation  rather  than  effusion.  Opium  is,  I  think,  of 
more  value  than  any  other  drug.  It  has  a  steadying  influence  upon  the 
excited  heart,  it  relieves  pain  and  also  quiets  the  distressing  cough.  The 
form  of  administration  is  immaterial.  The  patient  should  be  kept 
moderately  under  its  influence  throughout  the  active  stage  of  the  attack. 
Digitalis  is  sometimes  useful,  but  must  be  used  with  caution.  Alcohol 
is  seldom  indicated  and  has  often  done  much  harm  in  these  cases. 
"Strychnia  and  caffein  are  much  to  be  preferred  when  symptoms  of  heart 
failure  are  present.  In  the  rheumatic  form  anti-rheumatic  remedies  are 
indicated,  though  it  is  still  a  question  whether  they  accomplish  very 
much  after  a  severe  pericarditis  is  once  fairly  under  way.  Either  sali- 
cylate of  soda  or  aspirin  may  be  used.  Serous  effusions  usually  subside 
under  simple  tonic  treatment.  With  very  large  serous  effusions  aspira- 
tion may  relieve  distressing  symptoms,  after  which  the  rest  of  tlie  fluid 
may  undergo  absorption.  If  the  exploring  needle  shows  the  fluid  to 
be  purulent,  incision  and  drainage  should  be  practised  as  in  empyema. 
The  results  of  aspiration  are  exceedingly  unfavourable.  Of  eighteen 
cases  of  aspiration  of  the  pericardium  collected  by  Keating,  only  four 
recovered.    In  puncturing  the  pericardium  the  point  usually  selected  is  a 


CHRONIC   PERICARDITIS  WITH  ADHESIONS.  581 

little  to  the  left  of  the  border  of  the  sternum  in  tlie  fifth  intercostal 
space,  the  needle  being  directed  upward  and  outward.  In  cases  wliich  do 
not  end  fatally  a  prolonged  period  of  rest  in  bed  is  imperative  on  account 
of  the  dilatation. 

CHRONIC   PERICARDITIS   WITH   ADHESIONS. 

This  is  not  a  very  uncommon  condition.  It  is  usually  general,  but 
may  be  localised.  The  youngest  case  which  has  come  under  my  observa- 
tion was  in  a  child  sixteen  months  old,  who  died  fro  mi  acute  broncho- 
pneumonia. The  adhesions  were  old  and  general,  the  pericardial  sac 
being  completely  obliterated.  Chronic  adhesive  pei-icarditis  may  follow 
single  or  repeated  attacks  of  acute  rheumatic  pericarditis ;  it  may  be  tuber- 
culous. The  pericardium  may  become  very  greatly  thickened  and  its 
cavity  obliterated ;  it  may  be  adherent  externally  to  the  pleura,  diaphragm, 
and  chest  wall.  Other  changes  are  usually  present  in  the  heart.  It  is 
often  the  seat  of  chronic  myocarditis;  the  cavities  are  usually  greatly 
dilated,  and  the  heart  walls  much  hypertrophied.  Valvular  lesions  may 
be  present. 

Partial  adhesions  cause  no  symptoms  by  which  they  can  be  recognised, 
and  even  general  adhesions  sufficient  to  obliterate  the  pericardial  sac 
may  be  found  at  autopsy  when  not  suspected  during  life.  This  is  one  of 
the  conditions  in  which,  after  it  has  led  to  considerable  dilatation  of  the 
heart,  sudden  death  sometimes  occurs.  Usually  there  is  pallor,  slight 
cyanosis,  localised  oedema  of  the  chest  and  abdominal  walls,  and  dyspnoea 
upon  slight  exertion.  The  liver  and  spleen  are  often  enlarged  and  there 
may  be  ascites.     These  symptoms  often  lead  to  errors  in  diagnosis. 

The  heart  is  almost  invariably  much  enlarged,  chiefly  from  dilatation. 
On  inspection,  there  may  be  bulging  of  the  chest  wall,  with  a  dift'used 
and  often  feeble  or  absent  apex  beat.  The  characteristic  signs  are  a 
systolic  retraction  of  the  chest  at  or  near  the  apex  of  the  heart,  sometimes 
at  the  tip  of  the  sternum.  This  is  due  to  the  external  pericardial  ad- 
hesions, and  is  often  better  appreciated  by  palpation  than  by  inspection. 
It  is  followed  by  a  rapid  rebound,  associated  with  diastolic  collapse  of  the 
jugular  veins.  Pulsus  paradoxicus  may  also  be  present.  Percussion 
shows  an  increase  in  the  cardiac  dulness  in  all  directions.  The  position 
of  the  apex  and  the  percussion  outline  of  the  heart  do  not  change  with 
the  posture  of  the  patient,  and  the  cardiac  dulness  is  but  little  affected 
by  full  inspiration.  A  systolic  murmur  is  often  present.  The  diagnosis 
of  adherent  pericardium  always  presents  difficulties,  but  it  can  be  made 
with  tolerable  certainty  in  a  considerable  proportion  of  cases.  On 
account  of  the  enlargement  of  the  heart  and  the  frequency  of  murmurs, 
it  is  usually  mistaken  for  valvular  disease.  The  prognosis  is  very  bad. 
The  lesion  is  a  permanent  one,  and  tends  to  increase.  The  treatment  is 
symptomatic. 


582 


DISEASES  OF  THE   CIRCULATORY  SYSTEM. 


CHAPTER    IV. 


ENDOCARDITIS  AND   VALVULAR  DISEASE  OF   THE  HEART. 


Endocarditis  may  occur  even  in  foetal  life.  At  this  period  it  usu- 
ally affects  the  right  side  of  the  heart,  and  is  one  of  the  important  causes 
of  congenital  malformations.  In  infancy,  acute  endocarditis  is  exceed- 
ingly rare,  not  a  single  instance  being  found  in  over  one  thousand  autop- 
sies upon  children  under  three  years  of  age  of  which  I  have  records. 
From  the  third  to  the  fifth  year  it  is  not  so  rare,  and  after  five  years  is 
quite  common. 

The  following  table  gives  the  age  and  sex  in  a  series  of  cases  of 
valvular  disease  observed  by  Dr.  Crandall  and  myself : 


Age. 

1 

year. 

2 
yemra. 

3 
ye*™. 

* 

yean. 

6 
yean. 

« 

yeara. 

7 
yean. 

8 
yean. 

t 

yewa. 

10 
year*. 

11 

yean. 

yean. 

13 
jean. 

1      H 

yeart. 

Totals. 

Males  .  . 
Females. 



1 
1 

2 

2 
3 

2 
5 

4 

7 

6 
9 

4 
10 

9 
3 

8 
11 

6 
12 

5 
14 

7 
4 

6 
2 

1      55,  or  38% 
3     90,  "  62% 

Total. 

5 

7 

11 

15 

14 

12 

19 

18 

19 

11 

8 

4    145 

The  proportion  of  the  sexes  is  very  nearly  the  same  as  in  my  cases  of 
rheumatism.  Sturges,  in  100  cases  of  chronic  endocarditis,  gives  fifty- 
six  per  cent  females  and  forty-four  per  cent  males. 

Endocarditis  is  usually  spoken  of  as  secondary  to  rheumatism;  it  is 
rather  to  be  regarded  as  a  manifestation,  often  the  first,  of  that  disease. 
Of  117  cases  in  my  own  series,  ninety-three,  or  eiglity  per  cent,  gave  a 
history  of  previous  rheumatism.  Of  the  31  cases  which  at  the  first 
examination  gave  no  history  of  rheumatism,  8  subsequently  developed 
articular  symptoms,  and  2  chorea ;  so  tliat  nearly  ninety  per  cent  of  this 
series  of  cases  presented  conclusive  evidence  of  a  rheumatic  diathesis. 
Thirty  per  cent  had  chorea  previously,  or  developed  it  while  under  ob- 
servation. The  proportion  of  rheumatic  cases  corresponds  very  closely 
with  Cheadle's  observations.  In  a  series  of  150  cases  of  valvular  dis- 
ease. Still  found  distinct  evidences  of  rheumatism  in  142. 

Endocarditis  may  occur  alone  or  with  other  manifestations  of  rlieu- 
matism.  While  frequently  associated  with  acute  articular  rheumatism, 
in  a  much  larger  number  it  is  seen  with  articular  symptoms  which  are 
so  slight  as  to  be  overlooked  entirely  or  passed  over  as  unimportant.  It 
may  occur  with  or  follow  chorea,  tonsillitis,  or  torticollis,  with  or  without 
articular  symptoms.  The  proportion  of  rheumatic  cases  in  which  endo- 
carditis occurs  is  much  larger  in  children  than  in  adults.  In  rare  in- 
stances endocarditis  is  seen  in  the  course  of  nearly  all  the  infectious 
diseases,  most  frequently  with  scarlet  fever,  being  often  associated  with 
pericarditis;  but  even  in  these  conditions  it  is  possible  that  it  is  some- 


ENDOCARDITIS  AND   VALVULAR  DISEASE  583 

times  rheumatic.  The  hacteriology  of  rheumatic  endocarditis  has  not  yet 
been  determined  with  certainty. 

Lesions.— In  the  great  majority  of  cases  endocarditis  affects  the 
mitral  valve,  and  often  only  this.  In  150  autopsies  upon  children  dying 
of  cardiac  disease,  Poynton  found  the  mitral  valve  involved  in  149,  hut 
in  76  of  these  the  changes  were  not  marked  ;  in  only  9  was  there  marked 
mitral  stenosis.  Tlie  aortic  valve  was  affected  in  51,  but  in  only  9  was 
it  seriously  involved.  Very  striking  was  the  frequency  of  pericarditis. 
Pericardial  adhesions  were  present  in  113  cases,  and  in  77  the  adhesions 
were  complete,  i.  e.,  the  pericardial  cavity  was  obliterated.  These  find- 
ings agree  substantially  with  the  observations  of  other  English  author- 
ities, but  in  America  the  pericardial  lesions  are  certainly  not  so  prom- 
inent. 

The  pathological  changes  of  acute  endocarditis  do  not  differ  essen- 
tially in  early  life  from  those  seen  in  adults.  There  is  first  an  accumula- 
tion of  bacteria  upon  the  endocardium  of  tlie  valves.  These  produce 
necrosis,  which  is  followed  by  a  clot  formation,  consisting  chiefly  of  blood 
platelets  and  fibrin,  in  the  meshes  of  which  are  leucocytes  and  a  few  red 
cells.  The  next  change  is  a  growth  of  new  connective  tissue  cells  and 
blood-vessels,  which  may  be  slight  and  superficial,  l)ut  the  rheumatic 
lesion  usually  extends  deeply  with  an  extensive  proliferation  of  connective 
tissue  which  after  a  time  undergoes  contraction. 

In  the  mildest  forms  of  endocarditis  it  is  possible  for  complete  re- 
covery to  take  place.  In  other  cases  there  is  left  only  a  slight  valvular 
thickening,  not  enough  to  interfere  in  any  important  way  with  function. 
In  most  patients,  however,  more  marked  changes  are  left.  The  valvular 
segments  are  swollen,  adherent,  somewhat  shortened  and  consequently 
insufficient.  Other  changes  in  the  heart  usually  accompany  acute  endo- 
carditis. Dilatation  is  almost  invariably  present  and  is  an  important 
factor  in  producing  insufficiency.  In  cases  ending  fatally  there  is  very 
little  hypertrophy;  but  if  recovery  occurs,  hypertrophy  develops  and  the 
lesion  is  compensated  for  in  this  way.  A  certain  amount  of  myocarditis 
probably  occurs  in  every  severe  case.  It  is  most  marked  when  pericar- 
ditis is  also  present.  Emboli  in  children  are  rare.  Subsequent  attacks 
are  exceedingly  common  and  each  one  leaves  the  heart  more  seriously 
crippled. 

Chronic  inflammation  may  follow  the  first  attack  or  more  often  occur 
after  repeated  attacks.  The  changes  resulting  from  chronic  endocarditis 
are  practically  identical  with  those  seen  in  adult  life  and  need  not  be 
described  here.  Emphasis,  however,  should  be  laid  upon  the  fact  that 
the  younger  the  child  the  more  rapid  the  progress  of  the  disease. 

Symptoms. — When  endocarditis  occurs  as  a  primary  disease,  or  when 
it  is  the  only  manifestation  of  rheumatism,  it  may  begin  abruptly  with 
rather  severe  general  symptoms — a  temperature  of  101^  to  104°  F.,  pros- 


584  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

tration,  exaggerated  heart  action,  restlessness,  and  sometimes  dyspnoea. 
More  frequently,  however,  it  begins  much  less  acutely  with  only  general 
malaise  and  slight  fever,  which  often  is  not  recognised  without  the  ther- 
mometer. If  the  heart  is  not  watclied  the  diagnosis  is  not  made  and  there 
may  be  no  suspicion  of  the  nature  of  the  primary  attack  until  some  time 
afterward,  when  the  existence  of  valvular  disease  is  discovered.  If,  how- 
ever, the  heart  is  carefully  and  frequently  examined  there  is  heard,  usu- 
ally on  the  third  or  fourth  day  of  the  illness,  a  soft,  blowing,  systolic 
murmur  at  the  apex. 

Endocarditis  occurring  with  rheumatism  is  l)y  no  means  limited  to 
those  attacks  with  well-defined  articular  symptoms.  It  is  very  common 
and  often  severe  when  tlie  articular  symptoms  are  no  more  than  stiffness, 
pain  on  motion,  and  slight  swelling  of  the  feet  or  ankles.  There  is  no 
relation  between  the  severity  of  these  symptoms  and  the  seriousness  of 
the  cardiac  lesion.  Occurring  during  chorea  or  after  tonsillitis  there  may 
be  nothing  to  call  attention  to  the  heart  except  sometimes  an  increased 
rapidity  or  irregularity  of  the  pulse  and  possibly  increased  prostration; 
but  frequently  the  cardiac  condition  is  not  suspected  until  the  heart  is 
examined. 

Most  of  the  cases  of  acute  endocarditis  seen  in  this  country  are  of  tliis 
mild  type.  Attacks  of  such  severity  as  to  produce  death  in  the  acute 
stage  are  relatively  rare  here,  in  marked  contrast  to  the  observations  of 
English  writers. 

The  usual  duration  of  acute  endocarditis  is  from  two  to  four  weeks, 
the  general  symptoms  slowly  subsiding  and,  if  tlie  case  progresses  favour- 
ably, the  cardiac  symptoins  improve,  but  there  is  usually  left  beliind  a 
somewhat  damaged  heart  because  of  valvular  disease.  In  cases  progress- 
ing unfavourably  a  fatal  termination  may  come  in  the  course  of  from  two 
to  six  weeks  owing  usually  to  one  of  three  causes  or  a  combination  of 
these:  (1)  The  rapid  development  of  dilatation  accompanied  by  the 
usual  signs  of  cardiac  insufficiency;  (2)  pulmonary  complications,  gen- 
erally pneumonia;  (3)  the  supervention  of  acute  pericarditis. 

Course  of  Chronic  Valvular  Disease. — Chronic  valvular  disease  fol- 
lows one  or  more  attacks  of  acute  endocarditis,  and  may  exist  for  months 
and  sometimes  for  years,  before  it  is  recognised.  Its  course  is  usually 
divided  into  two  periods,  the  first  being  that  while  compensation  is  pres- 
ent, and  the  second  after  compensation  has  failed.  The  duration  of  the 
stage  of  compensation  is  indefinite.  The  only  subjective  symptom  that 
is  of  much  diagnostic  value  is  shortness  of  breath  on  exertion.  Occa- 
sionally other  symptoms  are  present,  such  as  praecordial  pain,  attacks  of 
palpitation,  headache,  epistaxis,  anaemia,  loss  of  weight,  and  cough. 
These  are  rarely  constant,  but  come  on  when  the  patient's  general  con- 
dition for  any  reason  is  below  normal.  As  a  rule,  there  is  in  young 
subjects  a  tendency  to  an  increase  in  the  disease,  although  this  is  often 


ENDOCARDITIS   AND   VALVULAR   DISEASE.  585 

slow,  and  may  be  interrupted  hy  long  jx-riods  in  wiiicli  the  process  ap- 
pears to  be  stationary.  At  such  times  the  patients  either  have  no  symp- 
toms, or  suffer  only  from  a  slight  amount  of  inconvenience  on  marked 
exertion. 

Failure  in  compensation  is  generally  brought  about  by  one  of  the 
following  causes:  The  most  frequent  is  an  intercurrent  attack  of  rheu- 
matism with  a  fresh  endocarditis,  wliich  in  a  short  time  leads  to  a  verv 
great  increase  in  the  heart's  disability.  It  may  be  due  to  additional  work 
thrown  upon  the  heart  from  excessive  muscular  exertion,  or  to  the  strain 
of  a  prolonged  attack  of  some  acute  illness,  especially  one  that  is  liable 
to  produce  changes  in  the  heart  muscle,  such  as  typlioid,  diphtheria,  or 
scarlet  fever.  It  is  sometimes  the  increased  work  wliich  is  thrown  upon 
the  heart  especially  at  the  time  of  puberty,  owing  to  the  rapid  growth 
of  the  body.  It  may  result  from  any  cause  wliich  seriously  affects  the 
patient's  general  nutrition,  particularly  when  this  is  associated  with 
marked  anaemia. 

The  symptoms  indicating  failure  of  compensation  are  marked  dysp- 
noea or  orthopnoea  and  cough,  sometimes  accompanied  by  profuse  ex- 
pectoration, which  may  be  bloody,  and  in  rare  cases  there  may  ])e  larger 
pulmonary  haemorrhages.  With  these  may  be  associated  other  signs  of 
pulmonary  congestion  and  even  pulmonary  oedema.  Tlie  obstruction  to 
the  systemic  venous  circulation  leads  to  dropsy,  which  usually  begins  in 
the  feet,  sometimes  in  the  face.  There  may  be  general  anasarca  and 
dropsy  of  the  serous  cavities,  especially  the  peritonaeum  and  pleura ;  also 
enlargement  and  functional  disturbances  of  the  liver,  enlargement  of  the 
spleen,  dyspeptic  symptoms,  and  chronic  congestion  of  the  kidney,  with 
scanty  urine  and  albuminuria.  There  may  be  dilatation  of  the  superficial 
veins  and  cyanosis;  and  there  may  be  cerebral  symptoms,  such  as  head- 
ache, dizziness,  and  fainting  attacks.  The  pulse  is  small  and  soft,  and 
the  heart's  action  rapid  and  irregular;  the  cardiac  sounds  are  feeble  and 
often  indistinguishable,  and  it  may  be  impossible  to  decide  what  mur- 
murs, if  any,  are  present. 

It  is  rare  to  see  all  the  symptoms  of  chronic  progressive  cardiac  fail- 
ure in  children  under  ten  years,  but  about  the  time  of  puberty  they  are 
common  enough.  The  symptoms  may  increase  in  severity  until  death 
occurs,  or  they  may  be  severe  for  a  time  and  then  nearly  disappear,  to 
return  again  after  a  longer  or  shorter  interval.^  Death  may  be  due  to 
sudden  cardiac  paralysis,  to  intercurrent  nephritis,  pneumonia,  embolism, 
inflammation  of  the  serous  membranes,  or  to  oedema  of  the  lungs. 

'  The  course  and  termination  of  these  cases  of  chronic  valvular  disease  is  well 
illustrated  by  the  following  history  of  a  little  girl  who  was  under  my  observation  for 
nine  years:  When  first  seen  she  was  seven  years  old,  and  gave  a  history  of  cardiac 
symptoms  for  one  year.  There  was  then  present  a  loud  mitral  regurgitant  murmur, 
with  considerable  hypertrophy.     There  was  general  dropsy,  and  all  the  symptoms 


586  DISEASES  OF  THE   CIRCULATORY  SYSTEM. 

Physical  Signs. — Mitral  murmurs  are  altogether  the  most  common 
both  in  acute  and  chronic  disease.  Of  141  cases  of  valvular  disease,  in 
children  under  fourteen  years,  observed  clinically,  mitral  murmurs  were 
present  in  135;  in  131  the  murmur  of  mitral  insufficiency  was  heard,  and 
in  99  this  alone.  In  mitral  insufficiency  there  is  regurgitation  of  blood 
from  the  left  ventricle  into  the  left  auricle  during  systole.  There  is 
heard  a  systolic  murmur,  synchronous  with  the  apex  impulse  and  with 
the  first  sound  of  the  heart,  which  may  wholly  or  in  part  replace  the  first 
sound.  It  is  loudest  at  the  apex,  transmitted  to  the  left,  and  usually 
heard  at  the  inferior  angle  of  the  left  scapula.  In  acute  endocarditis  the 
murmur  is  at  first  very  soft  and  usually  increases  in  intensity  for  sev- 
eral days.  It  may  be  represented  by  the  syllables  "  whoo-ta  "  pronounced 
in  a  whisper.  After  attaining  its  maximum  the  murmur  changes  but 
little  for  some  time.  It  may  then  diminish  and  eventually  disappear 
entirely;  but  usually  a  murmur  of  moderate  intensity  remains.  The 
only  other  important  sign  of  acute  endocarditis  is  enlargement  of  the 
heart  which  is  almost  entirely  from  dilatation.  If  the  acute  inflammation 
supervenes  upon  an  old  lesion,  the  previous  murmur  becomes  louder  and 
liarsher.  In  chronic  endocarditis  the  murmur  is  similar  to  that  of  acute 
endocarditis  but  generally  louder  and  more  widely  diffused,  and  may  be 
audible  all  over  the  chest.  It  is  accompanied  by  an  accentuation  of  the 
pulmonic  second  sound  and  by  signs  of  hypertrophy,  especially  of  the 

pointed  toward  acute  dilatation.  Under  treatment,  the  dropsy  and  other  symptoms 
disappeared,  and  she  went  on  comfortably  for  over  a  year.  In  her  eighth  and  ninth 
years  there  were  frequent  attacks  of  subacute  rheumatism,  during  which  time  the 
heart  lesion  steadilj'  increased  in  severity.  At  twelve  years  there  was  an  eruption  of 
subcutaneous  tendinous  nodules,  which  remained  for  over  two  years.  During  this 
year  there  was  heard  for  the  first  time  a  presystolic  mitral  murmur,  accomj)anied  by 
a  very  marked  thrill,  mitral  stenosis  having  been  gradually  brought  about  by  the 
slowly  progressing  endocarditis.  This  murmur  gradually  increased  in  intensitj'^  from 
that  time,  while  the  mitral  regiu-gitant  murmur  became  less  distinct.  The  apex  beat 
was  then  in  the  sixth  space,  two  and  a  half  inches  to  the  left  of  the  nipple.  From 
the  twelfth  to  the  fifteenth  year  she  grew  very  little  in  height  or  weight,  and  showed 
no  signs  of  maturity,  the  cardiac  symptoms  being  nearly  stationary.  In  the  fifteenth 
year  she  developed  a  marked  enlargement  of  the  liver  and  spleen  with  general  dropsy 
and  all  the  symptoms  of  cardiac  iasufficiency,  these  being  the  first  symptoms  of  this 
character  since  she  was  seven  years  old.  There  was  now  heard  for  the  first  time  an 
aortic  regiu"gitant  murmur  iti  addition  to  the  others  formerly  present.  The  symp- 
toms disappeared  under  treatment  in  the  course  of  a  few  months,  but  six  months  later 
returned  with  greater  severity  and  were  accompanied  by  albuminuria,  the  patient 
dying  from  heart  failure  in  a  few  weeks.  During  the  last  exacerbation  there  was 
heard  a  double  aortic  as  well  as  a  double  mitral  murmur. 

At  autopsy  the  heart  weighed  fifteen  ounces.  There  was  a  very  great  hyper- 
trophy, especially  of  the  right  ventricle,  which  was  as  thick  as  the  left.  All  the  cavi- 
ties were  much  dilated.  The  most  important  valvular  lesion  was  mitral  stenosis,  the 
orifice  not  admitting  the  end  of  the  little  finger.  The  valves  were  the  seat  of  cal- 
careous deposits.  The  curtains  of  the  aortic  valve  were  thickened  and  adherent; 
there  was  also  thickening  of  the  pulmonic  and  tricuspid  valves. 


ENDOCARDITIS  AND  VALVULAR  DISEASE.  587 

right  heart.  When  both  these  signs  are  wanting,  the  existence  of  mitral 
insufficiency  is  somewhat  doubtful,  as  a  similar  murnmr  may  I)e  func- 
tional or  accidental.  In  the  early  stages  of  the  disease  and  during  com- 
pensation, the  signs  of  hypertrophy  predominate;  in  the  later  stages  or 
with  broken  compensation,  those  of  dilatation. 

Mitral  stenosis  is  relatively  uncommon.  It  occurs  after  repeated  at- 
tacks of  rheumatism,  with  a  slowly  progressing  endocarditis.  It  is  usu- 
ally associated  with  mitral  regurgitation.  With  this  lesion  there  is  ob- 
struction to  the  flow  of  blood  from  the  left  auricle  into  the  left  ventricle. 
It  is  mainly  compensated  for  by  hypertrophy  of  the  right  ventricle,  but 
to  a  certain  degree,  also,  by  hypertrophy  of  the  left  auricle.  The  char- 
acteristic murmur  of  fully  developed  mitral  stenosis  is  presystolic,  pro- 
longed, rough  in  character,  and  terminates  abruptly  witli  a  sharp  first 
sound  of  the  heart.  It  is  loudest  at  or  just  above  the  apex,  but  is  audible 
over  only  a  circumscribed  area.  Quite  as  constant  and  important  for 
diagnosis  is  the  presence  of  a  "  purring  thrill,''  which  is  very  distinct 
upon  palpation,  and  terminates  sharply  as  the  apex  strikes  the  chest 
wall.  This  murmur  is  not  common  in  children  and  is  heard  only  in 
eases  in  which  cardiac  disease  has  lasted  several  years. 

With  milder  grades  of  mitral  stenosis,  or  earlier  in  the  course  of  the 
disease,  there  may  be  heard,  shortly  after  the  second  sound,  a  murmur 
softer  in  quality  and  of  short  duration.  It  is  usually  audible  above  and 
to  the  inner  side  of  the  apex  beat.  In  point  of  time  this  is  often  spoken 
of  as  the  early  diastolic  murmur  of  mitral  stenosis.  It  may  be  repre- 
sented by  the  whispered  syllables  "  whoo-ta-whoo,"  in  which  the  first  syl- 
lable is  the  mitral  systolic  murmur,  which  is  somewhat  prolonged;  the 
second  syllable  is  the  second  cardiac  sound ;  the  last  is  the  early  diastolic 
murmur,  which  is  much  shorter  than  the  systolic  murmur.  The  pulse  of 
mitral  stenosis  is  usually  small. 

Aortic  lesions  in  children  are  much  less  common  than  mitral  lesions, 
with  which  they  are  usually  associated;  they  are  seen  in  rather  older 
patients.  Aortic  insufficiency  is  much  more  frequent  than  aortic 
stenosis.  I  have  never  seen  it  as  the  only  lesion.  It  causes  a  regurgita- 
tion of  blood  from  the  aorta  into  the  left  ventricle  during  diastole.  It 
is  compensated  for  by  dilatation  and  hypertrophy  of  the  left  ventricle. 
The  signs  of  aortic  insufficiency  are  a  prolonged  diastolic  murmur,  with 
or  taking  the  place  of  the  second  sound  of  the  heart,  generally  loudest 
at  the  left  border  of  the  sternum  in  the  third  space,  and  transmitted 
downward  to  the  apex  of  the  heart  or  the  ensiform  cartilage.  This  is 
invariably  accompanied  by  signs  of  hypertrophy  and  dilatation  of  the 
left  ventricle,  which  are  usually  marked.  With  great  hypertrophy  there 
is  often  bulging  of  the  prsecordium  which  may  produce  striking  thoracic 
deformity.  A  characteristic  symptom  is  the  intense  throbbing  of  the 
carotids,  with  the  sudden  distention  followed  by  a  complete  collapse  of 


588  DISEASES  OF  THE   CIRCULATORY  SYSTEM. 

their  walls,  and  the  "  water-hammer "  pulse  of  Corrigan.     A  capillary 
pulse  is  often  seen. 

Aortic  stenosis,  unless  congenital,  is  very  rare  in  early  life,  and  almost 
never  occurs  as  the  only  lesion.  Aortic  stenosis  is  compensated  for  by 
hypertrophy  of  the  left  ventricle.  It  causes  a  systolic  murmur,  which  is 
usually  loudest  at  the  right  border  of  the  sternum  in  the  second  space, 
and  is  transmitted  upward,  being  distinct  in  tlie  carotids.  The  second 
sound  is  generally  weak  and  may  be  replaced  by  a  diastolic  murmur. 
A  systolic  thrill  over  the  aortic  area  is  usually  present.  Without  the 
signs  of  hypertrophy  of  the  left  ventricle,  a  positive  diagnosis  sliould 
not  be  made. 

Tricuspid  insufficiency  is  usually  secondary  to  disease  of  the  left  side 
of  the  heart,  occurring  in  its  late  stages.  It  most  frequently  follows 
mitral  insufficiency,  where  it  is  usually  due  to  dilatation  of  the  right 
ventricle  without  changes  in  the  valves.  It  may  be  secondary  to  certain 
diseases  of  the  hings,  such  as  emphysema,  chronic  interstitial  pneumonia, 
or  chronic  pleurisy,  and  it  may  be  due  to  congenital  malformation.  Tri- 
cuspid insufficiency  gives  a  systolic  murmur,  loudest  over  the  lower  part 
of  the  sternum,  but  heard  usually  over  a  small  area.  It  is  associated  with 
signs  of  dilatation  of  the  right  ventricle.  The  jugular  veins  stand  out 
prominently,  and  often  show  systolic  pulsation,  especially  upon  the  right 
side.  The  symptoms  associated  with  tricuspid  regurgitation  are  due  to 
general  systemic  venous  obstruction. 

-   Tricuspid  stenosis,  pulmonic  stenosis,  and  puTmo»  ic  insufficiency  are 
practically  unknown  in  childhood  except  as  congenital  lesions. 

Prognosis. — The  danger  to  life  in  acute  endocarditis  is  not  great  un- 
less it  is  accompanied  by  pericarditis;  but  wlien  both  are  present  the 
outlook  is  serious.  Of  115  fatal  cases  reported  by  Poynton,  thirty-five 
proved  fatal  in  the  primary  attack.  It  is  difficult  during  the  active  stage 
to  foretell  how  serious  will  be  the  resulting  damage  to  the  heart.  It  is 
only  by  watching  the  progress  of  a  case  that  one  can  decide.  As  a  rule 
the  younger  the  child  the  worse  the  prognosis. 

Complete  recovery  from  valvular  disease  is  possible  only  when  the 
lesions  are  very  slight.  Not  many  children  die  from  chronic  cardiac 
disease  before  reaching  the  age  of  ten  or  twelve  years.  Up  to  about 
the  time  of  puberty  many  children  do  very  well ;  then  they  begin  to  lose 
ground,  and  may  fail  rapidly.  But  more  often  it  is  a  fresh  endocarditis 
accompanying  an  intercurrent  attack  of  rheumatism  which  marks  the  be- 
ginning of  a  downward  course.  The  proportion  of  children  who  have 
serious  cardiac  lesions  before  the  age  of  eight  years  and  reach  adult 
life  in  good  condition  is  very  small. 

There  are  several  features  of  cardiac  disease  in  children,  in  conse- 
quence of  whicli  serious  lesions  tend  to  progress  more  rapidly  than  in 
adults.     The  muscular  walls  are  less  resistant,  and  hence  dilatation  oc- 


ENDOCARDITIS  AND   VALVULAR  DISEASE.  589 

curs  much  more  readily  tlian  in  adult  life.  'Vhe  \mivi  must  provide  not 
only  for  constant  needs,  but  for  the  growth  of  the  body.  If  the  patient's 
general  nutrition  is  poor  during  the  period  of  most  rapid  growth,  this 
tells  quickly  and  seriously  upon  the  heart,  and  dilatation  makes  rapid 
progress.  The  demands  made  upon  the  heart  at  puberty  arc  especially 
severe,  by  reason  of  the  rapid  growth  of  the  body  and  the  frequency  of 
anaemia  and  malnutrition.  There  is  always  present  the  danger  of  rapid 
advances  in  the  disease  from  intercurrent  attacks  of  rheumatism,  from 
which  children  are  more  likely  to  suffer  than  are  older  subjects.  Ex- 
tensive pericardial  adhesions  are  frequent,  and  seriously  handicap  the 
heart,  greatly  increasing  the  tendency  to  dilatation.  The  effect  upon  the 
heart  of  poor  food,  unhygienic  surroundings,  and  general  malnutrition 
is  much  more  marked  than  in  adults. 

These  unfavourable  conditions  are  in  part  offset  by  others  in  which 
the  child  has  an  advantage  over  the  adult.  Disease  of  tlie  coronary 
arteries  is  very  rare,  and  the  valvular  lesion  which  is  most  frequently  met 
with — mitral  "insufficiency — is  that  wliich  admits  of  the  most  complete 
compensation. 

In  making  a  prognosis  in  any  given  case,  the  amount  of  hypertrophy 
or  dilatation  which  exists,  and  the  presence  or  absence  of  pericardial  ad- 
hesions are  more  important  than  the  location  or  the  special  character  of 
the  murmur.  The  presence  of  valvular  disease  in  childhood  increases 
the  danger  from  every  acute  disease,  especially  pertussis,  diphtheria, 
pneumonia,  and  scarlet  fever.  The  chances  of  recurring  attacks  of  rheu- 
matism must  also  be  taken  into  account. 

Diagnosis. — Valvular  disease  is  to  be  particularly  distinguished  from 
conditions  in  which  there  are  heard  functional  or  accidental  murmurs. 
According  to  my  own  experience  the  latter  are  quite  common  even  in 
young  children.  Mistakes  usually  arise  from  attaching  too  much  impor- 
tance to  the  presence  of  murmurs,  and  too  little  to  the  changes  in  the 
walls  and  cavities  of  the  heart,  with  which  valvular  disease  is  almost  in- 
variably associated.  It  is  not  always  possible  to  decide  w^hether  a  murmur 
is  organic  or  functional  until  the  patient  has  been  for  some  time  under 
observation  and  treatment,  particularly  when  anaimia  is  present.  The 
diagnostic  points,  so  far  as  the  murmurs  are  concerned,  are  mentioned 
in  connection  with  accidental  murmurs. 

Treatment. — The  first  and  altogether  the  most  important  indication 
for  every  case  of  recent  endocarditis  is  to  secure  for  the  heart  as  complete 
rest  as  possible,  not  only  during  the  period  of  active  inflammation,  but 
for  several  succeeding  weeks.  The  reason  for  this  is  that  some  dilatation 
is  always  present  and.  this  very  readily  increases.  With  children,  proj^er 
rest  can  be  secured  only  by  keeping  them  in  bed;  and,  when  possible, 
in  a  recumbent  position.  The  duration  of  the  period  of  rest  after  mild 
attacks  of  endocarditis  should  be  at  least  six  weeks,  and  after  severe 


590  DISEASES  OF  THE  CIRCUIiATORY  SYSTEM. 

attacks,  three  months.  In  these  young  patients  changes  in  the  walls  of 
the  heart  take  j^lace  very  rapidly  and  the  gravest  consequences  are  liable 
to  follow  a  neglect  of  these  precautions.  In  old  cases  rest  is  indicated 
during  every  acute  exacerbation;  also  whenever  there  is  much  dilatation 
and  little  hypertrophy,  and  whenever  the  signs  of  failing  compensation 
are  present.  In  these  older  cases  rest  is  often  impossible  in  the  recumbent 
position ;  if  secured  at  all,  it  must  be  obtained  witji  the  child  in  the  sit- 
ting posture  or  at  least  propped  up  with  pillows.  Whether  much  can  be 
accomplished  by  the  administration  of  anti-rheumatic  remedies  after  en- 
docarditis has  developed  is  very  doubtful.  Salicylates  or  aspirin  and 
alkalies  should,  however,  invariably  be  used  with  every  fresh  manifesta- 
tion of  rheumatism,  to  prevent,  if  possible,  an  increase  in  the  cardiac  in- 
flammation. A  child  who  is  the  subject  of  a  chronic  valvular  disease 
should  be  constantly  under  a  physician's  observation.  Irreparable  harm 
often  results  from  ignorant  disregard  of  the  simplest  and  most  important 
rules  of  life  for  these  patients. 

Several  distinct  conditions  may  be  present  which  call  for  quite  differ- 
ent management.  The  essential  points  may  be  stated  in  a  few  words: 
For  all  recent  cases  and  during  all  exacerbations,  rest,  complete  and  pro- 
longed; for  deformed  valves  with  good  heart  walls  and  perfect  compen- 
sation, fresh  air,  moderate  exercise,  and  general  tonics;  for  feeble  heart 
walls,  failing  compensation  and  dilatation,  rest  and  cardiac  tonics. 

During  the  stage  of  compensation,  treatment  directed  especially  to 
the  heart  is  rarely  necessary.  The  main  purpose  should  be  to  maintain 
the  patient's  general  nutrition  at  the  highest  possible  point  during  the 
period  of  active  growth.  At  the  very  least  the  patient  should  be  carefully 
examined  three  or  four  times  each  year,  in  order  that  the  physician  may 
note  the  progress  of  the  disease,  and  be  able  to  direct  the  child's  educa- 
tion, occupation,  exercise,  and  surroundings  so  as  to  meet,  as  far  as 
possible,  the  changing  conditions.  To  this  end,  diet,  sleep,  study,  and 
exercise  should  receive  the  most  careful  attention.  If  malnutrition  and 
anaemia  are  allowed  to  go  on  unchecked  until  they  become  severe,  the 
cardiac  disease  may  make  rapid  strides,  and  as  much  harm  be  done  in  a 
few  months  as  otherwise  might  not  occur  in  years.  The  question  of  ex- 
ercise and  recreation  is  always  a  difficult  one  to  settle.  Often  too  little 
latitude  is  given,  and  the  heart,  like  the  voluntary  muscles,  loses  its  tone. 
Every  form  of  exercise  requiring  a  prolonged  severe  strain  should  be 
forbidden,  particularly  swimming  and  competitive  games,  like  ball  and 
tennis,  and  others  requiring  much  running;  but  skating,  rowing,  horse- 
back exercise,  regulated  gymnastics,  and  cycling  on  the  level — all  in 
moderation — may  be  allowed  not  only  without  harm,  but  with  the  great- 
est benefit;  but  any  of  these,  used  immoderately,  may  be  productive 
of  great  injury.  All  exercise  should  be  taken  with  regularity  and 
system,  the  amount  being  carefully  measured  by  the  child's  condition. 


MALIGNANT  ENDOCARDITIS.  591 

and  increased  freedom  allowed  onl}-  after  watcliiiio-  tho  efFoct.  If  the 
patient  is  a  boy  who  must  earn  his  own  livin<r,  ilic  ])liysician  should  see 
to  it  that  the  occupation  chosen  is  not  one  likely  to  make  special  de- 
mands upon  the  heart  or  to  expose  him  unduly  to  conditions  likely  to 
induce  rheumatism. 

Special  watchfulness  is  required  at  the  time  of  puberty  to  prevent 
overpressure  in  schools,  and  the  development  of  ananuia.  The  first  symp- 
toms of  these  conditions  should  be  treated  energetically,  and  if  the  heart 
seems  to  be  overtaxed  the  child  should  be  put  to  bed.  Those  who  are 
specially  liable  to  rheumatic  attacks  should,  if  possible,  spend  the  winter 
and  spring  months  in  a  warm,  dry  climate 

In  the  stage  of  failing  compensation,  the  saine  general  conditions  are 
present  as  in  adults,  and  they  are  to  be  managed  in  pretty  much  the  same 
way.  When  such  symptoms  are  first  seen,  prolonged  rest  in  bed  should 
be  insisted  upon  as  the  thing  most  likely  to  restore  the  normal  conditions. 
Digitalis  and  strophanthus  are  useful  in  children  with  about  the  same 
indications  as  in  adults,  viz.,  marked  dilatation,  dropsy,  low  arterial 
tension,  and  weak  pulse.  They  may  be  used  in  doses  of  from  five  to  ten 
drops  of  the  tincture  every  four  to  six  hours  for  a  child  of  ten  years. 
If  there  is  much  dilatation  of  the  right  side  of  the  heart  the  same  treat- 
ment is  indicated  as  described  in  pericarditis.  One  should  be  cautious 
about  using  digitalis  for  an  irregular  and  overacting  heart,  opium  being 
decidedly  preferable  under  these  conditions.  An  overloaded  venous  cir- 
culation may  be  relieved  by  diuretics,  by  saline  purgatives,  or  even  by 
venesection.  Iron  and  tonics  generally  are  indicated,  particularly  strych- 
nine and  cod-liver  oil. 

MALIGNANT  ENDOCARDITIS. 

Malignant  or  ulcerative  endocarditis  is  rare  in  childhood.  The 
youngest  cases  I  have  found  reported  are  one  by  Bond  in  an  infant  of 
two  and  a  half  months,  and  one  by  Harris  in  a  boy  four  years  old.  In 
Bond's  case  the  mitral  valve  was  affected.  It  was  due  to  the  bacillus 
pyocyaneus.  In  Harris'  case  the  right  side  of  the  heart  was  affected 
and  the  lesion  was  secondary  to  a  congenital  malformation.  Of  the 
cases  reported  in  early  life,  most  have  been  in  children  over  ten  years  of 
age.  Malignant  endocarditis  is  rarely  if  ever  primary.  It  may  be  seen 
in  any  infectious  disease  or  septic  process.  In  seventy-five  per  cent  of 
the  cases  it  is  ingrafted  upon  a  previous  valvular  disease.  In  my  series 
of  collected  cases  of  congenital  malformations  of  the  heart,  there  were 
four  deaths  from  malignant  endocarditis,  all  but  one,  however,  occurring 
in  adult  life.  The  bacteria  most  frequently  concerned  are  the  staphy- 
lococcus or  streptococcus,  next  the  pneumococcus,  and  rarely  the  gono- 
coccus,  the  influenza  or  the  pyocyaneus  bacillus. 

Malignant  endocarditis  presents  a  great  variety  of  symptoms,  often 


592  DISEASES  OF  THE   CIRCULATORY   SYSTEM. 

making  the  diagnosis  extremely  diflficult.  There  is  generally  a  remittent 
type  of  fever,  sometimes  repeated  rigors,  sweating,  low  delirium,  stupor 
or  coma,  and  extreme  prostration.  There  is  often  a  fme  petechial  erup- 
tion. Usually  there  is  a  cardiac  murmur,  the  location  of  which  depends 
upon  the  seat  of  the  disease ;  it  is  most  frequently  the  murmur  of  mitral 
regurgitation.  It  is  sometimes  faint,  and  may  be  absent.  From  the 
emboli  there  may  result  hemiplegia,  rapid  swelling  of  the  spleen,  bloody 
urine  or  pneumonia.  The  disease  lasts  from  three  weeks  to  three  months, 
death  being  the  almost  invariable  termination.  The  most  characteristic 
features  of  malignant  endocarditis  are  the  development  of  pyaemic  or 
typhoid  symptoms  with  a  petechial  eruption,  in  a  patient  who  has  pre- 
viously had  valvular  disease.  Blood  cultures  in  most  cases  give  positive 
results,  though  not  always  early  in  the  disease. 

The  treatment  is  symptomatic.  The  use  of  vaccines  has  not  met 
expectations;  in  the  most  acute  cases  no  benefit  has  generally  followed 
their  administration,  although  in  the  more  prolonged  types  they  seem 
at  times  to  have  been  of  value. 


MYOCARDITIS. 

Disease  of  the  muscular  wall  of  the  heart  is  rare  in  children,  and  of 
comparatively  little  importance,  except  in  connection  with  acute  endo- 
and  pericarditis  and  the  acute  infectious  diseases.  It  is  almost  invariably 
secondary  to  some  infectious  process.  Aside  from  the  rheumatic  condi- 
tions already  considered  the  diseases  which  furnish  most  of  the  cases 
are  scarlet  fever,  diphtheria,  and  influenza.  The  most  important  local 
cause  is  pericarditis  with  adhesions. 

Lesions. — In  extra-uterine  life,  myocarditis  as  a  rule  affects  chiefly 
the  wall  of  the  left  ventricle,  the  papillary  muscles,  or  the  septum,  but 
the  entire  organ  is  involved.  The  heart  is  of  a  grayish  or  yellowish-red 
colour,  very  soft,  friable,  and  flabby,  and  there  is  frequently  dilatation  of 
the  cavities. 

Two  varieties  of  myocarditis  are  described.  In  the  parenchymatous 
form  there  is  a  degeneration  of  the  muscle  fibre  which,  according  to 
Romberg,  is  most  frequently  albuminous,  next  fatty,  and  least  frequently 
hyaline.  There  is  a  loss  of  the  transverse  striations,  and  there  may  be 
complete  disintegration  of  the  fibres.  This  process  may  be  circumscribed, 
but  it  is  usually  diffuse.  In  the  interstitial  form  the  lesion  usually  occurs 
in  small,  circumscribed  areas.  There  is  an  infiltration  of  round  cells, 
chiefly  mononuclear,  between  the  muscular  fibres  of  the  heart.  The  proc- 
ess, when  acute,  may  result  in  absorption  or  in  the  production  of  small 
abscesses.  In  chronic  cases  it  may  lead  to  the  formation  of  areas  of  dense 
connective  tissue  resembling  cicatrices,  in  the  heart  wall.  Either  the 
interstitial  or  the  parenchymatous  form  may  occur  alone,  but  in  most 


ACCIDENTAL  MURMURS.  593 

of  the  acute  cases  they  are  combined.  In  addition,  there  is  usually  some 
degree  of  mural  endocarditis  and  inflammation  of  the  pericanliuin  next 
to  the  heart  wall.  Dilatation  frequently  foih)\vs.  Cardiac  aneurism  and 
even  rupture  have  been  known  to  occur  in  a  child  of  six  years  (Iladden's 
case). 

Symptoms. — In  many  cases  in  which  advanced  lesions  have  been 
found  at  autopsy  there  have  been  no  symptoms  appreciated  during  life. 
Careful  examination  of  the  heart,  however,  will  usually  show  an  altera- 
tion in  the  first  cardiac  sound,  the  muscular  quality  diminishing  and 
the  valvular  quality  increasing.  This  may  go  on  even  to  a  total  disap- 
pearance of  the  muscular  quality  and  only  a  flapping  valvular  sound  may 
remain.  The  first  and  the  second  sounds  are  then  almost  alike.  In  sn(;h 
severe  cases  diastole  is  relatively  short  and  the  rhythm  is  much  like  that 
of  foetal  life.  A  systolic  murmur  due  to  dilatation  of  the  auriculo-ven- 
tricular  ring,  or  to  imperfect  action  of  the  papillary  nniscles,  may  be 
heard  at  the  apex.  The  heart  is  usually  slightly  dilated,  but  may  be 
excessively  so.  Its  action  is  generally  increased  in  rapidity  and  may  be 
irregular;  a  slow  heart,  50  to  70,  with  feeble,  valvular  sounds  is  less 
frequent  but  very  characteristic.  The  apex  beat  is  diminished  in  intensity 
and  the  pulse  is  soft  and  weak.  The  blood  pressure  is  low,  frequently 
60  mm.  or  even  less.  Other  symptoms  may  be  present  that  are  dependent 
upon  feeble  heart  action — pallor,  dyspnoea,  slight  cyanosis,  and  attacks 
of  syncope.  Less  frequently  there  may  be  dropsy  of  the  feet  or  the  serous 
cavities,  and  scanty  urine,  sometimes  containing  albumin.  Death  may 
occur  suddenly  from  cardiac  paralysis  or  gradually  from  circulatory  fail- 
ure. Eecovery  may  take  place  after  alarming  symptoms  have  been 
present,  these  slowly  abating.  It  may  be  many  weeks  before  the  normal 
cardiac  sounds  are  heard. 

Treatment. — This  is  mainly  symptomatic.  After  severe  attacks  of 
those  infectious  diseases  in  which  myocarditis  is  liable  to  occur,  and  at 
any  time  when  it  is  suspected,  patients  should  be  kept  recumbent  for 
several  weeks,  and  special  care  exercised  to  prevent  any  sudden  exertion, 
as  death  has  resulted  from  so  slight  a  thing  as  suddenly  sitting  up  in 
bed.  Once  definite  symptoms  have  developed,  absolute  rest  is  imperative. 
Much  more  is  to  be  expected  from  complete  rest  than  from  drugs,  which 
as  often  employed  may  do  positive  harm.  Digitalis  should  be  used  with 
caution,  and  never  in  large  doses.  In  some  cases  with  symptoms  indicat- 
ing imminent  heart  failure  rather  striking  benefit  has  followed  the  use 
of  morphine  hypodermically. 

ACCIDENTAL   MURMURS. 

In  a  paragraph  upon  the  diagnosis  of  congenital   cardiac   disease, 
reference  has  already  been  made  to  a  type  of  nmrmur  frequently  heard 
39 


594  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

in  children  and  which  may  be  confounded  with  a  nuiiniur  due  to  organic 
disease. 

Accidental  murmurs  may  also  be  heard  in  cases  of  marked  anemia. 
These  are  not  rare  even  in  infancy.  They  may  be  confounded  with 
organic  murmurs  either  from  congenital  malformations  or  from  acquired 
disease.  In  any  anaemic  infant,  as  well  as  older  cliikl,  one  should  hesitate 
to  make  a  diagnosis  either  of  congenital  or  acquired  organic  disease,  from 
the  mere  presence  of  a  murmur. 

An  anaemic  murmur  is  usually  systolic,  generally  but  not  always  loud- 
est at  the  base  of  the  heart,  audible  in  the  carotids,  often  in  the  sub- 
clavians,  and  occasionally  over  any  large  artery.  The  murmur  varies 
from  day  to  day,  and  sometimes  it  is  altered  by  changing  the  position  of 
the  patient.  It  may  be  loud  enough  to  be  heard  over  a  great  part  of  the 
chest  in  front,  and  even  behind.  There  is  frequently  present  a  venous 
hum  in  the  neck.  There  are  no  signs  of  hypertrophy,  nor  is  tliere  tlie 
accentuated  second  sound  so  characteristic  of  mitral  disease.  The  pulse 
is  not  usually  strong.  Anaemic  murmurs  diminish  in  intensity  and  ulti- 
mately disappear  with  improvement  in  the  general  condition  of  the 
patient. 

FUNCTIONAL   DISORDERS   OF  THE   HEART. 

Disturbances  in  the  heart's  action  unconnected  with  organic  disease, 
are  not  very  common  in  young  children ;  but  after  the  seventh  year  they 
increase  in  frequency  up  to  tlie  time  of  puberty.  One  of  the  most  im- 
portant causes  is  indigestion;  another  is  overpressure  in  schools,  or  any- 
thing else  leading  to  nervous  exhaustion.  In  these  circumstances  it  is 
usually  associated  with  other  mental  or  psychical  disturbances.  An  im- 
portant predisposing  cause  is  the  demand  made  upon  the  heart  by  the 
rapid  growth  of  the  body  about  the  time  of  puberty,  particularly  when 
this  is  associated  with  anaemia.  In  some  of  the  cases  there  is  a  definite 
exciting  cause,  such  as  fright  or  great  excitement,  and  it  may  be  due  to 
the  excessive  use  of  tea,  coffee,  or  tobacco,  especially  in  the  form  of 
cigarette-smoking.  In  a  few  instances  it  has  been  traced  to  masturbation. 
It  may  follow  any  acute  disease,  such  as  typhoid  fever,  malaria,  or  one 
of  the  exanthemata,  and  occasionally  it  occurs  in  the  course  of  these  dis- 
eases, or  with  bronchitis  or  pneumonia. 

Symptoms. — The  usual  manifestations  are  attacks  of  palpitation ;  less 
frequently  there  is  tachycardia  or  bradycardia.  Tlie  majority  of  chil- 
dren complain  more  with  functional  disturbances  than  with  organic  dis- 
ease, certainly  while  the  latter  is  accompanied  by  compensation.  Attacks 
of  palpitation  occur  in  paroxysms.  In  the  severe  form  there  is  usually 
a  sense  of  oppression  in  the  region  of  the  heart,  with  some  dyspnoea,  or 
even  orthopncea.  The  pulse  is  usually  rapid,  from  120  to  130,  and  is 
irregular  both  as  to  force  and  rhythm.     The  carotids  pulsate  strongly. 


DISEASES   OF  THE   BLOOD-VESSELS.  595 

The  apex  impulse  is  felt  over  an  increased  area,  the  heart  sounds  are 
usually  strong  but  irregular,  and  sometimes  a  slight  murnuir  is  heard. 
The  face  is  pale  or  flushed.  There  may  l)e  headache,  vertigo,  spots  before 
the  eyes,  and  noises  in  the  ears.  Sometimes  there  is  siigiit  cyanosis  with 
cold  hands  and  feet,  and  general  perspiration.  The  frequency  of  these 
attacks  depends  upon  the  nature  of  the  exciting  cause.  Their  duration 
is  from  a  few  minutes  to  several  hours. 

Diagnosis. — Functional  disorders  are  differentiated  from  organic  car- 
diac disease  only  by  careful  and  repeated  examinations  of  the  heart.  In 
the  diagnosis  of  functional  disturbance  especial  importance  is  to  be  at- 
tached to  a  neurotic  or  neurasthenic  condition  of  the  patient,  to  the 
presence  of  some  adequate  exciting  cause,  the  absence  of  evidence  of 
enlargement  of  the  heart,  and  the  fact  that  the  pulmonic  second  sound 
is  not  increased. 

Prognosis. — This  in  most  cases  is  favourable,  for  with  the  removal 
of  the  cause,  with  improvement  in  the  ])atient's  general  condition,  with 
the  growth  of  the  body,  and  in  girls  with  the  establishment  of  menstrua- 
tion, the  attacks  usually  disappear. 

Treatment. — The  curative  treatment  is  to  be  directed  toward  the, 
cause.  When  no  special  cause  can  be  discovered  a  general  tonic  plan  of 
treatment  should  be  adopted,  with  careful  regulation  of  the  patient's  diet, 
exercise,  and  mode  of  life.  All  stimulating  food,  tea,  coffee,  and  tobacco 
should  be  prohibited.  Anaemia  should  receive  its  appropriate  remedies. 
The  hours  of  sleep  and  study,  and  the  amount  and  character  of  exercise 
allowed,  should  be  carefully  regulated.  Between  attacks  no  treatment 
of  the  heart  is  necessary.  During  attacks  bromides  or  valerian  may  be 
useful. 

DISEASES  OF  THE   BLOOD-VESSELS. 

Abnormally  Small  Arteries  (Arterial  hypoplasia). — This  condition 
is  not  a  very  common  one,  but  it  has  attracted  a  good  deal  of  attention, 
having  been  studied  especially  by  Virchow.  The  only  thing  which  is 
abnormal  in  the  circulatory  system  may  be  that  the  aorta,  and  sometimes 
all  the  large  vessels  are  only  two-thirds  or  three-fourths  their  usual 
calibre,  or  even  less.  This  may  interfere  seriously  with  the  growth  and 
development  of  the  body,  especially  of  the  genital  organs,  although  this 
result  is  not  a  constant  one.  The  condition  is  found  occasionally  in  cases 
of  chlorosis,  and  in  the  congenital  cases  it  may  be  the  chief  cause.  There 
is  sometimes  associated  a  certain  amount  of  hypertropby  of  the  heart. 
The  other  symptoms  are  anemia,  and  sometimes  an  imperfect  develop- 
ment of  the  body.    A  positive  diagnosis  during  life  is  impossible. 

Aneurism  and  Atheroma. — In  early  life  chronic  disease  of  the  blood- 
vessels is  exceedingly  rare,  yet  a  sufficient  number  of  observations  have 
been  recorded  to  show  that  even  young  children  are  not  exempt  from  this 


596  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

form  of  disease.  Sanne  ^  records  the  youngest  case,  which  occurred  in  a 
foetus  born  at  about  the  eighth  month,  in  whose  body  there  was  found  a 
large  aneurism  of  the  abdominal  aorta  just  below  the  origin  of  the 
renal  arteries.  Le  Boutillier  -  has  collected  seven  eases  of  thoracic  aneu- 
rism in  children  under  ten  years;  the  arch  of  the  aorta  was  tlie  usual 
seat. 

Probably  the  most  important  etiological  factor,  as  in  adult  life,  is 
syphilis,  but  in  only  a  few  of  the  cases  reported  was  the  evidence  of 
syphilis  conclusive.  In  two  cases  there  was  general  tuberculosis.  In  at 
least  two  cases  whooping-cough  appeared  to  act  as  a  contributing  cause. 
Aneurism  may  also  be  due  to  some  local  condition,  such  as  an  erosion 
from  a  bony  growth,  an  abscess  in  the  neighbourhood,  or  to  embolism. 
The  symptoms  and  course  of  aneurism  in  young  children  do  not  differ 
essentially  from  those  of  the  disease  as  seen  in  adults. 

In  addition  to  the  cases  of  aneurism  referred  to  above,  I  have  found 
reports  of  seven  cases  of  atheroma  in  very  young  subjects.  In  Sanne's 
case  the  patient  was  but  two  years  old,  and  patches  of  atheromatous  de- 
generation were  found  in  several  places  in  the  aorta.  In  Hawkins'  case, 
eleven  years  old,  there  was  found  extensive  atheromatous  disease  of  the 
aorta,  subclavian  and  carotid  arteries.  In  Filatoff's  case,  atheromatous 
degeneration  affected  the  arteries  at  the  base  of  the  brain,  causing  death 
from  cerebral  haemorrhage.  It  is  interesting  to  note  that  in  this  patient, 
who  was  only  eleven  years  old,  there  was  also  present  chronic  diffuse 
nephritis  with  contracted  kidney's.  A  similar  condition  of  the  kidneys 
and  arteries  was  observed  by  Dickinson  in  a  girl  of  six  years. 

Embolism  and  Thrombosis. — Embolism  is  very  rare  in  early  life,  even 
with  acute  endocarditis.  The  emboli  are  usually  swept  into  the  circu- 
lation from  vegetations  upon  the  valves  of  the  heart.  The  symptoms 
which  they  produce  will  depend  upon  the  nature  of  the  emboli  and  the 
vessels  occluded  by  them.  If  they  lodge  in  the  brain  they  may  cause 
paralysis  or  conMilsions;  if  in  the  spleen,  pain  and  swelling  of  this 
organ;  if  in  the  kidneys,  pain,  tenderness,  and  sometimes  haematuria; 
if  in  the  lungs,  cough,  sometimes  accompanied  by  haemoptysis  and  occa- 
sionally by  a  sharp  thoracic  pain.  If  the  emboli  are  infectious,  they 
may  give  rise  to  abscesses.  The  pathological  results  following  em- 
bolism are  similar  to  those  which  are  seen  in  adults. 

The  most  frequent  form  of  thrombosis,  that  occurring  in  the  sinuses 
of  the  brain,  is  discussed  in  connection  with  Diseases  of  the  Nervous 
System.  Cardiac  thrombi,  especially  of  the  right  side  of  the  heart,  are 
not  infrequently  found  in  patients  dying  from  heart  disease,  pneu- 
monia, and  occasionally  also  from  other  acute  inflammatory  processes 

'  Sann6,  Revue  Mcnsuelle  des  Maladies  des  I'Enfance,  vol.  v,  p.  56. 
*  American  Journal  of  the  Medical  Sciences,  May,  1906.     In  these  articles  will  be 
found  references  to  most  of  the  reported  cases. 


DISEASES  OF  THE   BLOOD-VESSELS.  597 

and  acute  infectious  diseases,  particularly  diphtheria.  These  thrombi 
are  in  most  cases  produced  durinjr  the  last  few  hours  of  life,  or  just  at 
the  time  of  death,  and  are  of  no  clinical  imjjorlance.  Tliey  fre(|uently 
extend  from  the  heart  into  the  larj^e  hkHxl-vessels,  })articuhir]y  the  pul- 
monary artery.  Thrombosis  occasionally  occurs  in  all  the  large  vascular 
trunks  in  childhood  as  well  as  in  adult  life. 

Thrombosis  of  the  Internal  Jugular  Vein. — Pasteur^  reports  a  case 
in  a  child  two  and  a  half  years  old,  in  which  the  middle  of  the  vein  was 
filled  with  an  organised  thrombus,  and  the  lower  portion  obliterated  and 
reduced  to  a  fibrous  cord.  The  symptoms  were  sw(dling,  oedema,  and 
cyanosis  of  the  face,  and  dilatation  of  the  facial  vein,  but  not  of  the  ex- 
ternal jugular.  There  were  clubbing  of  the  fingers  and  oedema  of  the 
feet,  but  not  of  the  arm.  The  heart  was  found  to  be  dilated  and  hyper- 
trophied,  but  was  not  the  seat  of  valvular  disease.  The  symptoms 
had  existed  since  an  attack  of  pneumonia,  eighteen  months  before 
death. 

Thrombosis  of  the  Vena  Cava. — Quite  a  number  of  cases  are  on  rec- 
ord where  this  has  occurred  as  the  result  of  pressure  from  large  abdom- 
inal tumours;  it  has  followed  new  growths  of  the  kidney  and  large 
masses  of  tuberculous  lymph  nodes.  ISTeurutter  and  Salmon  have  recorded 
a  case  of  thrombosis,  apparently  of  marantic  origin,  in  a  child  seven 
years  old.  The  thrombus  filled  the  vena  cava,  and  extended  to  the 
origin  of  the  hepatic  veins  and  into  both  femorals.  Death  occurred  from 
tuberculosis.  In  Scudder's  case  (seventeen  years  old)  there  was  appar- 
ently obliteration  (probably  congenital)  of  the  inferior  vena  cava;  there 
was  an  extensive  varicose  condition  of  all  the  abdominal  veins.  The 
symptoms  of  thrombosis  of  the  vena  cava  are  swelling  and  oedema  of  the 
feet — sometimes  of  the  abdominal  walls  and  the  groin — and  very  great 
dilatation  of  the  superficial  abdominal  veins. 

Thrombosis  of  the  Aorta. — A  case  has  been  reported  by  Leopold  in 
a  newly-born  child  which  was  delivered  by  version.  The  thrombus  was 
of  recent  origin,  and  filled  the  lower  aorta,  extending  into  the  femoral 
artery.  A  case  of  thrombosis  of  the  aorta  occurring  in  a  girl  of  thir- 
teen years  has  been  reported  by  Wallis.  The  aorta  was  very  narrow,  and 
probably  the  seat  of  syphilitic  disease.  The  thrombus  extended  from  the 
origin  of  the  renal  arteries  to  the  coeliac  axis. 

Thrombosis  in  Infectious  Diseases. — There  is  occasionally  seen  in 
typhoid  fever,  but  more  frequently  in  diphtheria,  thrombosis  of  some  of 
the  large  venous  trunks,  usually  of  one  of  the  lower  extremities.  The 
symptoms  are  pain,  localised  swelling,  and  partial  paralysis.  If  the 
artery  is  affected,  there  may  be  gangrene. 

1  Lancet,  February  11,  1888. 


SECTION   VI. 
DISEASES  OF  THE  URO-GENITA'L  SYSTEM. 

CHAPTER    I. 
THE   URINE  IN  INFANCY  ANJ)   CHILDHOOD. 

While  a  study  of  the  urine  is  of  much  less  importance  in  early  life 
than  of  the  symptoms  referable  either  to  the  digestive  or  respiratory 
system,  it  is  deserving  of  much  more  attention  than  it  has  generally  re- 
ceived. In  infancy  especially  it  is  attended  with  some  difficulty,  owing 
to  the  fact  that  it  is  by  no  means  an  easy  matter  to  secure  readily  speci- 
mens for  examination. 

Methods  of  Collecting  Urine. — In  male  infants  this  may  be  done  by 
placing  the  penis  in  the  neck  of  a  small  bottle,  which  lies  between  the 
thighs,  and  is  secured  in  position  by  pieces  of  tape  passing  over  the  hips 
and  beneath  the  perinaeum.  The  urine  of  female  infants  can  sometimes 
be  collected  in  a  similar  way  by  placing  a  small  cup  or  a  large-mouthed 
bottle  over  the  vulva  and  holding  it  in  place  by  the  napkin  or  by  pieces 
of  adliesive  plaster.  A  plan  often  successful  is  to  put  the  infant  upon  a 
chamber  after  a  long  sleep.  It  should  be  done  at  the  instant  of  waking 
or  the  child  may  be  wakened  for  the  purpose.  A  cold  hand  over  the 
bladder  facilitates  matters.  A  small  amount,  sufficient  to  test  for  albu- 
min, may  often  be  obtained  by  placing  absorbent  cotton  over  the  vulva 
or  penis.  The  most  certain  of  all  means,  however,  is  catlieterisation, 
which,  however,  should  not  be  resorted  to  unless  absolutely  necessary. 
A  soft-rubber  catheter,  size  6  or  7,  American  scale  (9  or  11  French), 
should  be  used  for  infants. 

Daily  Quantity. — This  is  relatively  much  larger  in  infants  than  in 
older  children  and  in  adults,  on  account  of  the  large  amount  of  water 
taken  with  the  food.  The  quantity  fluctuates  widely  from  day  to  day, 
according  to  the  amount  of  fluid  food  taken  and  the  activity  of  the  skin 
and  bowels.  The  figures  on  the  opposite  page  are  the  averages  obtained 
by  combining  the  results  of  the  investigations  of  Schabanowa,  Cruse, 
Camerer,  Pollak,  Martin-Ruge,  Berti,  Schiff,  and  Herter. 

Frequency  of  Micturition. — This  is  greatest  in  young  infants,  and 
diminishes  steadily  as  age  advances.  In  infancy,  during  the  waking 
hours,  the  urine  is  passed  very  frequently,  often  two  or  three  times  an 
598 


THE  URLNE  IN   INFANCY  AND  CHILDHOOD.  599 

Average  Daily  Quantity  of  Urine  in  Health. 


Age. 


First  twenty-four  hours  .  . 
Second  twenty-four  hours  . 

Three  to  six  daj^s 

Seven  days  to  two  months 

Two  to  six  months 

Six  months  to  two  years  . . 

Two  to  five  years 

Five  to  eight  years 

Eight  to  fourteen  years .  .  . 


Grammes. 


0 

10 

90 

150 

210 

250 

500 

600 

1,000 


to 


60 

90 

250 

400 

500 

600 

800 

1,200 

1,500 


Ounces. 


0  to    2 
\  "     3 


3 

5 

7 

8 

16 

20 

32 


8 
13 
16 
20 
26 
40 
48 


hour,  while  during  sleep  it  is  retained  from  two  to  six  hours.  By  the 
third  year  the  urine  may  be  held  during  sleep  for  eight  or  nine  hours, 
and  at  other  times  for  two  or  three  hours.  Such  control  of  the  sphinc- 
ter of  the  bladder  is  often  obtained  at  two  years,  and  sometimes  even  at 
an  earlier  period.  From  slight  nervous  disturbances  or  minor  ailments 
of  any  kind,  this  control  is  impaired,  and  the  water  may  be  passed  by 
children  of  four  or  five  years  with  the  frequency  seen  in  infants. 

Physical  Character  and  Composition. — The  urine  of  the  newly  born 
is  usually  highly  coloured.  During  later  infancy  it  is  pale  and  fre- 
quently turbid,  even  when  practically  normal,  owing  to  the  presence  of 
mucus;  this  turbidity  often  no  amount  of  filtration  will  entirely  remove. 
Less  frequently,  turbidity  depends  upon  urates.  The  urine  of  the  first 
few  days  of  life  often  shows  a  deposit  of  urates  or  uric  acid  in  the  form 
of  a  pink  or  reddish-yellow  stain  upon  the  napkin.  The  reaction  of  the 
urine  at  this  time  is  usually  strongly  acid,  but  throughout  the  rest  of 
infancy  it  is  faintly  acid  or  neutral. 

The  specific  gravity  is  higher  during  the  first  two  days  than  at  any 
time  in  infancy  on  account  of  the  scanty  supply  of  fluid  taken;  it  is 
usually  lowest  from  the  third  to  the  sixth  da}',  but  from  this  time  it  rises 
steadily  until  puberty  is  reached.  The  specific  gravity  varies  with  the 
quantity.  From  the  writers  already  referred  to,  the  following  figures 
are  taken : 

Specific  gravity. 

First  to  third  day 1 .010  to  1 .012 

Fourth  to  tenth  day 1  004  "  1 .008 

Tenth  day  to  sixth  mom': 1  004  "  1 .010 

Six  months  to  two  years 1  •  006  "  1 .  012 

Two  to  eight  years 1 .008  "  1 .016 

Eight  to  fourteen  years 1  •  012  "  1 .  020 

Microscopically,  the  urine  of  the  newly  born  shows  the  presence  of 
many  squamous  epithelial  cells,  mucus,  granular  matter,  and  crystals  of 
uric  acid  and  amorphous  or  crystalline  urates.     It  is  not  uncommon  to 


600  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

find  hyaline  and  even  granular  casts,  Martin-Ruge  found  hyaline  casts 
in  the  urine  of  fourteen  out  of  twenty-four  healthy  nursing  infants  ex- 
amined during  the  first  week.  Granular  casts  were  much  less  frequent. 
The  microscopical  appearances  of  the  normal  urine  of  later  infancy  and 
childhood  present  no  peculiarities. 

The  inorganic  salts  (phosphates,  chlorides,  sulphates)  are  all  present 
in  the  urine  of  the  newly  born,  but  in  relatively  small  quantities,  in- 
creasing as  age  advances.    The  colouring  matters  are  also  less  abundant. 

Albumin  is  often  present  in  the  urine  during  the  first  days,  but 
usually  in  small  amount.  Cruse  found  it  twenty-eight  times  in  ninety 
observations  upon  healthy  infants ;  usually  the  quantity  was  small, 
amounting  to  traces  only,  but  in  two  cases  it  was  quite  large  upon  the 
second  day.  These  observations  are  confirmed  by  the  investigations  of 
Martin-Kuge,  and  also  of  Pollak. 

Sugar  is  frequently  found  in  the  urine  of  liealthy  infants  during  the 
first  two  months.  It  may  be  made  to  appear  in  the  urine  of  healthy 
infants  by  simply  increasing  the  quantity  ingested.  The  different  sugars 
vary  as  regards  the  amount  which  can  be  taken  before  it  is  thus  elim- 
inated. According  to  Grosz,  lactose  appears  if  the  quantity  is  increased 
to  three  or  four  grammes  per  kilo,  of  body  weight;  glucose,  only  when 
five  grammes,  and  maltose,  not  until  seven  and  seven-tenths  grammes 
per  kilo,  are  given. 

CYCLIC   OR  ORTHOSTATIC  ALBUMINURIA. 

Etiology. — This  condition,  although  a  rare  one  in  young  children,  is 
occasionally  seen  between  the  ages  of  ten  and  sixteen  years.  I  shall  not 
in  this  connection  include  cases  sometimes  classed  as  febrile  albu- 
minuria, in  which  there  is  usually  present  the  condition  described  as 
acute  degeneration  of  the  kidneys. 

The  causes  of  orthostatic  albuminuria,  and  the  circumstances  in 
which  it  has  been  observed,  are  many  and  varied.  It  is  much  more 
common  in  males  than  in  females.  In  certain  cases  albuminuria  is 
distinctly  traceable  to  cold  bathing;  in  others,  to  fatigue  following  ex- 
cessive muscular  exercise;  in  still  others,  to  dyspeptic  conditions.  It 
may  be  associated  with  a  diet  rich  in  nitrogenous  food.  Sometimes  none 
of  these  conditions  exist,  and  there  is  simply  the  occasional  presence  of 
albumin  in  the  urine. 

The  theory  which  most  satisfactorily  explains  this  condition  is  that 
the  most  important  factor  is  a  mechanical  one — that  the  albuminuria  is 
due  to  the  upright  position.  The  vascular  pressure  in  the  kidney  may 
be  increased  by  deformities  of  the  spine. 

Symptoms. — Many  of  the  patients  exhibiting  cyclic  or  periodic  al- 
buminuria are  well  nourished,  and  have  no  other  signs  of  disease;  others 
show  dyspeptic  symptoms,  and  are  anaemic  and  poorly  nourished,  suffer- 


HEMATURIA.  601 

ing  from  headaches  and  other  neuroses.  Tlio  amount  of  albumin  is 
commonly  small.  In  many  patients  albuminui'ia  is  regularly  (yclic  in 
character,  albumin  being  absent  in  the  urine  passed  during  the  night 
or  early  morning,  but  present  during  the  day.  In  a  case  reported  l)y 
Tiemann,  the  morning  urine  showed  no  Irace  of  albumin  in  seventy- 
eight  of  eighty-four  examinations.  At  noon  albumin  was  present  in 
ninety-eight  of  one  himdred  and  thirteen  examinations.  It  is  not  in- 
frequently associated  with  temporary  glycosuria.  As  a  rule,  casts  are 
absent,  although  it  is  not  uncommon  to  find  a  few  hyaline  casts,  and 
occasionally  granular  casts  are  also  present.  But  dropsy,  cardiac  hyper- 
trophy, a  pulse  of  high  tension,  retinal  changes,  and  the  characteristic 
symptoms  of  nephritis  are  absent. 

Too  much  stress  is  certainly  laid  by  Pavy  and  many  other  writers 
upon  the  fact  that  the  albumin  is  found  in  the  urine  only  at  certain 
times  in  the  day.  This  is  not  peculiar  to  functional  albuminuria,  as  the 
same  thing  occurs  in  many  cases  of  chronic  nephritis,  especially  in  the 
early  stages,  when  the  amount  of  albumin  present  is  small.  All  these 
cases  must  be  carefully  watched  for  a  long  time  and  many  observations 
made,  before  nephritis  can  positively  be  excluded. 

Prognosis. — The  prognosis  in  purely  functional  albuminuria  is  good. 
But  many  patients  who  for  a  considerable  time  were  tliought  to  have 
only  functional  albuminuria  have  ultimately  developed  nei)hritis.  A 
favourable  prognosis  is  therefore  possible  only  after  long  observation. 

Treatment. — This  is  to  be  directed  toward  the  patient's  general  con- 
dition. Dyspeptic  symptoms  must  be  relieved,  the  patient's  mode  of  life 
regulated,  only  moderate  exercise  allowed,  and  a  simple  diet  given.  If 
the  urine  is  of  high  specific  gravit}^  and  contains  oxalate  of  lime  crys- 
tals, alkalies  and  mineral  waters  should  be  given  in  addition.  Iron  is 
indicated  if  there  is  anaemia. 


HiEMATURIA. 

Haematuria  is  characterised  by  the  presence  of  red  blood-cells  in  the 
urine,  and  is  to  be  distinguished  from  hgemoglobinuria  where  only  blood 
pigment  is  present. 

Haematuria  may  result  from  local  or  general  causes.  In  infancy  it 
may  be  due  to  new  growths  of  the  kidney.  Such  haemorrhages,  though 
rare,  may  be  abundant,  and  may  be  seen  early.  Haematuria  may  occur 
also  as  a  symptom  of  acute  nephritis,  especially  that  complicating  scarlet 
fever,  or  it  may  result  from  the  irritation  of  a  calculus  in  the  kidney,  the 
ureter,  or  the  bladder.  In  rare  instances  its  cause  is  a  new  growth  of 
the  bhadder,  and  it  may  be  due  to  traumatism.  It  may  sometimes  be 
produced  by  the  irritation  of  a  highly  concentrated  urine,  owing  to  the 
fact  that  too  little  fluid  is  taken.    I  saw  a  marked  example  of  this  in  an 


602  DISEASES  OF  THE  UROGENITAL  SYSTEM. 

infant  eight  months  old,  where  no  other  explanation  could  be  found. 
I  once  saw  haematuria  following  uric-acid  infarctions  in  the  newly  born. 
It  may  also  occur  at  tliis  time  as  one  of  the  symptoms  of  sepsis.  Among 
the  general  causes  the  most  important  are:  the  hemorrhagic  disease 
of  the  newly  born;  the  blood  dyscrasise,  such  as  scurvy,  purpura,  and 
haemophilia ;  and  infectious  diseases,  particularly  typhoid,  scarlet  fever, 
influenza,  and  malaria.  In  most  of  these  cases  the  amount  of  blood 
passed  is  small.  When  it  is  large  it  may  appear  in  the  urine  as  clear 
blood,  or  as  clots,  or  it  may  impart  simply  a  reddish  or  smoky  colour 
to  the  urine.  The  colour,  however,  is  not  so  reliable  as  a  microscopical 
examination. 

Large  haemorrhages  are  nmch  more  likely  to  come  from  the  kidneys 
than  from  the  bladder.  The  presence  of  blood  casts  from  the  renal 
tubules,  or  larger  ones  from  the  ureter,  are  conclusive  evidence  of  the 
renal  origin  of  the  haemorrhage. 

The  treatment  of  haematuria  should  be  directed  to  the  cause  upon 
which  it  depends.    In  infancy  scurvy  especially  should  not  be  overlooked. 

HiEMOGLOBINURIA. 

In  this  condition  blood  pigment  appears  in  the  urine  in  large  (juan- 
tity,  but  red  blood-cells  are  very  few  in  number,  or  are  absent  altogether. 
Ill  severe  cases  the  urine  may  be  almost  black.  There  is  commonly  a 
small  amount  of  albumin.  This  condition  may  be  recognised  by  the  ap- 
pearance of  granules  of  pigment  under  the  microscope,  or  by  Heller's  test ; 
the  most  conclusive  means  of  diagnosis,  however,  is  by  the  spectroscope. 

Epidemic  haemoglobinuria  (Winckefs  disease)  has  already  been  de- 
scribed in  the  chapter  on  Diseases  of  the  Newly  Born.  Haemoglobinuria 
may  be  due  to  certain  poisons,  as  carbolic  acid  or  chlorate  of  potash,  or 
to  certain  infectious  diseases,  as  scarlet  fever,  typhoid  fever,  malaria, 
sj'philis,  or  erysipelas. 

Paroxysmal  haemoglobinuria  occurs  in  childhood,  although  it  is  an 
exceedingly  rare  condition.  A  typical  case  in  a  child  of  four  and  a  half 
years  has  been  reported  by  Mackenzie.  This  was  a  delicate  child  of 
syphilitic  parents;  the  hasmoglobinuria  was  preceded  by  fever  and  chills, 
without  any  other  evidence  of  the  presence  of  malaria.  In  certain  chil- 
dren it  follows  exposure  to  cold  or  chilling  of  the  surface  of  the  body. 
The  treatment  of  this  condition  is  very  unsatisfactory,  but  susceptible 
individuals  should  reside  in  a  warm  climate.  For  further  description 
text-books  on  general  medicine  should  be  consulted. 

PYURIA. 

Pus  in  the  urine  may  exist  as  an  acute  or  a  chronic  condition.  In 
either  case,  in  a  child,  it  is  much  more  likely  to  come  from  the  pelvis  of 


INDICANURIA.  603 

the  kidney  than  from  any  other  source.  It  may,  however,  come  from 
any  part  of  the  genito-urinary  tract — the  kidney  or  its  pelvis,  the  ureters, 
the  hladder,  the  urethra,  or  the  vagina.  Sometimes  it  comes  from  an 
outside  source,  as  when  an  ahsccss  from  ])eri nephritis,  appendicitis,  or 
caries  of  the  spine  opens  into  the  urinary  tract. 

Coming  from  the  pelvis  of  tlie  kidney,  pus  may  indicate,  if  the  con- 
dition is  an  acute  one,  pyelitis,  pyelo-nephritis,  or  pyoneplirosis ;  if  it  is 
chronic,  it  points  to  renal  tuberculosis  or  calculus.  Tiie  amount  of  pus 
in  any  of  these  conditions  may  be  quite  large.  The  urine  is  turl)id  and 
usually  acid  in  reaction.  It  contains  many  epithelial  cells  of  the  tran- 
sitional variety.  A  urine  containing  much  pus  is  always  albuminous. 
It  is  rare  that  pus  comes  from  the  ureters  except  in  connection  with 
congenital  malformations  or  the  impaction  of  calculi.  Pus  from  the 
bladder  is  not  usually  in  large  quantity,  and  may  be  mixed  with  nmcus. 
The  urine  may  be  alkaline  or  acid  in  reaction;  there  may  be  associated 
the  symptoms  of  vesical  irritation  or  of  (ystitis.  Pus  from  the  lower 
genital  tract  "is  rare  in  children,  and  its  causes  may  often  be  recognised 
by  a  local  examination.  When  the  cause  of  pyuria  is  the  opening  of 
an  abscess  into  the  urinary  tract  there  is  generally  a  sudden  appear- 
ance of  pus  in  large  amount.  The  pyuria  is  usually  in  such  cases  of 
short  duration,  possibly  only  a  few  days,  and  it  may  disappear  (juite 
rapidly. 

The  nature  of  the  infection  can  be  determined  only  by  cultures  made 
from  a  catheterised  specimen.  This  information  is  of  considerable  aid 
both  in  diagnosis  and  prognosis. 

The  treatment  of  pyuria  depends  altogether  upon  its  cause.  Im- 
provement in  the  symptorris  sometimes  follows  the  use  of  hexamethyl- 
enamine  (urotropin),  which  may  be  given  in  doses  of  from  two  to  five 
grains  three  times  a  day  to  a  child  of  five  years. 

INDICANURIA. 

Indicanuria  is  a  condition  characterised  by  the  presence  of  indican 
in  the  urine.  Indican  (indoxyl-potassium  sulphate)  is  derived  from 
indol,  which  is  formed  in  the  intestine  by  the  agency  of  bacteria  from 
the  excessive  putrefaction  of  protein.  It  may  also  be  produced  in  other 
parts  of  the  body  where  putrefactive  processes  are  going  on,  as  in  ex- 
tensive suppuration  without  drainage,  in  pulmonary  cavities,  empyema, 
etc.  Indican  is  only  one  of  the  ethereal  sulphates  produced  in  the  man- 
ner above  indicated,  and  when  other  conditions  like  those  mentioned  are 
excluded  it  may  be  taken  as  an  index  of  the  amount  of  putrefaction 
going  on  in  the  intestine. 

Indicanuria  is  most  frequently  a  symptom  either  of  acute  or  chronic 
intestinal  disease.     It  is  important  as  being  a  guide  by  which  we  may 


604  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

estimate  the  other  symptoms  in  these  conditions,  and  the  effects  of 
treatment.  While  a  trace  of  indican  is  frequently  present  in  healtli,  a 
strong  indican  reaction  is  always  to  be  considered  abnormal  in  a  child. 
The  indications  are  to  diminish  intestinal  putrefaction.  The  treat- 
ment is  mainly  dietetic.  Indicanuria  is  usually  increased  by  a  meat  diet 
and  diminished  by  a  milk  diet.  Other  measures  are  referred  to  in  the 
treatment  of  chronic  intestinal  indigestion. 

ACETONURIA— DIACETONURIA,  ETC. 

Acetone  exists  in  small  quantities  in  the  urine  of  healthy  children. 
It  is  also  found  in  large  quantities  in  many  febrile  diseases.  Acetone, 
diacetic,  and  /3-oxybutyric  acids  are  products  formed  in  the  incomplete 
metabolism  of  fat.  Normal  combustion  of  fat  can  not  take  place  unless 
there  is  at  the  same  time  combustion  of  carbohydrates.  The  substances 
mentioned  are  therefore  found  in  the  urine  whenever  an  insufficient 
amount  of  carbohydrate  is  ingested,  or  when  the  amount  ingested  can 
not  be. utilised.  In  acute  diseases  these  substances  are  present  for  the 
first  reason  mentioned;  in  diabetes,  for  the  second  reason.  There  is  no 
connection  between  acetonuria  and  the  nervous  symptoms  accompany- 
ing fever. 

Acetone,  diacetic,  and  ^-oxybutyric  acids  are  regularly  found  in  the 
urine  of  patients  suffering  from  C3'clic  vomiting;  they  are  probably  a 
result,  not  the  cause,  of  the  attacks.  In  progressing  cases  of  diabetes 
and  in  diabetic  coma  these  substances  are  present  in  large  amount. 

ANURIA. 

By  this  term  is  meant  an  arrest  of  the  urinary  secretion.  To  that 
form  which  occurs  in  the  course  of  renal  disease  the  terra  "  suppres- 
sion "  is  generally  applied.  Anuria  is  to  be  carefully  distinguished 
from  retention,  from  the  scanty  secretion  which  occurs  whenever  food  is 
refused  or  withheld  on  account  of  illness,  and  also  from  that  which  ac- 
companies acute  diarrhoea,  with  large,  watery  discharges.  Anuria  is 
sometimes  seen  in  the  newly  born,  where  it  depends  upon  some  mal- 
formation of  the  genital  tract;  or,  more  frequently,  upon  uric-acid  in- 
farctions in  the  kidneys.  The  first  urine  passed  after  such  an  attack 
is  very  often  highly  acid,  and  may  contain  an  abundance  of  uric-acid 
crystals  and  larger  masses  visible  to  the  naked  eye.  Other  cases  admit 
of  no  such  explanation.  For  the  time,  the  secretion  appears  to  be  com- 
pletely arrested,  as  the  bladder,  both  by  palpation  and  catheterisation, 
is  found  to  be  empty.  This  condition  is  uncommon  in  infancy,  but  it 
may  continue  for  from  twelve  to  thirty-six  hours.  So  long  as  infants 
appear  to  be  perfectly  normal  in  every  other  respect,  the  suspension 


DIABETES   INSIPIDUS    (POLYURIA).  605 

of   the   urinary   secretion   even    for   twenty- four    hours   need   excite   no 
anxiety. 

The  treatment  consists  in  the  administration  of  sweet  spirits  of 
nitre,  in  combination  with  the  acetate  or  citrate  of  potasli,  and  plenty 
of  water.  To  a  newly-born  infant  one  minim  of  the  nitre  and  one  grain 
of  the  citrate  of  potash  may  be  given  every  hour  or  two,  in  water,  until 
the  urinary  secretion  is  established,  which  will  usually  be  in  six  or 
eight  hours.  If  the  urine  is  very  highly  acid,  and  stains  the  napkins, 
the  potash  should  be  continued  for  several  days.  J  lot  fomentations  over 
the  kidneys  may  be  used. 


DIABETES  INSIPIDUS   (POLYURIA). 

This  is  a  chronic  disease  characterised  by  the  excretion  of  a  very 
large  amount  of  pale  urine  of  low  specific  gravity.  It  is  invariably  ac- 
companied by  polydipsia.  The  disease  is  an  exceedingly  rare  one  in 
children. 

The  exact  pathology  of  diabetes  insipidus  is  not  known;  but 
from  the  conditions  under  which  it  occurs  it  is  believed  to  be  a 
neurosis. 

Etiology. — Of  eighty-five  cases  collected  by  Strauss,  twenty-one  were 
in  children  under  ten  years  of  age  and  nine  under  five  years.  In  Rob- 
erts's collection  of  seventy  cases,  the  disease  began  in  twenty-two  chil- 
dren before  ten  years,  and  in  seven  during  infancy.  In  some  cases  it 
begins  soon  after  birth.  Males  are  more  frequently  afi:ected  than  females, 
and  in  certain  cases  heredity  is  an  important  factor.  Weil  has  published 
a  remarkable  example  of  the  disease  existing  in  many  members  of  a 
single  family.  Falls  or  blows  upon  the  head,  concussion  of  the  brain, 
tumours  of  the  brain,  especially  of  the  occipital  region,  or  chronic  hydro- 
cephalus, all  have  been  found  associated  with  diabetes  insipidus.  It 
sometimes  has  followed  the  acute  infectious  diseases;  but  in  many  cases 
no  cause  whatever  can  be  found. 

Symptoms. — The  quantity  of  urine  is  enormous,  usually  exceeding 
even  that  in  diabetes  mellitus.  From  five  to  twenty  pints  daily  may  be 
passed.  The  urine  is  pale,  the  specific  gravity  from  1.001  to  1.006,  and 
it  contains  neither  albumin  nor  glucose.  In  a  few  cases  the  presence  of 
inosite  (muscle  sugar)  has  been  found.  Restricting  the  amount  of  fluid 
taken  causes  a  very  marjced  diminution  in  the  amoimt  of  urine.  The 
intense  thirst  leads  patients  to  drink  enormously  of  water  and  other 
fluids. 

Nervous  symptoms  are  usually  present.  There  may  be  disturbed 
sleep  from  the  frequent  micturition,  palpitation,  flushing  of  the  face  and 
other  vaso-motor  disturbances,  headache,  restlessness,  and  neuralgia. 
There  may  be  incontinence  of  urine.     The  bladder  sometimes  becomes 


606  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

enormously  distended.  In  one  of  my  cases  it  held  forty-five  ounces  and 
reached  above  the  umbilicus.  Tiie  skin  is  pale  and  dry,  and  perspiration 
is  scanty.  The  general  health  may  not  be  disturbed.  In  most  cases, 
however,  it  is  somewhat  affected,  and  there  may  be  the  usual  symptoms 
of  malnutrition,  and  even  neurasthenia.  If  it  affects  young  children, 
their  growth  may  be  retarded.  The  appetite  usually  remains  quite 
good.  The  temperature  is  at  times  slightly  subnormal.  The  course  of 
the  disease  is  indefinite.  It  is  very  chronic,  and  may  last  for  many  years, 
death  taking  place  only  from  intercurrent  affections. 

Prognosis. — A  few  of  the  cases  recover  spontaneously.  Those  of  short 
duration  are  often  cured  by  treatment.  Of  the  chronic  cases  in  which 
the  disease  is  well  established  very  fe\v  are  controlled.  The  prognosis  is 
worse  if  there  are  marked  disturbances  of  the  digestive  tract  or  organic 
brain  disease. 

Diagnosis. — This  is  easily  made  from  the  two  marked  symptoms,  ex- 
cessive thirst  and  pol}Tiria.  From  diabetes  mellitus  it  is  easily  distin- 
guished by  the  lower  specific  gravity  and  the  absence  of  sugar  from  the 
urine.  In  older  children,  chronic  nephritis  with  contracted  kidney  may 
be  confounded  with  it. 

Treatment. — Fluids  should  be  moderately  restricted.  It  is  a  serious 
mistake  to  reduce  the  quantity  of  fluids  too  much,  since  the  drinking  is 
not  the  cause  of  the  diuresis.  The  diet  should  be  simple  and  nutritious. 
The  general  treatment  should  be  directed  to  the  condition  of  malnutri- 
tion. The  clothing  should  be  warm,  and  a  moderate  amount  of  exercise 
should  be  allowed.  Drugs,  in  most  cases,  are  of  little  use;  but  decided 
improvement  has  sometimes  followed  the  prolonged  use  of  codeine ;  other 
cases  have  been  benefited  by  the  bromides  and  belladonna.  Treatment 
must  be  continued  for  many  months  to  be  of  any  value. 


CHAPTER    II. 
DISEASES  OF   THE  KIDNEYS. 

MALFORMATIONS  AND   MALPOSITIONS. 

Malformations  of  the.  kidney  are  not  infrequent.  In  seven  hun- 
dred and  twenty-six  consecutive  autopsies  at  the  New  York  Infant  Asy- 
lum malformations  of  the  kidney  or  ureters  were  met  with  in  seventeen 
cases.  This  does  not  represent  the  actual  frequency  with  whicli  tiiey 
occur,  for  in  about  half  tha,t  number  of  autopsies  in  two  other  institu- 
tions only  a  single  example  was  seen.  Adding  to  the  cases  mentioned 
two  others  seen  elsewhere,  there  are  twenty  cases  of  renal  malformation 
of  which  I  have  notes,  classed  as  follows : 


MALFORMATIONS  AND   MALPOSITIONS  OF  KIDNEYS.         607 

Fusion  of  the  kidneys,  or  horseshoe  kidney 4  cases. 

Supernumerary  ureters 4      " 

Hydronephrosis  (alone) 8      " 

Congenital  cystic  kidney  (alone) 2      " 

Hydronephrosis  and  cystic  kidney 1  case. 

Single  kidney 1     " 

In  all  malformations  the  left  kidney  is  much  more  frequently  affected 
than  the  right,  the  proportion  heing  nearly  two  to  one.  Malformations 
are  more  often  seen  in  males  than  in  females.  Only  two  of  these  con- 
ditions are  of  clinical  importance — viz.,  cystic  degeneration  and  hydro- 
nephrosis. 

Cystic  Kidneys. — Two  varieties  of  this  malformation  are  met  with. 
In  one  the  cysts  are  few  in  number  and  large ;  in  the  other  they  are  very 
numerous  and  small.  When  the  cysts  are  large  the  renal  tumour  may  fill 
the  abdominal  cavity,  even  interfering  with  the  birth  of  the  child.  The 
condition  is  generally  bilateral,  and  the  patients  die  in  early  infancy. 
The  more  common  form,  that  with  small  cysts,  also  affects  both  sides 
as  a  rule.  The  organ  often  is  not  enlarged,  and  it  may  even  be  smaller 
than  normal.  The  surface  of  the  kidney  is  studded  with  small  cysts, 
which  usually  vary  in  size  from  a  pin's  head  to  that  of  a  pea.  The  en- 
tire organ  may  consist  of  nothing  but  a  mass  of  cysts,  held  together  by 
loose  connective  tissue.  In  other  cases  the  cysts  are  less  numerous,  and 
much  renal  tissue  remains.  The  cysts  are  formed  bj'the  dilatation  of 
the  uriniferous  tubules  owing  to  occlusion,  which  occurs  in  the  devel- 
opment of  the  kidney.  The  large  cysts  are  recognised  as  abdominal 
tumours;  the  small  ones  usually  give  no  symptoms,  and  are  found  acci- 
dentally at  autopsy  in  patients  dying  from  other  diseases. 

Hydronephrosis. — Of  the  thirteen  cases  of  which  I  have  notes,  this  ex- 
isted as  the  principal  deformity  in  eleven.  In  two  cases  it  was  associated 
respectively  with  cystic  degeneration  of  the  opposite  kidney  and  horse- 
shoe kidney.  In  seven  cases  only  the  left  side  was  affected;  in  six  there 
was  double  hydronephrosis.  Nine  patients  were  males  and  four  females. 
Seven  died  before  they  were  six  months  old,  and  only  two  lived  to  be  two 
years  old.  This  condition  is  undoubtedly  the  result  of  some  obstruction 
to  the  outflow  of  urine  in  the  ureter,  bladder,  urethra,  or  prepuce,  but  in 
only  three  of  my  cases  could  there  be  found  an  obstruction  sufficient  to 
explain  the  deformity.  In  five  there  was  marked  hypertrophy  of  the 
bladder.  In  no  case  was  a  calculus  found  as  the  cause  of  the  ob- 
struction. In  most  of  the  cases  the  ureter  was  dilated  to  a  diameter 
of  from  one-fourth  to  one-half  inch,  and  in  five  it  was  so  large  as  to  be 
easily  mistaken  for  the  intestine.  Usually  the  ureters  appear  much 
elongated  and  sacculated;  the  pelvis  and  the  calices  of  the  kidney  may 
be  slightly  dilated  or  the  greater  part  of  the  kidney  may  be  destroyed, 
leaving  only  a  series  of  communicating  pockets  surrounded  by  a  thin 


608 


DISEASES  OF  THE   URO-GENITAL  SYSTEM. 


cortex  of  renal  tissue.     After  a  time  chronic  nephritis  usually  develops. 
This  may  involve  both  kidneys,  even  though  the  hydronephrosis  is  uni- 


Fio.    102. — Congenital   Hydronephrosis,    Dilated    Ureters,    and   Hypeutrophied 
Bladder.     (From  a  child  one  month  old.) 


lateral.  In  two  cases,  typical  examples  of  the  atrophic  form  (contracted 
kidney)  were  seen,  one  of  these  children  dying  at  the  age  of  one  month.^ 
The  organs  are  shown  in  Fig.  102. 

1  This  was  in  every  way  a  remarkable  case.  The  child  died  apparently  of  maras- 
mus. There  was  double  hydronephrosis,  the  ureters  being  three-fourths  of  an  inch 
in  diameter.  The  right  kidney  was  nodular  upon  the  surface,  and  had  a  very  ad- 
herent capsule.  Just  beneath  the  capsule  there  were  small  cysts  containing  pus. 
The  left  kidney  was  the  seat  of  hydronephrosis,  only  its  cortex  remaining,  this  being 
about  one-sixth  of  an  inch  in  thickness.  Microscopical  examination  showed  great 
thickening  of  the  capsule  of  the  right  kidney,  and  several  small  abscesses  situated  in 
the  cortex  just  beneath  the  capsule.  The  rest  of  the  kidney  was  converted  into  a 
mass  of  dense  fibrous  tissue  in  which  were  scattered  many  uriniferous  tubules.     The 


MALFORMATIONS  AND   MALPOSITIONS  OF  KIDNEYS.         609 

Urinary  symptoms  are  noted  in  but  few  cases  during  life,  and  the 
diagnosis  is  seldom  made.  The  cause  of  death  is  usually  some  inter- 
current disease. 

Double  hydronephrosis  is  generally  associated  with,  or  results  in, 
such  changes  in  the  kidneys  that  the  patients  die  during  infancy.  It 
may  give  rise  to  one  or  more  tumours,  which  sometimes  attain  a  large 
size.  Even  when  renal  tumours  can  not  he  made  out,  the  hypertrophied 
bladder  may  be  felt  as  a  hard  globular  tumour  in  the  hypogastrium. 
Changes  in  the  urine  may  not  be  present  until  the  disease  is  very  far 
advanced.  There  may  be  the  general  and  local  symptoms  of  chronic 
diffuse  nephritis,  or,  when  infection  of  the  genital  tract  occurs,  there  are 
added  the  symptoms  of  pyelitis.  In  the  great  majority  of  cases  the  con- 
dition is  unrecognised,  the  patient  dying  of  some  disease  not  perhaps  in 
itself  fatal,  but  rendered  so  by  the  condition  of  the  kidneys. 

If  hydronephrosis  is  unilateral  there  may  be  no  symptoms  until  the 
dilatation  of  the  pelvis  of  the  kidney  has  reached  a  sufficient  size  to  form 
an  abdominal  tumour.  In  most  of  the  cases  in  children  this  condition 
has  been  noted  between  the  third  and  the  eleventh  years.  This  tumour 
may  be  situated  in  the  lumbar  region,  or  it  may  fill  the  abdomen.  It  is 
cystic,  and  may  be  confounded  with  a  dermoid  cyst  of  the  ovary.  On 
aspiration  a  fluid  is  withdrawn  which  may  be  clear,  or  of  a  brownish 
colour,  and  recognised  as  urine  by  the  fact  that  it  contains  urates  and 
urea.  After  aspiration  the  urine  passed  per  urethram  may  be  bloody. 
Aspiration  affords  only  temporary  relief,  as  the  tumour  quickly  refills. 
If  an  incision  is  made  and  the  kidney  drained,  a  cure  may  result  with 
the  formation  of  a  fistula.  This  may  continue  indefinitely,  or  infection 
of  the  fistulous  tract  may  occur  and  suppurative  nephritis  be  set  up, 
which  speedily  carries  off  the  patient.  A  better  operation  is  nephrec- 
tomy, which  may  result  in  a  permanent  cure  if  the  opposite  kidney  is 
healthy,  which  is  usually  the  case  if  the  child  is  over  three  years  of  age, 
for  the  reason  above  stated,  viz.,  that  a  child  with  malformation  of  both 
kidneys  usually  dies  in  infancy. 

Movable  Kidney. — This  is  a  rare  condition  in  young  children.  Comby 
has  collected  eighteen  cases,  of  which  sixteen  were  in  girls  and  two  in 
boys.  Movable  kidney  was  recognised  before  the  tenth  year  in  eight 
cases,  and  in  two  of  these  before  the  fourth  month.  It  has  been  ascribed 
to  too  long  a  pedicle,  which  may  be  congenital;  also  to  pressure  from 
abdominal  tumours,  and  to  injury.     The  most  important  symptoms  are 

left  kidney  was  the  seat  of  chronic  diffuse  nephritis  of  the  atrophic  variety,  with  well- 
marked  changes  in  the  medullary  portions.  The  cortex  showed  much  exudation  and 
less  atrophy,  being  nearly  normal  in  thickness.  The  small  size  of  the  organ  was  due 
chiefly  to  atrophy  of  the  pyramids.  The  walls  of  the  bladder  were  greatly  hyper- 
trophied, being  in  places  one-fourth  of  an  inch  thick.  The  urethra  and  prepuce  were 
normal. 

40 


610  DISEASES  OF  THE  UROGENITAL  SYSTEM. 

paroxysmal  pain,  which  may  follow  exertion,  and  a  movable  tumour.    A 
twist  in  the  ureter  may  produce  hydronephrosis, 

URIC-ACID   INFARCTIONS. 

These  consist  in  a  deposit  in  the  straiglit  tubes  of  the  kidneys  of  uric 
acid  or  of  amorphous  or  crystalline  urates;  usually  both  kidneys  are 
affected,  and  all  the  pyramids  of  each  kidney.  The  infarctions  appear 
to  the  naked  eye  as  fine,  brownish-yellow,  fan-shaped  striae.  Associated 
with  them  there  may  be  granular  deposits  of  uric-acid  salts  in  tiie  pelvis 
of  the  kidney,  and  sometimes  evidences  of  catarrhal  inflammation  of  the 
pelvis,  including  even  the  presence  of  blood.  This  condition  probably 
occurs,  to  some  degree,  at  least,  in  nearly  all  infants  during  the  first  ten 
days  of  life.  It  was  formerly  supposed  that  the  discovery  of  these  ap- 
pearances was  proof  that  an  infant  had  breathed,  and  a  certain  medico- 
legal importance  was  therefore  attached  to  them.  This  is  now  known 
not  to  be  the  case,  as  they  are  sometimes  found  in  still-born  infants. 

The  cause  of  this  condition  is  the  excretion  of  uric  acid  before  there 
is  sufficient  water  to  dissolve  it,  so  that  the  crystals  are  deposited  in  the 
tutes.  Uric-acid  infarctions  are  found  chiefly  in  children  dying  before 
the  end  of  the  second  week,  although  it  is  not  uncommon  to  see  them  as 
late  as  the  third  or  fourth  or  even  the  sixth  month.  In  most  of  the 
cases,  as  the  urinary  secretion  becomes  more  abundant,  the  deposits  are 
washed  out  in  the  urine  and  appear  as  brownish-red  or  pink  stains  upon 
the  napkins.  Infarctions  may  give  rise  to  a  slight  inflammation  of  the 
renal  tubules,  but  very  rarely  to  any  serious  lesion;  sometimes  they 
remain  as  deposits  in  the  calices  or  the  pelvis  of  the  kidney  or  in  the 
bladder,  forming  the  nucleus  of  a  calculus.  The  symptoms  to  which  they 
give  rise  are  mainly  scanty  urination  during  the  first  week  of  life,  and 
occasionally  anuria  for  the  first  day  or  two.  Sometimes  there  is  evidence 
of  severe  pain ;  priapism  may  be  present,  and  there  is  the  stain  upon  the 
napkin  already  referred  to.  The  treatment  is  to  give  water  freely  and 
some  alkaline  diuretic  such  as  citrate  of  potash.  One  grain  should  be 
given  every  two  hours  until  the  secretion  is  fully  established  ;  this  in  most 
cases  will  be  within  twenty-four  hours. 

CHRONIC  CONGESTION  OF  THE  KIDNEY. 

This  results  from  interference  with  the  return  circulation  of  the 
kidney,  and  may  be  caused  by  congenital  malformation  or  valvular  dis- 
ease of  the  heart,  chronic  broncho-pneumonia  or  chronic  pleurisy;  also 
by  the  pressure  of  any  abdominal  tumour  upon  the  inferior  vena  cava 
or  the  renal  veins. 

The  kidneys  are  generally  enlarged,  firmer  than  normal,  and  dark- 
coloured.  All  the  capillary  vessels  are  swollen  and  distended  witli  blood, 
and  their  walls  are  thickened.    In  addition  to  the  symptoms  of  the  pri- 


ACUTE   DIFFUSE   NEPHRITIS.  611 

mary  disease,  the  amount  of  urine  passed  is  usually  scanty  and  of  high 
specific  gravity.  Albumin  and  casts  are  generally  present,  hut  are  not 
constant.  The  treatment  should  he  directed  toward  the  primary  condi- 
tion, and,  in  addition,  an  effort  should  he  made  to  increase  the  urine  hy 
alkaline  diuretics,  caffein,  digitalis,  and  diuretin. 

ACUTE   DEGENERATION   OF  THE   KIDNEYS. 

In  the  succeeding  pages  devoted  to  the  kidney  I  have  followed  in  the 
main  Prudden's  classification. 

In  acute  degeneration  of  the  kidney  the  ])rin(i])al  or  only  change  is 
in  the  epithelium  of  the  tuhules.  It  is  exceedingly  common  hoth  in  in- 
fancy and  in  childhood,  being  found  to  a  greater  or  less  degree  in  all 
autopsies  upon  patients  dying  of  acute  infectious  diseases,  but  it  is  most 
marked  in  cases  of  scarlet  fever,  diphtheria,  and  acute  pleuro-pneumonia. 
It  may  be  found  in  any  disease  characterised  by  prolonged  high  temj)era- 
ture;  and  it  is  the  explanation  of  the  cases  of  so-called  febrile  albu- 
minuria. The  cause  is  in  all  probability  direct  irritation  of  the  epithelium 
of  the  tubules  by  the  toxins  eliminated  by  the  kidneys.  It  may  also  be 
induced  by  irritating  drugs,  such  as  cantharides  or  turpentine.  By  some 
writers  these  cases  have  been  classed  as  examples  of  acute  nephritis ;  hence 
the  great  discrepancy  which  exists  in  statements  made  as  to  the  fre- 
quency of  nephritis  in  the  different  infectious  diseases. 

The  kidneys  are  usually  slightly  enlarged,  softer,  and  paler  than 
normal.  On  section  the  cortex  may  be  somewhat  thickened,  and  the 
straight  tubules  marked  by  yellowish-gray  lines.  It  is  the  appearance 
commonly  spoken  of  as  cloudy  swelling.  The  kidneys  are  seldom  much 
congested.  The  microscope  shows  a  granular  degeneration  and  death  of 
the  epithelium  of  the  tubules,  and  when  severe  this  may  be  accompanied 
by  congestion  and  the  exudation  of  serum. 

Acute  degeneration  of  the  kidneys  gives  rise  to  no  symptoms  in  addi- 
tion to  those  of  the  original  disease,  except  the  appearance  of  a  moderate 
amount  of  albumin  in  the  urine,  with  a  few  hyaline,  granular,  or  epi- 
thelial casts.  It  can  not  be  said  that  such  a  condition  adds  much  to  the 
danger  from  the  original  disease.  In  cases  that  recover,  the  condition  of 
the  kidney  becomes  entirely  normal.  The  development  of  the  symptoms 
of  degeneration  of  the  kidneys  in  infectious  diseases  calls  for  no  special 
treatment  beyond  a  continuance  of  the  fluid  diet. 

ACUTE   DIFFUSE   NEPHRITIS. 

(Acute  Interstitial  Nephritis;  Acute  Exudative  Nephritis;  Glomerulo-nephritis; 
Acute  Bright' s  Disease.) 

Etiology. — This  variety  of  nephritis  occurs  apparently  as  a  primary 
disease  both  in  infants  and  in  older  children.    Most  such  cases  are  un- 


612  DISEASES  OF  THE   UROGENITAL  SYSTEM. 

doubtedly  of  infectious  origin,  although  the  point  of  entrance  of  the 
infection  may  be  diflRcult  or  impossible  to  determine.  Acute  diffuse 
nephritis  is  rery  frequently  secondary  to  the  acute  infectious  diseases, 
especially  to  scarlet  fever  and  diphtheria.  It  occasionally  follows 
measles,  varicella,  empyema,  typhoid  fever,  acute  diarrhoeal  diseases, 
pneumonia,  meningitis,  influenza,  and  malaria.  It  is  the  characteristic 
variety  of  secondary  nephritis  occurring  in  severe  septic  conditions.  The 
exciting  cause  of  the  infllammation  is  in  some  cases  the  irritation  from 
toxins ;  but  usually  there  is  in  addition  the  entrance  of  pathogenic  organ- 
isms carried  by  the  circulation.  Thus  in  post-scarlatinal  nephritis,  of 
which  the  one  under  consideration  is  the  characteristic  form,  the  cause  is 
now  generally  admitted  to  be  the  toxins  of  the  primary  disease,  to  which 
in  many  cases  is  added  infection  by  the  streptococcus.  While  nephritis 
is  more  frequent  after  severe  attacks  of  scarlet  fever,  it  may  occur  after 
those  which  are  very  mild,  even  when  patients  have  been  kept  in  bed 
throughout  the  disease.  The  frequency  of  nephritis  as  a  sequel  of  scarlet 
fever  varies  much  in  different  epidemics;  the  average  is  from  six  to 
ten  per  cent.  I  have  seen  two  cases  of  acute  nephritis  in  infants,  the 
apparent  cause  of  which  was  the  irritation  of  a  highly  concentrated  urine. 
This  was  the  result  of  the  infants  taking  for  a  long  time  very  little 
food,  and  almost  no  water. 

Lesions. — In  severe  cases  the  kidneys  are  usually  enlarged,  soft,  and 
cedematous.  The  capsule  is  non-adherent.  The  cortex  is  thickened, 
either  reddened  or  pale;  frequently  it  is  mottled  with  red,  owing  to  the 
presence  of  small  haemorrhages.  There  may  be  congestion  of  the  entire 
organ ;  or  the  pyramids  may  seem  unusually  red  by  contrast  with  the  pale 
and  thickened  cortex. 

All  the  structures  of  the  kidney — glomeruli,  tubular  epithelium,  and 
interstitial  tissue — are  involved  in  the  inflammatory  process.  Tlie  cells 
covering  the  glomerular  tufts  of  capillaries  are  swollen  and  proliferated. 
They  have  frequently  undergone  fatty  degeneration  and  separated.  The 
epithelial  cells  lining  Bowman's  capsule  may  undergo  the  same  changes, 
but  usually  to  a  lesser  degree.  The  space  between  the  capsule  and  the 
tuft  may  contain  exfoliated  epithelium  in  considerable  quantity,  also  cell- 
detritus,  albuminous  (granular)  exudate,  leucocytes,  and  red  blood-cells. 
The  tubular  epithelium  undergoes  albuminous  and  fatty  degeneration 
and  may  desquamate.  Thus  the  tubules  may  contain  epithelial  frag- 
ments, serum,  red  blood-cells,  leucocytes,  and  casts.  The  interstitial 
connective  tissue  is  infiltrated  with  serum  and  in  places  with  small  round 
cells.  In  cases  of  longer  duration  a  general  increase  of  the  connective 
tissue  may  take  place,  which  is  permanent. 

When  the  glomerular  changes  are  especially  marked,  as  in  acute 
nephritis  following  scarlet  fever,  the  process  is  often  spoken  of  as 
glomerulo-nephritis.     If  the  degeneration  of  the  tubular  epithelium  is 


ACUTE   DIFFUSE   NEPHRITIS.  613 

extreme,  as  in  severe  cases  of  diphtheria  dying  sliortly  after  the  onset, 
the  nephritis  may  be  described  as  the  pnrcnrlii/matons  or  dcgcncmtive 
type.  In  the  hwmorrhagic  form  tliere  arc  lia'inorrliagcs  into  the  tubules, 
glomeruli,  or  interstitial  tissue.  In  infants  and  young  children  the  ex- 
udative type  of  acute  diffuse  nephritis  is  especially  frequent.  In  this 
there  is  an  exudative  inflammation  with  large  accumulations  of  leucocytes, 
serum,  and  red  blood-cells  in  the  glomeruli  and  tubules,  the  parenchyuia 
and  interstitial  tissue  sometimes  being  markedly  and  sometimes  but 
slightly  changed.  Should  the  interstitial  tissue  suffer  early  and  severely, 
the  nephritis  becomes  of  the  productive  or  interstitial  type.  This  form  is 
most  frequently  seen  with  severe,  proti-acted  cases  of  scarlet  fever  and 
diphtheria,^  especially  in  older  children.  It  sometimes  occurs  as  an  ap- 
parently independent  process. 

Symptoms. — 1.  Primary  Form  in  Infants. — These  cases  are  not  com- 
mon, and  the  symptoms  are  so  obscure  that  they  are  often  overlooked. 
At  least  ten  such  cases  have  come  under  my  observation.  'J'he  inflamma- 
tion in  most  of  them  was  of  the  exudative  type. 

The  onset  in  nearly  every  instance  was  abrupt,  usually  with  high 
fever  and  vomiting,  the  temperature  being  in  several  cases  over  104°  F. 
Dropsy  was  very  exceptional,  being  noted  in  but  six  cases ;  in  most  of 
these  it  was  slight,  and  seen  only  toward  the  close  of  the  disease.  Fever 
was  present  in  all  cases.  In  those  observed  by  myself  it  was  high  and 
irregular  in  type,  ranging  from  101°  to  105°  F.  The  duration  of  the 
disease  was  from  eight  days  to  four  weeks,  the  average  being  about  two 
and  a  half  weeks.  Vomiting  and  diarrhoea  were  noted  in  half  the  cases, 
but  were  rarely  prominent,  and  marked  either  the  onset  of  the  attack, 
or  were  traceable  to  indigestion  accompanying  the  fever;  very  rarely  did 
they  exist  as  symptoms  of  uraemia.  Ana3mia  was  a  prominent  symptom 
in  nearly  every  case,  and  it  was  this  which  enabled  me  in  several  instances 
to  make  a  correct  diagnosis.  Xervous  symptoms  were  usually  prom- 
inent. In  several  patients  there  was  dyspnoea  without  pulmonary  dis- 
ease, partly  due,  no  doubt,  to  the  anaemia.  In  nearly  all  cases  there  was 
marked  restlessness  or  muscular  twitchings,  and  in  three  there  were  con- 
vulsions. Dulness  and  apathy  were  present  in  the  majority  of  the  fatal 
cases,  but  deep  coma  was  never  seen.  Several  patients  presented  the 
typical  symptoms  of  the  typhoid  condition.  The  urine  was  rarely  scanty 
until  near  the  close  of  the  disease,  and  sometimes  not  even  then.  Sup- 
pression of  urine  occurred  In  but  a  few  cases.  Albumin  was  frequently 
absent  early  in  the  attack,  but  was  invariably  present  at  a  late  period, 
although  rarely  in  large  amount.  Casts  were  found  in  all  cases  that  were 
carefully  examined  microscopically.     They  were  not  usually  numerous, 

1  Councilman,  Mallory,  and  Pearce,  Diphtheria:  A  Study  of  the  Bacteriology  and 
Pathology  of  Two  Hundred  and  Twenty  Fatal  Cases,  1901. 


614  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

and  were  chiefly  of  the  hyaline,  granular,  and  epithelial  varieties.  No 
blood  easts  were  seen.  There  were  usually  many  pus  cells  and  renal 
epithelial  cells,  together  with  red  blood-cells  in  moderate  numbers. 

Of  the  twenty-four  cases,  sixteen  died  and  eight  recovered.  Of  my 
own  ten  cases,  nine  were  fatal,  the  diagnosis  being  confirmed  by  autopsy 
in  every  case  but  two.  Whether  these  figures  represent  the  actual  mor- 
tality of  the  disease  it  is  difficult  to  say.  No  doubt  there  are  many  mild 
cases  which  are  unrecognised.  The  severe  ones,  however,  are  quite  uni- 
formly fatal,  chiefly  on  account  of  the  tender  age  of  the  patients. 

2.  Primary  Form  in  Older  Children. — This  also  is  a  rare  form  of 
renal  disease.  As  compared  with  the  same  condition  in  infants,  the  onset 
is  usually  less  abrupt,  the  febrile  symptoms  are  less  marked,  and  the  ter- 
mination is  less  frequently  fatal.  Dropsy  is  rarely  marked,  and  often 
there  is  none  at  all.  The  urine  is  only  slightly  diminished  in  quantity ; 
the  amount  of  albumin  is  small;  casts  are  not  numerous,  and  usually 
hyaline,  epithelial,  or  granular;  very  rarely  is  there  much  blood  present. 
Uraemia  is  infrequent,  and  the  prognosis  is  better  than  in  infancy. 

The  interstitial  type  may  begin  abruptly  with  febrile  symptoms, 
dropsy,  headache,  lumbar  pains,  scanty  urine,  and  often  with  vomiting; 
or  it  may  come  on  somewhat  insidiously  with  few  constitutional  symp- 
toms, but  with  dropsy  and  changes  in  the  urine. 

3.  Secondary  Form. — The  secondary  nephritis  of  acute  infectious  dis- 
eases may  occur  at  the  height  of  the  febrile  process  or  at  a  later  period, 
and  its  severity  is  generally  proportionate  to  the  intensity  of  the  infection. 
The  general  symptoms  of  nephritis  are  often  not  marked,  and  dropsy 
is  rare;  so  that  unless  the  urine  is  examined  the  condition  may  be  over- 
looked. The  urinary  changes  are  essentially  the  same  as  those  already 
mentioned  in  the  primary  cases.  Suppression  of  urine  and  the  develop- 
ment of  the  symptoms  of  acute  uraemia  are  infrequent.  While  nephritis 
adds  considerably  to  the  danger  from  the  primary  disease,  it  is  seldom 
itself  the  cause  of  death,  although  this  is  sometimes  the  case  in  scarlet 
fever  or  diphtheria. 

The  characteristic  type  of  nephritis  which  follows  scarlet  fever  most 
frequently  develops  during  the  third  or  fourth  week  of  the  disease.  The 
onset  may  be  gradual,  dropsy  being  first  noticed.  Or  it  may  begin  ab- 
ruptly without  dropsy,  but  with  headache,  vomiting,  scanty  urine,  fever, 
and  even  convulsions.  The  temperature  generally  ranges  from  100°  to 
101.5°  F.,  but  in  very  severe  attacks  it  may  be  104°  or  105°  F.  While 
dropsy  is  usually  present,  it  may  be  slight  or  absent  in  severe  and  even  in 
fatal  cases.  It  is  first  seen  in  the  face,  next  in  the  feet,  legs,  and  scrotum ; 
there  may  be  general  anasarca,  with  dropsy  of  the  serous  cavities  of  the 
body,  the  pleura,  or  the  peritonaeum,  rarely  the  pericardium.  As  the 
disease  progresses  there  is  always  a  very  marked  degree  of  anaemia. 

The  urine  is,  as  a  rule,  greatly  diminished  in  quantity,  and  may  be 


ACUTE   DIFFUSE   NEPHRITIS.  615 

suppressed.  Albumin  is  invariably  present,  altliougb  not  always  at  tirst; 
it  is  usually  in  large  amount,  often  enough  to  render  the  urine  solid 
upon  boiling.  The  urine  is  of  a  dark,  reddish-brown  or  smoky  colour, 
owing  to  the  presence  of  red  blood-cells  or  lupmoglobin.  The  total 
amount  of  urea  eliminated  is  far  below  the  normal.  The  specific  gravity 
may  be  low,  even  though  the  quantity  is  very  small.  Casts  are  present 
in  great  numbers,  chiefly  hyaline,  granular,  and  epithelial  casts  from  the 
straight  tubes;  not  infrequently  there  are  blood  casts.  Eed  blood-cells 
are  present  in.  great  numbers ;  also  many  leucocytes,  and  renal  epithelium. 

The  duration  of  the  active  symptoms  in  cases  terminating  in  recovery 
is  from  one  to  three  weeks.  The  temperature  and  dropsy  gradually  sub- 
side. Improvement  in  the  urine  is  shown  by  an  increase  in  quantity,  by 
an  increased  elimination  of  urea,  and  by  a  diminution  in  the  amount  of 
blood,  albumin,  and  the  number  of  casts.  A  few  casts  may  persist  for 
several  weeks,  and  a  small  amount  of  allmmin  for  two  or  tliree  months. 

In  the  graver  cases,  when  the  onset  is  accomj)anied  by  liigh  temper- 
ature, painin  the  back  and  loins,  and  a  rapid,  full  pulse  of  high  tension, 
the  urine  is  very  scanty  and  is  often  suppressed.  Then  follow  the  symp- 
toms of  uraemia.  In  children  this  is  usually  manifested  by  vomiting, 
great  restlessness  or  apathy,  and  often  by  diarrhoea.  Less  fre((uently 
there  is  headache,  dimness  of  vision,  stupor  developing  into  coma,  or 
convulsions.  If  the  secretion  of  urine  is  re-established,  the  nervous  symp- 
toms abate  and  the  patient  may  recover.  This  has  been  know'n  to  occur 
after  complete  suppression  has  lasted  thirty-six  hours.  Care  should  be 
taken  not  to  mistake  retention  for  suppression.  If  doubt  exists,  percus- 
sion of  the  bladder  and  the  use  of  the  catheter  will  quickly  settle  the 
question. 

There  are  several  complications  for  which  the  physician  must  con- 
stantly be  on  the  lookout  during  attacks  of  acute  nephritis;  the  most 
frequent  are  pneumonia,  pleurisy,  pericarditis,  and  endocarditis;  more 
rarely  there  may  be  meningitis  and  oedema  of  the  glottis.  It  is  from 
complications  or  acute  uraemia  that  death  usually  occurs. 

Prognosis. — This  is  to  be  considered  from  two  points  of  view:  first, 
the  danger  to  life  during  the  acute  stage  of  the  disease,  and,  secondly, 
the  danger  of  the  development  of  chronic  nephritis.  The  great  majority 
of  patients  survive  the  acute  stage,  and  not  infrequently  even  those  re- 
cover who  have  presented  grave  symptoms  of  uremic  poisoning.  The 
quantity  and  specific  gravity  of  the  urine,  and  the  number  and  variety  of 
the  casts,  are  a  much  better  guide  in  prognosis  than  the  amount  of  albu- 
min. The  existence  of  severe  nervous  symptoms,  such  as  stupor,  intense 
headache,  dimness  of  vision,  and  persistent  vomiting,  add  much  to  the 
gravity  of  the  case,  as  does  also  the  presence  of  any  serious  complication. 
In  general  it  may  be  said  that  if  there  is  no  suppression  of  urine,  or  if 
there  are  no  symptoms  of  uraemia  and  no  complications,  recovery  is 


616  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 

almost  certain  if  the  child  is  over  three  years  old ;  in  Aounger  children 
the  outlook  is  less  favourable.  The  general  opinion  prevails  that  acute 
diffuse  nephritis  in  childhood,  whether  it  is  primary  or  occurs  as  a  com- 
plication of  scarlet  fever,  is  rarely  followed  by  the  chronic  form  of  the 
disease;  and  such  was  the  view  I  formerly  held.  Larger  experience, 
however,  has  convinced  me  that  this  sequel  is  not  very  uncommon.  The 
interval  of  apparent  health  may  sometimes  cover  a  period  of  several 
years,  and  the  later  nephritis  may  be  attributed  to  other  causes;  but  all 
cases  of  scarlatinal  nephritis  should  be  carefully  watched  for  a  long  time, 
and  after  a  severe  attack  a  guarded  prognosis  should  always  be  given 
as  regards  the  ultimate  result.^ 

Treatment. — Prophylaxis  is  important,  and  relates  principally  to  the 
secondary  form  which  occurs  .in  the  course  of  infectious  diseases,  espe- 
cially post-scarlatinal  nephritis;  but  the  measures  here  outlined  apply 
equally  to  all  varieties.  The  inflammation  of  the  kidney  being  in  most 
of  these  cases  the  result  of  direct  irritation  by  the  toxins  which  are  elim- 
inated by  them,  it  follows  that  elimination  through  the  skin  and  intes- 
tines should  be  increased,  and  that  the  urine  should  be  rendered  as  little 
irritating  as  possible  by  largely  increasing  its  quantity.  The  first  indi- 
cation is  met  by  frequent  sponging,  warm  baths,  and  keeping  the  bowels 
freely  opened  by  saline  cathartics,  sufficient  being  given  to  produce  one 
or  two  loose  movements  daily.  To  meet  the  second  indication,  the  pa- 
tient should  be  kept  upon  a  diet  of  milk  and  farinaceous  food,  at  least 
for  the  three  weeks  of  the  disease,  and,  if  possible,  for  a  full  month. 
At  the  same  time  he  should  drink  very  freely  of  alkaline  mineral  waters, 
or  of  plain  water.  If  milk  is  not  well  borne,  kumyss,  whey,  buttermilk, 
or  junket  may  be  used,  or  thin  gruels  mixed  with  milk.  When  the  first 
trace  of  albumin  appears  in  the  urine  this  plan  of  treatment  should  in- 
variably be  followed.  In  addition  to  these  measures,  after  an  attack  of 
scarlet  fever  the  patient  should  be  kept  in  bed  for  at  least  a  week  after 
the  temperature  has  become  normal. 

The  mild  cases  of  acute  nephritis  tend  to  spontaneous  recovery  under 
the  hygienic  and  dietetic  treatment  outlined,  i.  e.,  rest  in  bed,  the  diet 
mentioned,  the  drinking  of  large  quantities  of  water,  ;ind  attention  to  the 
action  of  the  skin  and  bowels.  These  measures  should  be  continued  so 
long  as  the  urine  contains  any  considerable  amount  of  albumin,  or  so 
long  as  the  patient's  general  condition  will  permit.     Should  he  become 

*  The  following  case  may  be  cited  as  an  illustration  of  this  point:  A  girl  at  the  age 
of  seven  years  had  scarlet  fever,  followed  by  nephritis;  the  droi)sy  having  lasted,  it 
was  rep)orted,  for  three  months.  She  wa.s  believed  to  have  rocovcrrd  jx^rfectly,  and 
remained  in  apparent  health  until  she  was  sixteen,  when,  as  a  supposed  result  of  a 
severe  chilling,  she  developed  dropsy  and  all  the  symptoms  of  acute  no^jhritis.  From 
that  time,  although  she  lived  for  three  years,  and  was  often  for  months  at  a  time 
seemingly  in  the  best  of  health,  her  urine  was  never  free  from  casts  and  albumin,  and 
she  finally  died  in  uraemic  convulsions. 


ACUTE   DIFFUSE   NEPHRITIS.  617 

very  anaemic,  or  lose  much  in  wciglit,  it  may  l)e  necessary  to  enlarge  the 
diet  by  the  addition  of  more  solid  food.  An  increase  in  the  diet  and 
exercise  should  be  made  very  gradualh',  and  the  effect  upon  the  urine 
carefully  watched. 

The  severe  cases,  with  scanty  urine,  fever  and  marked  dropsy,  re- 
quire more  active  treatment.  Free  diaphoresis  should  be  maintained  by 
the  hot  pack  or  vapour  bath.  Active  counter-irritation  should  be  main- 
tained over  the  kidneys  by  dry  cups  followed  by  ])oultices,  or  tlie  mustard 
paste.  Two  or  three  loose  movements  from  the  bowels  sliould  be  secured 
by  the  administration  of  calomel  or,  l)ettcr  by  Kochelle  or  l^psom  salts. 
Harm  is  sometimes  done  by  carrying  this  depletion  too  far,  and  its  effect 
upon  the  patient's  general  condition  must  be  closely  watched.  If  sup- 
pression of  urine  occurs  with  the  development  of  ura}inic  symptoms — 
delirium,  high  temperature,  flushed  face,  vomiting,  and  a  pulse  of  high 
tension — nitroglycerin  is  indicated;  a  child  of  five  years  may  take  gr.  ^^75- 
every  hour  for  five  or  six  doses,  or  until  an  effect  is  produced. 

In  addition  to  these  measures  rectal  injections  of  a  normal  salt  solu- 
tion should  be  given  high  in  the  colon,  at  a  temperature  of  from  104° 
to  108°  F.  At  least  two  quarts  should  be  given  several  ti::ies  a  day,  to  be 
continued  until  a  free  flow  of  urine  is  established.  This  is  one  of  the 
most  valuable  means  we  possess  of  increasing  elimination  by  the  kidneys 
and  skin. 

The  nervous  symptoms  of  uraemia  are  best  relieved  l)y  chloral,  which 
should  be  given  per  rectum.  When  such  symptoms  are  marked,  from 
six  to  ten  grains  are  required  for  a  child  of  five  years,  to  be  rejieated 
in  two  hours  if  no  improvement  is  seen.  Urosmic  convulsions  may  some- 
times be  averted  by  the  use  of  morphine  hypodermically.  In  extreme 
conditions  not  relieved  by  the  measures  mentioned,  venesection  should 
by  all  means  be  practised ;  from  three  to  six  ounces  of  blood  may  be  drawn 
from  a  child  of  five  years,  according  to  his  general  condition  and  the 
urgency  of  the  symptoms.  The  depressing  effect  may  largely  be  overcome 
by  immediately  following  this  with  an  intravenous  injection  cf  a  normal 
salt  solution.  Twice  as  much  as  the  fluid  drawn  should  be  introduced. 
This  will  almost  invariably  give  at  least  temporary  relief,  which  may 
afford  time  for  the  operation  of  other  measures  such  as  catharsis  and 
diaphoresis.  Pulmonary  oedema  is  no  contra-indication  to  bleeding; 
the  best  of  all  guides  as  to  its  use  is  a  pulse  of  very  high  tension. 

One  should  always  be  on  the  lookout  for  complications,  especially 
dropsy  of  the  serous  cavities,  pericarditis,  and  oedema  of  the  lungs.  Con- 
valescence is  nearly  always  slow,  and  a  patient  who  has  suffered  from 
nephritis  needs  careful  attention  for  a  long  time.  Anemia  is  always 
present,  and  iron  is  required.  The  diet  should  be  carefully  restricted 
for  several  months;  much  nitrogenous  food  should  be  avoided.  If  the 
disease  tends  to  pass  into  a  subacute  form,  the  child  should,  if  possible, 


618  DISEASES  OF   THE   UROGENITAL  SYSTEM. 

be  sent  to  a  warm  climate,  and  kept  there  during  the  succeeding  winter, 
and  every  means  taken  to  improve  the  general  nutrition.  Flannels 
should  he  worn  next  to  the  skin,  and  special  precautions  taken  against 
any  exposure  which  might  cause  an  exacerbation  of  the  disease. 

CHRONIC   NEPHRITIS. 

Chronic  inflammation  of  the  kidney  is  an  infrequent  condition  in 
childhood.  In  infancy  it  is  almost  unknown,  except  in  connection  with 
congenital  hydronephrosis  or  other  malformations  of  the  kidney.  Two 
pathological  varieties  arc  met  with:  (1)  chronic  diffuse  nephritis  of 
the  parenchymatous  or  degenerative  type;  (2)  chronic  diffuse  nephri- 
tis of  the  interstitial  or  productive  type.  As  the  disease  progresses  the 
former  may  assume  the  characteristics  of  the  latter  variety. 

Etiology. — Chronic  nephritis  is  most  frequently  seen  as  a  sequel  of 
the  acute  nephritis  of  scarlet  fever,  less  often  after  other  acute  infections. 
The  only  other  important  causes  in  early  life  are  hereditary  syphilis, 
chronic  tuberculosis,  and  valvular  disease  of  the  heart.  Nearly  all  the 
cases  occur  in  children  over  five  years  of  age. 

Lesions. — The  lesions  of  chronic  nephritis  in  childhood  do  not  differ 
essentially  from  those  seen  in  later  life.  In  the  chronic  parenchymatous 
type  the  kidneys  are  usually  enlarged,  the  surface  is  smooth  or  slightly 
nodular,  and  the  thickened  cortex  yellowish-white  on  section.  These  are 
often  called  "large  white  kidneys."  On  the  other  hand,  the  kidneys 
may  be  nearly  normal  in  appearance,  or  smaller  and  with  a  thinner  cortex 
than  is  usual.  lit  the  so-called  "  large  red  kidneys  "  the  cortex  is  red  or 
mottled  red  and  yellow,  owing  to  haemorrhages  into  the  tubules  or  in- 
terstitial tissue.  The  microscope  shows  that  the  renal  epithelium  is 
swollen,  granular,  fatty,  and  degenerated.  •  The  tubes  contain  leucocytes, 
red  cells,  cast  matter,  and  the  detritus  of  broken-down  epithelial  cells. 
In  some  places  they  are  dilated,  in  others  atrophied.  In  the  glomeruli 
there  is  a  growth  of  capsule  cells,  compression  and  atrophy  of  the  tufts, 
with  the  formation  of  new  connective  tissue. 

In  the  chronic  diffuse  nephritis  of  the  interstitial  typo  (granular 
kidney)  the  organs  are  smaller  than  normal,  with  a  nodular  surface  and 
adherent  capsule.  The  cortex  is  thinned,  and  the  colour  is  gray  or  red. 
In  addition  to  the  lesions  found  in  the  preceding  variety,  there  is  an 
extensive  production  of  new  connective  tissue,  which  is  irregularly  dis- 
tributed throughout  the  kidneys.  The  tubules  in  some  places  are  dilated 
to  form  cysts  of  considerable  size,  while  in  others  they  have  completely 
disappeared.  The  glomeruli  may  be  atrophied  to  little  fibrous  balls; 
or  if  chronic  congestion  has  ])receded  the  inflammation,  some  may  be 
large  and  the  capillaries  dilated  with  hyaline  degeneration  of  their 
walls. 


CHRONIC  NEPHRITIS.  619 

Symptoms. — 1.  Chronic  Nephritis  of  the  Parenchymatous  Tijpe. — 
This  form  of  the  disease  may  be  chronic  from  the  outset,  or  follow  an 
acute  attack  from  which  the  patient  is  often  helieved  to  have  recovered 
completely.  The  symptoms  sometimes  iimiicdiately  follow  the  acute 
attack;  at  others  there  is  an  interval  of  api)arent  recovery,  extending 
over  a  few  months  or  even  years.  Very  rarely  no  such  history  of  an 
antecedent  acute  attack  can  be  obtained,  and  the  symptoms  come  on 
gradually  and  insidiously.  Such  cases  occur  chiefly  in  older  children, 
and  their  clinical  features  do  not  diifer  essentially  from  those  of  adult 
life. 

As  a  rule  dropsy  is  present,  although  it  is  variable  in  amount,  and 
fluctuates  considerably  from  time  to  time.  Tiiere  may  be  not  only 
oedema  of  the  cellular  tissue,  but  efl'usion  into  the  pleura,  peritonaeum, 
and  even  the  pericardium.  As  the  case  progresses,  anaemia  is  always  a 
marked  symptom.  There  are  various  disturbances  of  digestion — loss  of 
appetite,  occasional  vomiting,  and  attacks  of  diarrhoea.  From  time  to 
time  nervous  symptoms  may  be  quite  prominent,  such  as  headaches,  sleep- 
lessness, neuralgia,  fatigue  upon  slight  exertion,  and  dyspna'a.  Attacks 
of  epistaxis  are  not  infrequent. 

For  the  greater  part  of  the  time  the  urine  contains  albumin  and 
casts.  They  vary  much  in  amount  at  different  periods  in  the  disease, 
according  to  the  rapidity  of  its  progress.  During  periods  of  exacerbation, 
both  albumin  and  casts  are  very  abundant,  while  in  the  intervals  the 
amount  of  albumin  may  be  small  and  the  casts  few.  The  casts  are 
hyaline,'  granular,  epithelial,  and  fatty.  The  daily  quantity  of  urine  is 
much  reduced  during  the  periods  of  exacerbation,  while  at  other  times 
it  may  be  nearly  normal.    The  specific  gravity  is  usually  normal  or  high. 

If  amyloid  degeneration  is  present,  there  are  generally  associated  with 
the  renal  symptoms,  others  dependent  upon  amyloid  changes  in  other 
organs.  The  spleen  and  liver  are  enlarged;  there  may  be  ascites  and 
diarrhoea,  and  there  is  usually   present  a  peculiar  alabaster  cachexia. 

The  duration  of  this  form  of  chronic  nephritis  depends  much  upon 
the  surroundings  of  the  patient  and  the  treatment.  It  is  rarely  shorter 
than  two  years,  and  it  may  last  for  many  years.  The  progress  is  always 
irregular,  and  marked  by  periods  of  exacerbation  and  remission.  The 
patients  die  from  acute  uraemia,  from  some  intercurrent  disease,  or  from 
complicating  pneumonia,  pleurisy,  pericarditis,  endocarditis,  or  from 
pulmonary  oedema. 

2.  Chronic  Nephritis  of  the  Interstitial  Type. — This  is  a  very  rare 
disease  in  early  life,  being  much  less  frequent  even  than  the  preceding 
variety  of  nephritis.  In  some  cases  there  is  a  history  of  hereditary 
syphilis ;  in  others,-  of  chronic  alcoholism.  The  early  symptoms  are  few, 
and  the  disease  usually  develops  insidiously.  The  urine  is  pale,  exces- 
sive in  amount,  and  of  low  specific  gravity — 1.001  to  1.008.     Albumin 


620  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 

is  often  absent,  and,  when  found,  the  quantity  is  small.  Dropsy  like- 
wise is  rare,  and  never  marked.  Nervous  symptoms  are  often  prominent, 
such  as  headache,  attacks  of  spasmodic  dyspnoea  resembling  asthma, 
neuralgias,  and  disturbances  of  vision.  Higli  arterial  tension  and  hyper- 
trophy of  the  left  ventricle  are  regular  symptoms;  and  even  atheroma- 
tous degeneration  of  the  arteries  may  be  present.  Dickinson  reports  an 
instance  of  this  in  a  patient  only  six  years  of  age.  Late  in  the  disease, 
haemorrhages  may  occur,  and  these  may  be  the  cause  of  death.  Filatoff 
lias  reported  a  cerebral  ha?morrliage  in  a  child  of  eleven  years.  Acute 
uraemia  is,  however,  the  usual  termination  of  this  form  of  nephritis. 
The  course  is  slow,  and  the  disease  may  be  overlooked  until  the  final 
uraemic  symptoms  occur. 

Prognosis. — The  prognosis  of  chronic  nephritis  as  to  complete  re- 
covery is  always  unfavourable;  and  although  cases  are  seen  in  which 
symptoms  are  absent  for  several  years,  they  almost  invariably  return. 
As  to  the  duration  of  the  disease,  no  exact  prognosis  can  be  given,  because 
from  the  symptoms,  it  is  difficult  or  impossible  to  determine  exactly  the 
extent  of  the  disease  in  the  kidney  and  the  rapidity  of  its  progress.  The 
continued  passage  of  a  large  amount  of  urine  of  low  specific  gravity  is  in- 
variably to  be  interpreted  as  evidence  of  fibroid  changes  in  the  Mal- 
pighian  tufts,  and  is  a  bad  symptom.  A  large  amount  of  dropsy,  the 
coexistence  of  valvular  disease  of  the  heart,  and  marked  renal  insuf- 
ficiency, as  shown  by  the  quantitative  examination  of  the  urine,  are  all 
very  unfavourable  symptoms. 

Diagnosis. — Chronic  nephritis,  like  the  acute  forms,  is  likely  to  be 
overlooked  because  of  the  failure  to  examine  the  urine  in  children. 
Regular  and  frequent  examinations  should  be  made  in  all  cases  of  con- 
vulsions, of  persistent  or  frequent  headaches,  severe  ansemia,  hypertrophy 
of  the  heart,  high  arterial  tension  and  of  general  malnutrition,  as  well 
as  when  the  more  obvious  symptoms  of  renal  disease,  such  as  dropsy  and 
scanty  urine,  are  present.  Nor  should  one  be  too  ready  to  make  the 
diagnosis  of  functional  albuminuria  because  he  finds  albumin  on)}'  oc- 
casionally and  in  small  quantity.  All  such  cases  demand  most  careful 
observation  and  the  closest  attention  for  a  long  period  before  excluding 
organic  renal  disease. 

Treatment. — Children  with  chronic  nephritis  are  to  be  treated  on  the 
same  general  plan  as  adults.  The  purpose  of  treatment  is  to  retard  as 
much  as  possible  the  progress  of  the  disease  and  to  relieve  the  symptoms 
as  they  arise.  It  is  of  the  greatest  importance  to  remove  the  patient 
from  conditions  in  which  exacerbations  are  liable  to  occur.  If  it  is  pos- 
sible, he  should  be  sent  to  a  warm,  dry  climate  in  winter,  and  all  exposure 
to  cold  avoided ;  an  out-door  life  is  desirable.  Most  patients  require  gen- 
eral tonic  treatment  with  very  moderate  but  regular  exercise,  never  car- 
ried to  the  point  of  fatigue,  as  much  rest  as  possible  in  a  recumbent 


TUBERCULOSIS  OF  THE   KlDxNEY.  621 

position,  a  fluid  diet,  consisting  largely  of  milk  as  long  as  this  can  be 
borne,  and  the  administration  of  iron.  Dropsy  calls  for  a  salt-free  diet, 
diuretics,  saline  cathartics,  and  vascular  stimulants.  Jf  unemia  de- 
velops, with  high  arterial  tension  and  stupor,  lieadache,  and  convulsions, 
venesection  should  be  resorted  to,  or  nitroglycerin  used.  Morphine  may 
be  given  hypodermically  if  the  nervous  symptoms  are  very  marked. 

Decapsulation  of  the  kidney  is  to  be  considered  in  cases  growing 
progressively  worse  in  spite  of  medical  treatment.  The  immediate  risks 
of  the  operation  are  rather  less  than  would  be  expected.  I  liave  seen 
striking  temporary  benefit  in  several  cases  when  this  operation  was  done 
upon  young  children.  In  no  case,  however,  was  the  improvement  per- 
manent, all  the  patients  dying  within  a  year  after  it  was  performed. 

TUBERCULOSIS  OF  THE   KIDNEY. 

In  general  tuberculosis,  miliary  tubercles  are  frequently  seen  both 
upon  the  surface  of  the  kidney  and  in  its  substance.  These  give  rise  to 
no  symptoms  and  are  of  no  clinical  importance.  Larger  tuberculous 
deposits  are  extremely  rare  in  early  life.  They  usually  occur  in  patients 
who  are  the  subjects  of  general  tuberculosis,  and  are  associated  with 
tuberculosis  of  other  parts  of  the  genito-urinary  tract,  or  they  may  exist 
as  the  primary,  or  even  the  only,  tuberculous  lesion  in  tlie  body.  Ascend- 
ing infection  occurs  occasionally  but  it  is  rare ;  nearly  all  cases  are  of  the 
descending  type,  i.  e.,  primary  in  the  kidney.  Infection  of  the  kidney 
therefore  generally  takes  place  through  the  circulation  and  not  from  the 
bladder.  Aldibert's  figures  show  that  in  children  the  bladder  usually 
escapes  even  when  the  kidneys  are  tuberculous,  for  of  thirteen  cases  of 
renal  tuberculosis  the  bladder  was  involved  in  but  two.  The  disease  when 
primary  begins  in  the  cortex,  but  soon  extends  to  the  mucous  membrane 
of  the  pelvis  and  the  calices  of  the  kidney,  and  also  to  the  pyramids. 
As  a  rule,  but  one  kidney  is  affected.  The  process  may  be  confined  to 
the  pyramids,  where  are  found  cheesy  nodules  which  may  be  single  or 
multiple.  These  ultimately  break  down  and  form  abscesses.  The  process 
may  result  in  almost  complete  destruction  of  the  pyramids,  and  even  of 
portions  of  the  cortex,  so  that  the  kidney  may  consist  of  a  mere  shell  of 
renal  tissue.  Suppuration  in  the  neighbourhood  of  the  kidney  (peri- 
nephritic  abscess)  often  coexists. 

The  symptoms  are  quite  indefinite.  There  may  be  localised  pain  and 
tenderness  in  the  region  of  the  kidney,  and  a  tumour  if  there  is  peri- 
nephritis. The  symptoms  of  irritability  of  the  bladder  may  be  almost  as 
severe  as  in  cases  of  calculus.  Pus  usually  appears  in  the  urine  as  a  con- 
stant symptom,  and  blood  is  often  present.  But  the  only  thing  that  is 
diagnostic  is  the  discovery  of  tubercle  bacilli  in  the  urine. 

The  treatment  is  the  same  as  in  adults. 


622  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 


MALIGNANT  TUMOURS  OF  THE   KIDNEY. 

In  the  great  majority  of  cases  tumours  of  the  kidney,  are  malignant. 
Of  fifty-one  eases  collected  by  Aldibert  which  were  operated  upon,  forty- 
eight  were  malignant,  and  three  benign. 

Malignant  growths  are  almost  invariably  primary.  In  children  under 
five  years,  although  not  common,  they  are  yet  more  frequent  than  any 
other  variety  of  malignant  tumour  of  the  abdomen.  The  earlier  cases 
reported  were  classed  as  carcinoma.  It  is  now  well  established  that  car- 
cinoma is  very  infrequent,  and  that  nearly  all  the  cases  are  varieties  of 
sarcoma.  The  tumour  grows  from  the  cortex  of  the  kidney,  or  from  the 
pelvis,  sometimes  from  the  adrenals.  It  may  infiltrate  the  whole  kidney, 
so  that  there  is  no  trace  of  renal  structure  remaining,  or  it  may  form 
an  immense  tumour  on  one  side  of  the  kidney,  which  is  only  partially 
invaded.  These  tumours  are  very  rarely  cystic,  but  they  are  quite  soft, 
and  haemorrhages  often  occur  into  their  substance.  There  may  be  sec- 
ondary growths  in  the  liver,  the  lungs,  the  retroperitoneal  glands,  in  the 
opposite  kidney,  in  the  intestines,  or  in  the  pancreas.  Pressure  of  the 
tumour  upon  the  ureter  may  lead  to  hydronephrosis,  and  upon  the  in- 
ferior vena  cava,  to  thrombosis  of  that  vessel.  As  it  grows,  the  tumour 
sometimes  becomes  adherent  to  nearly  all  the  abdominal  organs  by 
localised  peritonitis.  It  may  lead  to  ascites,  but  it  very  rarely  causes  gen- 
eral peritonitis.  The  growth  may  reach  a  great  size,  usually  from  five  to 
fifteen  pounds,  but  in  one  case  reported  by  Jacobi  it  weighed  thirty-six 
pounds.  In  Seibert's  collection  of  forty-eight  cases  the  right  kidney 
was  involved  in  twenty-four,  the  left  in  twenty-two,  and  both  kidneys 
in  two  cases. 

Etiology. — These  tumours  of  the  kidney  may  be  congenital.  This 
was  true  of  5  cases  in  a  series  of  55  collected  by  Jacobi.  The  majority 
occur  in  early  childhood.  In  the  collection  of  130  cases  by  Longstreet 
Taylor  in  which  the  ages  are  given,  106  were  observed  during  the  first 
five  years,  and  57  of  these  in  the  first  two  years  of  life.  The  sexes  were 
about  equally  affected. 

Symptoms. — The  principal  symptoms  are  tumour,  haematuria,  and 
cachexia.  The  tumour  is  usually  first  noticed.  It  is  in  most  cases  dis- 
covered in  the  loin,  but  grows  forward  toward  the  median  line.  Its  sur- 
face may  be  lobulated  and  irregular  or  quite  smooth ;  and  although  solid, 
it  is  sometimes  so  soft  as  to  give  an  •  obscure  sensation  of  fluctuation. 
It  may  grow  to  an  enormous  size,  causing  displacement  of  the  liver, 
spleen,  intestines,  and  lungs.  The  progress  of  the  growth  is  usually 
rapid,  so  that  from  the  size  of  a  fist,  the  tumour  may  grow  in  the  course 
of  five  or  six  months  so  as  to  fill  the  aladomen.  By  careful  palpation  it 
will  be  found — certainly  when  the  tumour  is  small — that  although  it 
may  be  quite  freely  movable,  its  attachment  is  near  the  lumbar  spine. 


MALIGNANT  TUMOURS  OF  THE   KIDNEY. 


623 


Hsematuria  maj  be  the  first  symptom  noticed.  The  amount  of  blood 
passed  is  sometimes  quite  large,  l)ut  is  usually  small,  and  may  be  discov- 
ered only  by  the  microscope.  Pain  is  rare,  and  is  due  to  localised  peri- 
tonitis. Constitutional  symptoms  are  absent  until  the  tumour  has  at- 
tained a  large  size,  when  a  cachexia  develops  and  the  patient  wastes 
steadily  while  the  tumour  continues  to  grow.  The  pressure  effects 
are  dyspnoea,  from  compression  of  the  lungs;  a>dema  of  the  lower 
extremities,  from  pressure  upon  or  thrombosis  of  the  vena  cava; 
vomiting  and  indigestion,  from  pressure  upon  the  stomach  and  in- 
testines. Secondary  de- 
posits very  rarely  cause 
any  symptoms  except  in 
the  lungs,  where  they  may 
give  rise  to  cough,  and  even 
to  haemoptysis. 

The  course  of  the  dis- 
ease is  steadily  from  bad  to 
worse.  The  usual  duration 
of  life  in  patients  not  op- 
erated, upon  is  from  three 
to  ten  months  after  the  tu- 
mour is  large  enough  to  be 
easily  discovered. 

Diagnosis. — The  impor- 
tant points  are,  the  position 
and  attachment  of  the  tu- 
mour, its  steady  growth 
and  solid  character,  haema- 
turia,  and  the  age  of  the 
patient  (under  five  years). 
It  may  be  confounded  with 
hydronephrosis,  dermoid 
cyst  of  the  ovary,  enlarge- 
ment of  the  spleen,  retro- 
peritoneal sarcoma,  tu- 
mours of  the  liver,  or  even 
of  the  abdominal  wall. 

Treatment. — Nothing  is 
to  be  said  regarding  the 
medical  treatment  of  these 

cases.  Unless  operated  upon,  they  invariably  terminate  fatally.  Some 
of  the  results  of  operation  during  recent  years  have  been  so  encour- 
aging that  no  case  should  be  abandoned,  no  matter  how  young  the 
patient,  but  recurrence  in  the  opposite  kidney  is  probable. 


Fig.  103. — Sarcoma  of  the  Kidney.  Child  thir- 
teen months  old.  Weight  of  tumour,  seven 
pounds.  This  patient  was  followed  for  sixteen 
years  and  there  was  no  recurrence. 


624  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 

Benign  Tumours. — These  are  distinguished  by  their  slow  growth, 
and  by  the  fact  that  the  constitutional  syin])tonis  are  mild  or  wanting. 
Of  the  three  cases  mentioned  by  Aldibert,  one  was  adenoma,  one  fibroma, 
and  one  was  fibro-cystic. 

PYELITIS— PYELO-CYSTITIS. 

Pyelitis  is  an  inflammation  of  the  mucous  membrane  lining  the  pel- 
vis of  tiie  kidney;  cystitis  is  an  inflammation  of  the  nmcous  membrane 
of  the  bladder.  They  may  exist  separately  or  together.  With  pyelitis 
there  may  be  inflammation  of  the  ureter  or  of  the  kidney  itself  (pyelo- 
nephritis), and  it  may  be  acute  or  chronic.  It  may  result  in  tlie  accu- 
mulation of  pus  in  considerable  amount  in  the  pelvis  of  the  kidney 
(pyonephrosis). 

Etiology. — The  most  frequent  local  cause  of  pyelitis  is  irritation  from 
renal  calculi.  It  is  also  associated  with  congenital  malformations  of 
the  kidneys  or  ureters,  with  renal  tuberculosis  and  renal  tumours.  It 
may  result  from  an  extension  of  inflammation  from  the  tissues  sur- 
rounding the  kidney  (perinephritis),  or  from  an  abscess  opening  into 
tiie  pelvis  of  tiie  kidney.  Acute  pyelitis  sometimes  occurs  as  a  compli- 
cation of  scarlet  or  typhoid  fever,  diphtheria,  influenza,  or  pyaemia;  but 
it  is  also  seen  apart  from  these  diseases,  when  it  occurs  apj)arently  as  a 
primary  aft'ection.  In  most  of  the  severe  cases  of  pyelitis  there  is  also 
present  a  certain  amount  of  nephritis. 

Acute  pyelitis  in  young  children  is  usually  due  to  an  ascending  in- 
fection from  the  bladder.  In  these  cases  the  evidences  of  inllaniniation 
of  the"  bladder  are  slight  or,  more  frequently,  entirely  wanting.  This 
form  of  inflammation  occurs  almost  invariably  in  female  infants.  Cul- 
tures made  from  the  urine  have  shown  with  great  uniformity  the  pres- 
ence of  the  colon  bacillus.  In  many  of  the  cases  the  pyelitis  is  preceded 
by  an  attack  of  diarrhoea.  It  is  surprising  tiiat  vulvo-vaginitis  is  seldom 
present.  It  seems  quite  possible  that  infection  may  also  occur,  especially 
in  male  infants,  by  a  direct  extension  from  the  intestine  to  the  bladder, 
or  through  the  blood.  Trumpp  examined  the  urine  in  sixteen  patients 
with  gastro-enteritis  and  found  the  colon  bacillus  in  thirteen,  of  whom 
nine  were  females. 

Lesions. — When  pyelitis  develops  from  a  local  cause  it  is  usually 
unilateral;  otherwise  both  sides  are  involved.  In  the  cases  of  acute 
cystitis  or  pyelo-cystitis  there  are  the  usual  appearances  of  an  acute 
catarrhal  inflammation  of  the  mucous  membrane,  with  congestion,  swell- 
ing, and  sometimes  minute  haemorrhages.  In  chronic  cases  tliere  is 
thickening  and  sometimes  a  granular  condition  of  the  lining  membrane. 
There  may  be  an  accumulation  of  pus  of  considerable  size,  distending 
the  pelvis  and  calices  (pyonephrosis).     If  the  condition  is  one  depend- 


PYELITIS— PYELO-CYSTITIS.  625 

ing  upon  a  calculus  or  congenital  deformity,  and  in  all  protracted  and 
severe  cases,  the  kidney  itself  is  involved  to  a  greater  or  less  degree ;  the 
extent  of  the  nephritis  will  depend  upon  the  nature  of  the  exciting  cause 
and  the  duration  of  the  process. 

Symptoms. — The  history  of  the  following  case  illustrates  the  main 
clinical  features  of  acute  infectious  pyelitis,  in  this  instance  occurring 
apparently  as  a  primary  disease : 

A  previously  healthy  female  infant  of  eight  months  was  taken  sud- 
denly with  a  chill,  followed  by  a  very  high  fever.  The  child  was  ill  for 
ten  days  before  the  nature  of  the  disease  was  -suspected.  During  this 
time  the  temperature  ranged  between  101°  and  106°  F.,  touching  105° 
nearly  every  day;  but  the  chill  was  not  repeated.  The  other  constitu- 
tional symptoms  were  not  severe.  At  the  first  examination  of  the  urine 
there  was  found  a  large  amount  of  pus,  which  on  standing  was  equal  to 
one-twelfth  of  the  volume  of  the  urine  passed ;  the  reaction  was  strongly 
acid.  There  were  no  signs  of  vaginitis  or  vulvitis,  no  ardor  urince,  no 
evidence  of  local  pain  either  in  the  bladder  or  kidney,  no  abnormal  fre- 
quency of  micturition,  no  localised  tenderness,  and  no  vomiting.  At 
later  examinations  there  were  found  in  moderate  numbers  epithelial  cells 
from  the  bladder,  and  the  tubules  and  pelvis  of  the  kidney,  also  a  few 
hyaline  casts,  but  not  more  albumin  than  would  be  explained  by  the 
amount  of  pus.  Under  no  treatment  except  alkaline  diuretics,  the  tem- 
perature gradually  fell  to  normal,  and  the  pus  steadily  diminished  in 
quantity,  and  at  the  end  of  five  weeks  had  practically  disappeared  from 
the  urine.  A  report  sixteen  months  later  stated  that  the  child  had  re- 
mained well  and  entirely  free  from  urinary  symptoms. 

In  some  cases  there  are  recurring  chills,  with  wide  fluctuations  in 
temperature;  in  others  there  may  be  only  pyuria,  with  moderate  fever 
and  few  other  constitutional  symptoms.  The  course  of  the  temperature 
is  a  very  irregular  one.  The  fever  is  seldom  continuous,  but  may  be 
interrupted  by  periods  of  normal  temperature,  lasting  several  days.  The 
duration  of  the  acute  attack  may  be  from  two  to  six  weeks,  and  pus  cells 
may  be  found  microscopically  for  a  much  longer  time.  If  the  disease 
complicates  one  of  the  acute  infectious  diseases,  pyuria  may  be  the  only 
symptom.  If  cystitis  is  also  present  micturition  is  frequent,  and  may  be 
painful.  The  urine  in  acute  pyelo-cystitis  is  turbid  from  the  presence 
of  pus,  the  amount  of  which  may  be  from  one  to  fifty  per  cent  of  the 
volume  of  the  urine.  The  amount  of  pus  varies  greatly  from  day  to 
day.  It  is  often  abundant  when  the  temperature  is  low,  and  almost 
absent  when  the  temperature  is  high,  this  fluctuation  depending  upon  the 
accumulation  or  the  discharge  of  the  pus.  The  quantity  of  urine  is 
generally  somewhat  diminished,  and  it  may  be  quite  scanty.  The  reac- 
tion is  usually  acid,  even  though  the  amount  of  pus  is  large.  Albumin 
is  present  in  proportion  to  the  amount  of  pus  or  the  degree  of  nephritis. 
41 


626  DISOEASES  OF  THE  URO-GENITAL  SYSTEM. 

Red  blood-cells  are  found  under  the  micro6<x>pe  in  most  of  the  very 
acute  cttses,  and  may  be  in  sufficient  numbers  to  colour  the  urine.  The 
pus  cells  in  recent  cases  are  usually  well  preserveil.  but  in  old  cases  they 
may  be  degenerated.  There  are  many  epithelial  cells — conical,  fusi- 
Uam,  and  irregxilar  cells  with  long  tails.  There  may  be  renal  epithelium 
and  hyaline,  granular,  or  epithelial  casts,  varying  in  number  with  the 
seTerity  of  the  nephritis.  In  a  catheterised  specimen  the  colon  bacillus 
is  usually  present  in  pure  culture. 

In  chronic  pyelitis  only  pyuria  may  be  present,  or  there  may  be  a 
tumour,  owing  to  the  pyonephrosis.  From  time  to  time,  in  the  chronic 
form,  there  may  be  intermittent  attacks  of  acute  pyelitis  resembling 
those  above  described.  In  pyelitis  depending  upon  congenital  malfor- 
mations>  pyuria  is  usually  the  oidy  symptom,  uidess  pyonephrosis  is 
present.  With  t^culi  we  may  have  acute  or  chronic  pyelitis ;  there  may 
be  localised  pain,  tenderness,  sometimes  a  tumour,  occasionally  hema- 
turia, and  perhaps  a  history  of  renal  ctJic  or  the  passage  of  graveL 
With  tuberculoisis.  there  is  chronic  pyuria  and  the  presence  of  tubercle 
baeiUi  in  the  urine.  The  symptoms  of  general  tuberculosis  are  com- 
monly associated.  If  there  fe  perinephritis,  the  inflammation  is  usually 
acute,  and  there  are  present  the  local  symptoms  of  the  original  disease. 
If  an  abscess  op»)s  into  the  pelvis  of  the  kidney,  there  may  be  a  sudden 
discharge  of  pus  in  large  quantity  with  a  subsidence  of  previous  local 
symptoms,  including  the  tumour.  With  neopUisms,  both  pus  and  blood 
may  be  found  in  the  uriike,  bat  the  latter  is  more  frequent. 

HiapMiris. — The  characteristic  symptoms  of  acute  pyelitis  are  chills, 
which  may  be  repeated,  high  and  fluctuating  temperature,  scanty  uriue, 
frequently  pain  and  tenderness  over  the  kidneys,  and  pyuria.  The  diag- 
Bosis  of  pyelitis  is  made  only  by  an  examination  of  the  urine,  wliich 
sbmld  never  be  omitted  in  cases  of  obscure  high  temperature,  even  in 
infancy,  particularlv  if  chills  are  present.  When  cystitis  is  associated, 
the  only  additional  symptoms  may  be  pain  and  other  signs  of  Tesk»l 
irritation.  These  symptoms,  with  an  acid  urine  containing  a  large 
amount  of  pus  and  ^tbdial  cells  like  those  described,  are  sui£oient  to 
establish  the  diagnosis  of  pydo-cystitis.  If  the  pus  comes  from  the 
opening  of  an  abscess  into  the  bladder,  ureter,  or  pelvis  of  the  kiilney. 
the  local  sigiis  of  aidi  absce^  will  usually  be  presenL 

RncMiis. — In  cases  aj^paiently  primary,  and  in  those  complicating 
mfectkas  axtd  other  diseases,  the  prognosis  is  good.  The  danger  is 
tiatAj  fnmk  the  nephritis  wiuch  follows  or  ccmqdicates  the  jHrocess.  In 
cans  dqpeading  npon  local  conditions,  the  prognosis  will  depend  upon 
Ae  aateie  o£  the  eicitiag:  caose.  Here,  also,  the  principal  danger  is 
from  nqpluitiB.  If  cakvK  are  piesent  and  if  pyonephrosis  occurs,  the 
■ay  die  finan  exhaustion  before  a  serious  d^ree  of  nephritis 

■Bvdoped. 


RKNAL  c;ai/;i:ij.  (j27 

Treatment. — Water  hIiouM  Ik;  giv<!n  fro<;ly,  arnl  alkalioH  up  lo  the 
point  of  neutralising  the  exccHHive  aci'lity  of  Uk;  iiri/u;.  In  InfantH,  from 
fifteen  to  twenty-five  grainH  of  the  citrate  of  pobinh  are  refjuired  daily 
for  thiH  purpose.  If  the  urine  in.  alkaline,  [(erizoie  aeid  may  [>e  used  in 
the  game  doses.  The  most  widely  userl  refn(;fly  Ih  liexarfietliylenarnine 
(urotropin),  which  may  he  given  in  doHew  of  one  or  two  grains  every 
three  hours  to  an  infant  of  a  year,  and  pro(;orlionat/;  dosrjs  to  ohler  chil- 
dren. I  have  seen  it  us<id  in  larg(,-  and  Hrnall  doHCH  in  canes  fjf  aciiU; 
pyelitis,  hut  have  not  heen  convinced  of  its  value,  niont  canes  prompt  I  y 
recovering  without  it.  Occasionally  pyelitis  is  very  resistent  to  any  form 
of  treatment,  the  exacerhations  and  remisHions  continuing  for  many 
weeks.  For  such  ohstinate  cases  vaccines,  f>referaldy  the  autog(;nous 
variety,  should  he  tried.  Striking  henefit  has  sometimes  followed  their 
u«e.  If  calculi  are  present  the  same  treatment  is  inditrated.  Surgical 
interference  is  called  for  if  pyonephrosis  develops,  or  if  the  disease  is 
evidently  unilateral  and  the  kidney  is  s<!riou.sly  involved,  'i'he  advis- 
ahility  of  surgical  interference  will  depend  upon  the  clearness  of  diag- 
nosis and  the  severity  of  the  symptoms. 

RENAL  CALCULI. 

Small  renal  calculi  are  very  common  in  infancy.  In  the  autopsy 
room  we  frequently  gee,  on  opening  the  kidneys  of  young  infants,  fine 
brown  granules  in  the  pelvis  and  calices,  and  occasionally  a  calculus  aa 
large  as  a  small  pea  is  found.  They  are  usually  composed  of  uric  acid. 
Only  once  in  over  one  thousand  autopsies  of  which  I  have  records,  wag 
a  stone  of  any  considerable  size  seen  in  an  infant.  In  this  case  it  was 
an  inch  in  length  and  half  an  inch  wide.  It  is  surprising  that  these  are 
8o  rare,  when  we  consider  how  very  frequently  the  minute  calculi  are 
met  with.  The  probable  explanation  is,  that  the  majority  of  them  are 
dissolved  or  washed  down  into  the  bladder  and  passed  per  urelhram 
because  of  the  fluid  diet  of  the  first  two  years.  The  granular  deposits 
are  usually  lodged  in  the  pelvis  of  the  kidney,  and  are  generally  seen 
upon  both  sides.  With  the  larger  collections  there  is  often  a  slight 
catarrhal  pyelitis. 

Symptoms. — The  small  deposits  give  no  symptoms,  and  even  quite 
large  calculi  may  be  found  at  autopsy  where  no  indication  of  their  pres- 
ence had  existed  during  life,  as  in  the  case  above  mentioned.  In  some 
cages  gymptomg  are  produced  which  resemble  those  of  renal  calculi  in 
the  adult.  In  infants  less  definite  symptoms  are  often  passed  over  as 
merely  intestinal  colic. 

In  well-marked  cases  in  older  children  there  is  tenderness,  pain  local- 
ised over  the  affected  kidney,  or  radiating  to  the  bladder,  the  f^erinaeum, 
and  even  the  opposite  kidney,  and  there  may  be  irritation  and  retraction 


628  DISEASES  OF  THE   URO-GENITAL  SYSTEM. 

of  the  testicle.  The  urine  may  show,  especially  after  exercise,  a  trace  of 
blood;  there  may  be  the  added  symptoms  of  pyelitis,  with  some  fever, 
localised  tenderness,  and  the  appearance  in  the  urine  of  pus  and  epi- 
thelial cells  from  the  pelvis  of  the  kidney. 

Eenal  colic  is  produced  when  a  stone  of  any  considerable  size  passes 
from  the  kidney  to  the  bladder.  It  is  characterised  by  symptoms  similar 
to  those  seen  in  the  adult.  There  are  sudden  attacks  of  severe  sickening 
pain  in  the  loins,  shooting  down  the  thigh  or  to  tlie  testicle.  There  may 
be  vomiting  and  even  collapse.  The  urine  is  passed  frequently,  in  small 
quantities,  and  contains  blood.  The  symptoms  quickly  subside  when 
the  stone  reaches  the  bladder.  The  calculus  may  sometimes  become  im- 
pacted in  the  ureter  and  give  rise  to  hydronephrosis  or  pyonephrosis, 
which  soon  becomes  pyelo-nephritis. 

The  existence  of  small  calculi  may  be  suspected  from  the  symptoms 
above  mentioned;  the  diagnosis  is  made  positive  by  the  appearance  of 
gravel  in  the  urine.  The  use  of  the  Eontgen  rays  is  of  service  in  recog- 
nising even  small  calculi. 

Treatment. — The  only  medical  treatment  consists  in  a  fluid  diet,  the 
free  use  of  alkaline  mineral  waters,  and  a  sufficient  quantity  of  some 
drug  to  render  the  urine  alkaline.  Such  measures  will  relieve  only  the 
milder  conditions.  With  larger  calculi  and  more  marked  symptoms,  a 
surgical  operation  should  be  considered  and  should  be  urged  in  propor- 
tion to  the  severity  of  the  symptoms  and  the  clearness  of  the  diagnosis. 
If  calculous  pyelitis  exists,  it  is  certain  sooner  or  later  to  lead  to  serious 
nephritis,  and  it  is  only  a  question  of  time  when  the  kidney  will  be  dis- 
abled. The  same  is  true  of  hydronephrosis  from  the  impaction  of  a  cal- 
culus in  the  ureter,  Aldibert  has  collected  four  cases  of  nephrectomy  in 
children  for  renal  calculi  in  which  the  kidney  was  healthy,  with  three 
recoveries  and  one  death  from  shock.  In  nine  cases  of  operation  for 
calculous  pyonephrosis,  there  were  six  recoveries  and  three  deaths.  The 
earlier  the  operation  the  greater  the  chances  of  success,  because  of  the 
better  condition  of  the  other  kidney.  Although  the  continued  use  of 
water  and  the  so-called  solvents  may  relieve  some  of  the  symptoms,  it 
is  very  questionable  whether  they  do  more. 

TRAUMATIC  HYDRONEPHROSIS. 

In  addition  to  the  hydronephrosis  which  results  from  congenital  mal- 
formations and  from  the  impaction  of  calculi,  a  form  is  occasionally 
seen  following  severe  injury  to  the  kidney.  The  pathology  of  hydro- 
nephrosis in  these  cases  is  not  well  understood.  After  the  early  symp- 
toms of  traumatism  have  subsided,  there  develops  in  from  two  weeks  to 
two  months  a  tumour  in  the  region  of  the  kidney,  which  may  reach  a 
considerable  size  and  present  all  the  ordinary  characteristics  of  hydro- 


PERINEPHRITIS.  629 

nephrosis  arising  from  otlier  causes.  This  tumour  may  disappear  spon- 
taneously, or  it  may  increase  in  size  and  demand  surgical  intervention 
for  its  cure.  In  seventeen  cases  which  Aldibert  has  collected  there 
was  only  one  of  spontaneous  recovery;  aspiration  was  done  in  seven 
cases,  with  six  cures  and  one  death;  incision  with  or  without  nephrec- 
tomy was  practised  in  nine  cases,  with  seven  recoveries  and  two  deaths. 

PERINEPHRITIS. 

This  consists  in  an  inflammation  in  the  cellular  tissue  surrounding 
the  kidney,  which  may  terminate  in  resolution  or  in  suppuration.  It  is 
not  of  very  uncommon  occurrence,  and  is  of  importance  chiefly  from  the 
frequency  with  which  it  is  confounded  with  disease  of  the  hip  or  spine. 
Perinephritis  may  be  secondary  to  suppurative  processes  in  the  kidney 
itself,  whether  from  calculi  or  tuberculous  deposits,  or  it  may  be  primary. 
In  children  the  latter  is  the  common  form.  Primary  perinephritis  is 
attributed  to  traumatism,  cold,  or  exposure,  or  it  may  develop  without 
assignable  cause.  It  usually  runs  an  acute  or  subacute  course;  very 
rarely  it  may  be  chronic. 

For  the  clinical  picture  of  this  disease  I  am  chiefly  indebted  to  a 
paper  by  Gibney,  who  has  published  a  report  of  twenty-eight  cases  of 
primary  perinephritis  in  children.  The  ages  of  these  patients  were  be- 
tween one  and  a  half  and  fifteen  years,  the  majority  being  between  three 
and  six  years.  The  two  sides  and  the  two  sexes  were  about  equally 
affected.  About  one-third  of  the  cases  were  clearly  traceable  to  trau- 
matism; in  the  others  no  adequate  exciting  cause  could  be  discovered. 
The  majority  of  the  cases  were  referred  to  the  hospital  with  the  diag- 
nosis of  hip- joint  disease  or  caries  of  the  spine.  Eesolution  followed  in 
twelve  of  these  cases,  and  sixteen  terminated  in  suppuration. 

When  abscess  forms,  it  usually  burrows  between  the  lumbar  muscles 
and  comes  to  the  surface  posteriorly  near  the  middle  of  the  ilio-costal 
space ;  it  may  burrow  forward  between  the  abdominal  muscles  and  point 
just  above  Poupart's  ligament;  very  rarely  it  may  follow  the  psoas 
muscle  and  appear  at  the  upper  and  inner  aspect  of  the  thigh,  like  an 
ordinary  psoas  abscess;  or  it  may  open  into  the  peritoneal  cavity. 

Symptoms. — The  onset  of  acute  perinephritis  may  be  quite  abrupt, 
with  chill,  fever,  and  localised  pain;  or  it  may  be  gradual,  with  stiffness 
of  the  spine,  lameness  referred  to  the  hip,  and  deformity  due  to  contrac- 
tion of  the  flexors  of  the  thigh.  The  pain  is  usually  felt  in  the  loin,  but 
may  be  referred  to  the  groin,  to  the  inner  side  of  the  thigh,  or  to  the 
knee.  It  is  often  severe,  and  increased  by  using  the  limb.  It  is  in  most 
cases  accompanied  by  localised  tenderness  in  the  neighbourhood  of  the 
kidney.  There  is  lameness  upon  the  affected  side,  which  may  come  on 
gradually,  being  sometimes  referred  to  the  hip  and  sometimes  to  the 


630  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

spine.  These  symptoms  often  develop  slowly  in  the  course  of  two  or 
three  weeks.  They  are  usually  accompanied  by  a  slight  elevation  of  tem- 
perature. In  the  most  acute  cases  the  temperature  is  high  (103°  to  104° 
F.),  and  prostration  severe. 

As  the  disease  progresses,  fever  is  a  constant  symptom,  the  tempera- 
ture usually  varying  between  101°  and  103°  F.  There  is  in  most  cases 
increasing  deformity,  and  finally  tiie  patient  may  be  unable  to  walk  at 
all.  On  examination  at  the  height  of  the  disease,  there  is  found  in  a 
typical  case  a  deviation  of  the  spine  with  the  concavity  toward  the  af- 
fected side ;  the  thigh  may  be  held  flexed  to  a  right  angle ;  passive  exten- 
sion is  resisted  and  causes  pain,  although  all  the  other  movements  at  the 
hip  joint  are  normal.  In  the  lumbar  region  there  is  tenderness,  and 
there  may  be  an  area  of  infiltration  filling  the  ilio-costal  space.  At  first 
this  is  only  appreciable  by  percussion,  but  later  a  distinct  tumour  is 
present.  In  addition  to  the  tumour  in  the  usual  region,  there  is  some- 
times one  at  the  upper  and  inner  aspect  of  the  thigh,  owing  to  a  bur- 
rowing of  pus,  and  the  sacs  may  communicate. 

Lameness,  pain,  deformity,  and  fever  sometimes  exist  for  two  or 
three  weeks  before  any  tumour  can  be  made  out.  The  constitutional 
symptoms  are  often  severe.  The  size  of  the  abscess  is  sometimes  very 
great.  In  one  case  I  saw  it  extend  from  the  spine  to  the  median 
line  in  front,  and  from  the  crest  of  the  ilium  nearly  to  the  free  border 
of  the  ribs.  The  amount  of  pus  varies  from  a  few  ounces  to  two  or 
three  pints.  Urinary  symptoms  are  sometimes  wanting;  at  other  times 
there  is  increased  frequency  of  micturition,  accompanied  by  pain  from 
an  irritation  referred  to  the  bladder.  The  urine  may  contain  pus  from  a 
complicating  pyelitis.  In  only  one  of  Gibney's  cases  was  this  present. 
It  developed  in  the  fourth  week,  and  the  case  recovered. 

The  duration  of  the  disease  in  the  acute  cases  varies  from  three  to 
eight  weeks ;  in  the  subacute  it  may  be  five  or  six  months.  When  sup- 
puration occurs  the  symptoms  subside  quite  rapidly  after  the  pus  has 
been  evacuated,  and  recovery  is  complete.  When  resolution  takes  place, 
there  is  a  gradual  subsidence  of  the  symptoms,  and  often  some  stiffness 
of  the  thigh,  with  slight  lameness  for  several  months.  In  the  series  of 
cases  above  referred  to,  sixty-five  per  cent  recovered  completely  in  three 
months. 

Diagnosis. — In  many  cases  a  diagnosis  of  hip-joint  disease  is  made, 
but  that  disease  develops  more  insidiously,  is  very  much  more  chronic, 
and  rarely  produces  so  great  deformity  in  a  year  as  is  often  seen  in  peri- 
nephritis in  two  or  three  weeks;  abscess  is  infrequent  during  the  first 
year  of  the  disease.  In  perinephritis,  on  the  other  hand,  we  have  a 
tolerably  acute  onset,  sometimes  with  chill,  fever,  marked  lameness,  and 
deformity,  developing  in  two  or  three  weeks ;  abscess  often  forms  in 
a  month,  and  complete  and  permanent  recovery  usually  follows  after  a 


MALFORMATIONS  OF  THE  GENITAL  ORGANS.  631 

few  months  at  most;  the  deformity  is  due  solely  to  flexion  of  the 
thigh;  all  other  movements  at  the  hip  may  he  free,  and  joint  tenderness 
is  absent.  Psoas  abscess  from  Pott's  disease  may  cause  deformity,  tu- 
mour, and  lameness  similar  to  that  seen  in  perinephritis,  but  on  examina- 
tion there  is  found  the  angular  prominence  and  other  signs  of  disease 
of  the  lumbar  vertebrge.  In  cases  of  doubt  the  tuberculin  test  may  give 
important  aid  in  diagnosis. 

Prognosis. — Primary  perinephritis  in  children  almost  invariably  ter- 
minates in  complete  recovery.  Of  the  twenty-eight  cases  referred  to, 
and  eight  subsequently  observed  by  Gibney,  all  recovered  perfectly.  The 
only  condition  likely  to  prove  fatal  is  rupture  of  the  abscess  into  the 
peritoneal  cavity. 

Treatment. — The  patient  should  be  put  to  bed  and  kept  as  quiet  as 
possible  throughout  the  attack. .  In  the  early  stage,  hot  fomentations  or 
an  ice-bag  should  be  applied  over  the  affected  side;  heat  is  generally  to 
be  preferred.  Abscesses  should  be  opened  early,  to  prevent  burrowing 
and  the  danger  of  a  possible  rupture  into  the  peritoneal  cavity. 


CHAPTER    III. 

DISEASES  OF  THE  GENITAL  ORGANS. 

MALFORMATIONS. 

Adherent  Prepuce. — This  condition  is  sometimes  called  false  phi- 
mosis. It  is  so  constantly  present  that  it  can  hardly  he  regarded  as  a 
malformation.  It  is,  however,  a  condition  needing  attention  in  every 
male  infant.  The  prepuce  should  be  forcibly  retracted  so  as  to  expose 
the  glans  completely.  The  smegma  should  then  be  washed  away,  the 
glans  covered  with  a  drop  of  oil,  and  the  skin  drawn  forward.  This 
should  be  repeated  daily  until  there  is  no  disposition  to  a  recurrence  of 
the  adhesions. 

Phimosis. — This  is  such  a  narrowing  of  the  prepuce  that  it  can  not 
be  retracted  over  the  glans.  The  degree  of  phimosis  varies  greatly.  In 
very  rare  cases  there  is  no  preputial  opening.  In  other  cases  the  orifice 
is  so  small  that  no  part  of  the  glans  can  be  exposed,  and  there  is  obstruc- 
tion to  the  outflow  of  urine ;  but  usually  a  small  part  of  the  glans  can  be 
seen.  Phimosis  may  be  complicated  by  an  elongated  prepuce  (hyper- 
trophic phimosis),  and  the  elongation  may  exist  without  any  narrowing 
of  the  orifice,  although  this  is  usually  present  to  some  degree. 

The  presence  of  phimosis  makes  cleanliness  impossible  in  many  cases, 
aud  want  of  cleanliness  leads  to  infection  and  to  balanitis.  This  is  quite 
frequent,  even  in  infants.    It  may  be  complicated  by  urethritis,  and  even 


632  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

by  cystitis.  Another  consequence  of  the  straining  induced  by  phimosis 
is  hernia,  which  may  be  either  inguinal  or  umbilical.  To  cure  the 
hernia  is  often  impossible,  unless  the  phimosis  is  relieved.  Keflex  symp- 
toms may  come  from  preputial  adhesions  as  well  as  from  phimosis.  The 
hyperaesthetic  condition  and  the  resulting  pruritus  cause  frequent  pria- 
pism, and  are  among  the  common  causes  of  masturbation.  Phimosis  may 
produce  other  nervous  symptoms,  such  as  insomnia,  night  terrors,  etc. 
It  often  causes  frequent  micturition,  dysuria,  and,  in  fact,  most  of  the 
symptoms  of  stone  in  the  bladder.  It  sometimes  leads  to  vesical  spasm 
and  retention  of  urine,  but  more  frequently  to  nocturnal  incontinence. 

The  list  of  reflex  phenomena  which  have  been  ascribed  to  phimosis 
is  a  long  one,  and  includes  most  of  the  functional  nervous  diseases  of 
childhood.  There  has  been  in  the  past  a  disposition  on  the  part  of  some 
to  attribute  nearly  all  the  nervous  disturbances  of  boyhood  to  phimosis, 
and  an  exaggerated  importance  has  certainly  been  attached  to  this  con- 
dition. Still,  in  a  delicate,  anaemic  child  with  unstable  nervous  centres, 
phimosis  is  capable  of  giving  rise  to  nervous  symptoms  of  a  serious  char- 
acter. It  is  an  important  etiological  factor  in  many  neuroses,  and  one 
which  should  not  be  overlooked.  On  the  other  hand,  a  very  marked  degree 
of  phimosis  often  exists  in  healthy  children  without  producing  any  symp- 
toms whatever. 

Treatment. — Every  case  of  phimosis  should  receive  attention  in  in- 
fancy. Often  very  little  treatment  is  needed;  but  trouble  is  likely  to 
come  sooner  or  later  if  it  is  neglected.  When  there  is  a  very  long  prepuce 
with  phimosis,  the  operation  of  circumcision  should  in  my  opinion  be 
done,  even  when  the  degree  of  phimosis  is  slight.  Many  cases  of  phimosis 
in  which  the  prepuce  is  not  long  can  be  relieved  by  stretching.  If  no  part 
of  the  glans  can  be  exposed,  the  simplest  plan  is  to  slit  up  the  dorsum 
of  the  prepuce  with  a  pair  of  scissors  and  forcibly  break  up  the  adhesions. 
The  corners  of  the  flaps  thus  made  can  then  be  snipped  off  and  one  stitch 
inserted  on  either  side.  In  the  case  of  obscure  nervous  symptoms  in  older 
boys,  the  condition  of  the  prepuce  should  be  examined  and  the  same  rules 
of  treatment  applied.  In  cases  of  hernia,  or  prolapsus  ani,  when  phimosis 
is  present  it  should  be  relieved. 

Hypospadias. — In  this  condition  the  urethra  is  not  continued  to  the 
tip  of  the  penis^  but  opens  on  the  inferior  surface  some  distance  back, 
being  represented  in  front  of  this  only  by  a  shallow  furrow.  In  more 
severe  cases  there  is  a  deep  fissure  which  divides  the  scrotum,  and  some- 
times even  the  perinaeum.  Into  this  fissure  the  urethra  opens.  This  is  a 
condition  likely  to  be  mistaken  for  that  of  hermaphrodism,  especially 
as  the  testicles  are  frequently  in  the  abdominal  cavity. 

Epispadias. — This  is  a  condition  in  which  the  urethra  opens  on  the 
dorsal  surface  of  the  penis.  It  is  much  less  frequent  than  hypospadias. 
There  may  be  simply  a  division  of  the  glans,  or  the  fissure  may  extend 


MALFORMATIONS  OF  THE  GENITAL  ORGANS.  633 

the  whole  length  of  the  organ  and  be  complicated  by  exstrophy  of  the 
bladder. 

Exstrophy  of  the  Bladder. — In  the  complete  form  there  is  a  median 
fissure  from  the  umbilicus  to  the  tip  of  the  penis.  It  includes  the  an- 
terior abdominal  wall,  the  pelvic  bones,  and  the  urethra.  The  bones  are 
entirely  separated  at  the  symphysis,  or  connected  behind  the  bladder  by 
a  fibrous  band.  The  hypogastric  region  is  occupied  by  a  rod,  mucous 
surface,  slightly  corrugated,  which  is  all  there  is  of  the  bladder.  In  the 
lower  lateral  portions  of  the  red  mucous  membrane  two  slightly  rounded 
elevations  are  seen,  from  which  urine  oozes.  These  are  the  openings  of 
the  ureters.  The  penis  is  short,  and  presents  a  shallow  furrow  on  its 
dorsal  surface.    The  testes  are  often  in  the  abdominal  cavity. 

An  analogous  deformity  is  sometimes  seen  in  girls.  There  is  a  division 
of  the  clitoris  and  the  labia  minora  and  majora.  The  fissure  may  be  so 
deep  as  to  reach  nearly  to  the  anus.  The  vagina  is  usually  absent.  The 
rectum  may  open  into  the  prolapsed  bladder. 

All  these. deformities  are  compatible  with  long  life.  In  most  of  them 
the  individual  is  incapable  of  procreation.  In  exstrophy  of  the  bladder, 
whether  complete  or  partial,  patients  are  a  nuisance  to  themselves  and  to 
all  about  them.  It  is  almost  impossible  to  prevent  the  clothing  from 
being  soaked  with  urine,  which  gives  everything  connected  with  the 
patient  a  strong  ammoniacal  odour.  The  skin  is  often  excoriated.  Op- 
eration for  the  relief  of  these  cases  should,  I  think,  always  be  undertaken. 
The  operation  to  be  recommended  is  the  transplantation  of  the  ureters 
into  some  part  of  the  large  intestine,  usually  the  rectum.  The  results 
are  often  most  surprising.  The  rectum  soon  becomes  tolerant  of  the 
urine,  holds  it  for  hours  without  difficulty  and  evacuates  it  without  dis- 
comfort.   Ascending  infection  of  the  kidney  seldom  occurs. 

Undescended  Testicle — Cryptorchidism. — In  foetal  life  the  testes  are 
situated  in  the  abdominal  cavity  below  the  kidneys.  They  usually  descend 
into  the  scrotum  during  the  ninth  month,  but  in  children  born  at  term 
the  testicles  may  be  in  the  inguinal  canal,  or  even  in  the  abdomen.  The 
former  condition  is  quite  frequent,  being  present  in  fully  ten  per  cent  of 
all  male  children.  In  most  of  these  the  descent  takes  place  without  dif- 
ficulty during  the  first  weeks  of  life,  and  causes  no  symptoms.  In  others 
the  condition  may  persist.  Spontaneous  descent  may  take  place  at  any 
time  before  puberty,  the  chances,  however,  steadily  lessening  as  age  ad- 
vances. When  in  the  inguinal  canal,  on  account  of  its  exposed  situation, 
the  testicle  may  be  injured,  or  become  painful  and  tender  as  puberty 
approaches.  In  any  abnormal  position  it  probably  will  not  develop  prop- 
erly, and  may  remain  without  function,  but  interference  with  the  devel- 
opment of  the  body  is  rare.    Hernia  is  ^  frequent  complication. 

When  in  the  inguinal  canal,  descent  of  the  testicle  may  sometimes  be 
facilitated  by  manipulation.    If  the  condition  is  unilateral,  operation  is 


634  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

unnecessary  except  for  relief  of  pain.  If  it  is  double,  operation  should 
be  performed  before  puberty,  preferably  in  the  eleventh  or  twelfth  year. 
Transplantation  into  the  scrotum  is  at  this  time  simple,  and  usually  suc- 
cessful. Should  pain  be  persistent,  and  transplantation  impossible,  the 
testicle  may  be  replaced  in  the  abdominal  cavity.  Removal  is  indicated 
only  when  degeneration  has  taken  place. 

With  the  exceptions  already  mentioned,  deformities  of  the  female 
genitals  belong  rather  to  gynaecology  than  to  paediatrics,  since  they  are 
chiefly  of  the  internal  organs,  and  do  not  usually  give  symptoms  before 
puberty. 

DISEASES  OF  THE  MALE  GENITALS. 

Balanitis. — Balanitis,  or  inflammation  of  the  prepuce,  is  one  of  the 
results  of  phimosis.  It  may  follow  decomposition  of  the  smegma,  infec- 
tion of  the  mucous  membrane,  injury,  or  masturbation.  The  parts  are 
swollen,  cedematous,  red,  painful,  and  sometimes  bathed  in  pus.  Re- 
traction of  the  prepuce  is  impossible.  Under  proper  treatment  the  in- 
flammation usually  subsides  in  two  or  three  days,  but  there  may  be  some 
discharge  for  a  considerable  time.  Abscess  may  follow,  and  even  gan- 
grene of  the  prepuce.  The  most  severe  cases  are  likely  to  be  complicated 
by  anterior  urethritis.  I  have  frequently  seen  erysipelas  start  from 
balanitis,  and  occasionally  diphtheria  occurs  here. 

The  object  of  treatment  is  to  remove  the  irritating  and  infectious 
material  lodged  beneath  the  foreskin.  This  may  be  quite  difficult.  It  is 
best  accomplished  by  syringing  with  a  1-5,000  bichloride  solution,  and 
the  constant  application  of  a  wet  antiseptic  dressing.  Ice  is  often  useful 
when  the  oedema  is  great.  It  is  sometimes  necessary  to  slit  up  tlie 
prepuce  before  the  parts  can  be  thoroughly  cleansed,  and  in  severe  cases 
this  is  often  the  quickest  method  of  cure.  Circumcision  should  not  be 
done  during  an  attack. 

Urethritis. — This,  like  the  same  disease  in  females,  may  be  simple 
or  specific.  Both  forms  are  less  frequent  in  little  boys  than  in  the  other 
sex.  In  simple  urethritis  the  inflammation  usually  affects  only  the  an- 
terior part  of  the  canal,  the  fossa  navicularis.  There  is  a  slight  discharge 
of  pus,  and  sometimes  pain  on  micturition.  The  most  frequent  cause 
is  want  of  cleanliness. 

Gonorrhoeal  inflammation  is  more  common.  This  occurs  even  in  in- 
fants, but  most  of  the  cases  are  in  those  over  seven  years  old.  The  usual 
cause  is  direct  contagion.  The  symptoms  are  more  severe  than  in  the 
simple  form,  and  resemble  the  same  disease  in  the  adult,  with  the  ex- 
ception that  constitutional  symptoms  are  usually  absent.  A  microscopical 
examination  of  the  discharge  is  the  only  positive  means  of  diagnosis 
between  the  two  varieties.  In  these  cases  it  reveals  the  gonococcus  in 
great  numbers.     Conjunctivitis  and  arthritis  are  seen  as  complications. 


DISEASES  OF  THE   MALE   GENITALS.  635 

just  as  in  the  female.  Orchitis  is  very  rare,  but  balanitis  and  bubo  are 
not  infrequent.  Poynter  has  reported  a  case  in  a  boy  of  three  years,  who, 
when  five  years  old,  required  treatment  for  a  urethral  stricture.  He  was 
infected  by  a  nurse. 

The  first  thing  in  the  treatment  is  always  to  keep  the  parts  covered, 
otherwise  the  infection  is  almost  certain  to  be  carried  by  the  hands  to 
other  mucous  membranes,  usually  the  conjunctiva.  In  other  respects 
the  treatment  is  the  same  as  in  the  adult. 

Hydrocele. — Hydrocele  consists  in  an  accumulation  of  serum  in  some 
part  of  the  serous  pouch  brought  down  by  the  testicle  in  its  descent.  In 
infants  it  is  usually  due  to  the  imperfect  closure  of  this  pouch  at  some 
point,  where  a  fluid  accumulation  occurs.  Four  varieties  of  hydrocele 
are  met  with  in  young  children: 

1.  Congenital  Hydrocele. — In  this  the  condition  is  a  congenital  one, 
although  the  tumour  is  not  necessarily  present  at  birth.  The  tunica  vagi- 
nalis communicates  with  the  general  peritoneal  cavity.  There  is  present 
an  elongated  tumour,  extending  from  the  bottom  of  the  scrotum  through- 
out the  whole  length  of  the  cord.  The  tumour  is  reducible,  sometimes 
spontaneously  by  position,  sometimes,  when  the  opening  is  smaller,  only 
by  pressure.  It  reduces  slowly,  without  gurgling,  never  going  back  en 
masse  like  a  hernia.  The  tumour  is  translucent,  and  is  flat  on  percussion. 
The  testicle  is  above  and  posterior,  and  usually  indistinctly  felt.  Con- 
genital hydrocele  may  be  complicated  by  hernia. 

2.  Hydrocele  of  the  Tunica  Vaginalis  with  the  Canal  Closed. — In 
this  form  the  accumulation  of  fluid  is  in  the  scrotum,  communication 
with  the  peritoneal  cavity  having  been  entirely  cut  off  by  the  complete 
obliteration  of  this  pouch  in  the  canal  in  the  normal  way.  This  is  one  of 
the  most  frequent  forms.  It  gives  rise  to  an  oval  or  pear-shaped  tumour, 
quite  tense  and  firm,  usually  about  two  inches  in  length.  The  cord  is 
distinctly  felt  above  it,  the  testicle  is  behind  and  somewhat  above  it,  and 
not  always  felt  very  distinctly.  This  variety  gives  translucency  and  the 
usual  elastic  feeling  of  a  hydrocele. 

3.  Hydrocele  of  the  Cord. — This  is  one  of  the  rare  forms.  The 
serous  pouch  which  accompanies  the  spermatic  cord  is  open  above,  and 
communicates  with  the  peritoneal  cavity;  but  below  it  is  closed.  The 
scrotum  is  normal,  and  the  testicle  is  in  its  usual  position.  The  tumour 
is  small,  elongated,  and  reducible,  and  entirely  above  the  scrotum.  Usu- 
ally it  stops  at  some  point  in  the  inguinal  canal.  This  hydrocele  also 
may  be  complicated  by  hernia.  The  diagnostic  points  are  the  same  as 
in  the  form  first  mentioned. 

4.  Encysted  Hydrocele  of  the  Cord.— The  peritoneal  pouch  of  the 
cord  in  this  variety  is  closed  for  some  distance  above,  and  again  below, 
but  somewhere  in  its  course  it  is  open,  and  here  the  fluid  accumulates  in 
the  form  of  a  cyst.     When  small  it  resembles  an  undescended  testicle; 


636  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

but  on  examination  this  organ  is  found  below  and  in  its  normal  position. 
When  in  the  canal,  it  is  often  mistaken  for  a  lymph  gland,  sometimes 
for  a  small  hernia.  The  tumour  is  usually  about  the  size  of  an  almond. 
It  is  elastic  and  irreducible,  and  translucent  like  the  other  varieties. 

Treatment  of  Hydrocele. — In  the  congenital  form  the  application  of 
a  truss  will  sometimes  cause  obliteration  of  the  canal,  so  as  to  shut  off 
the  hydrocele  sac  from  the  general  peritoneal  cavity.  It  is  subsequently 
managed  like  an  ordinary  hydrocele  of  the  tunica  vaginalis.  In  infants 
and  young  children  it  is  rare  that  active  operative  measures  are  called 
for  in  any  variety  of  hydrocele,  as  these  usually  tend  to  disappear  spon- 
taneously in  the  course  of  a  few  months.  Iodine  may  be  applied  locally 
over  a  hydrocele  of  the  cord,  but  should  not  be  applied  to  the  scrotum. 
Some  cases  are  cured  by  a  simple  puncture  with  a  needle,  allowing  the 
fluid  to  drain  off  into  the  cellular  tissue  of  the  scrotum  from  which  it 
is  absorbed;  others  by  a  single  aspiration  with  a  hypodermic  syringe. 
It  is  seldom  necessary  to  resort  to  the  injection  of  irritants  like  iodine 
or  carbolic  acid,  but  they  may  be  used  if  the  fluid  returns  after  repeated 
aspirations. 

DISEASES  OF  THE  FEMALE  GENITALS. 
Vaginitis. 

This  is  a  catarrhal  inflammation  usually  affecting  only  the  vaginal 
mucous  membrane,  but  may  involve  the  urethra,  bladder,  and,  in  older 
girls,  the  lining  membrane  of  the  uterus,  the  tubes,  and  even  the  peri- 
tonaeum. It  may  be  either  simple  or  specific  (gonorrhceal) ;  the  purulent 
form  is  almost  invariably  specific. 

Simple  Vaginal  Catarrh. — This  may  be  seen  at  any  age,  even  in  in- 
fancy, but  is  most  frequent  after  the  second  year.  It  occurs  especially 
in  girls  suffering  from  malnutrition  and  anaemia,  and  whose  personal 
cleanliness  is  neglected.  It  may  follow  any  of  the  infectious  diseases, 
particularly  measles.  It  sometimes  complicates  varicella  with  a  local 
lesion  in  the  vagina.  It  may  be  traumatic,  as  from  attempted  rape  or 
the  introduction  of  foreign  bodies.  Other  causes  are  pinworms  and 
scabies.    It  is  sometimes  the  cause,  sometimes  the  result  of  masturbation. 

Symptoms. — The  disease  generally  begins  as  a  subacute  catarrhal  in- 
flammation, the  discharge  being  the  first,  and  in  mild  cases  the  only 
symptom.  It  is  of  a  white  or  yellowish  white  colour  and  not  very  abun- 
dant. If  the  parts  are  not  kept  clean  the  odour  of  the  discharge  is  quite 
foul.  In  severe  cases  the  discharge  is  abundant,  and  may  excoriate  the 
skin  of  the  labia  and  thighs.  The  mucous  membrane  is  swollen  and  red, 
but  there  is  only  a  moderate  secretion.  Microscopical  examination  of 
the  discharge  shows  bacteria  in  large  numbers  and  of  many  varieties,  but 
they  are  chiefly  the  ordinary  cocci.  With  proper  treatment  and  in  chil- 
dren who  are  in  good  general  condition,  the  disease  usually  lasts  from 


DISEASES  OF  THE  FEMALE  GENITALS.  637 

one  to  three  weeks;  or,  under  unfavourable  conditions,  there  may  be  a 
persistent  leucorrhceal  discharge  for  a  longer  time. 

Gonococcus  Vaginitis. — So  far  from  being  rare,  as  was  once  thought, 
this  disease  has  been  shown  by  recent  observations  to  be  exceedingly  com- 
mon among  girls  of  all  ages,  even  young  infants.  It  is  especially  in 
hospitals  and  other  institutions  that  it  is  seen,  and  here  it  must  be  con- 
sidered one  of  the  most  frequent  and  most  troublesome  of  house  infec- 
tions. Eoutine  microscopical  examinations  which  I  have  had  made 
of  the  vaginal  discharges  of  children  in  various  institutions  usually 
revealed  the  existence  of  gonococcus  vaginitis,  often  in  a  mild  form, 
in  from  two  to  ten  per  cent  of  the  inmates.  Epidemics  in  institutions 
are  exceedingly  common  and  very  difficult  to  control.  Only  one  who  has 
experienced  such  epidemics  can  appreciate  what  a  scourge  vaginitis  may 
become.  No  less  than  four  such  epidemics  were  observed  in  the  Babies' 
Hospital  between  the  years  1899  and  1904.  During  this  period  273 
cases  were  observed  in  this  institution.^  Gonococcus  vaginitis  often  exists 
in  day-nurseries  or  homes  for  foundlings,  as  well  as  in  general  hospitals 
and  asylums  for  older  children.  In  out-patient  practice,  and  among  the 
poor  in  tenements,  cases  are  constantly  seen,  and  even  among  the  well- 
to-do  this  disease  is  by  no  means  rare.  From  the  manner  in  which  it  is 
contracted,  it  should  not,  in  young  children,  be  considered  a  venereal 
disease. 

In  institutions,  gonococcus  vaginitis  can  generally  be  traced  to  some 
child  admitted  with  an  acute  form  of  the  disease.  Before  the  condition 
is  recognised  and  the  patient  quarantined,  an  entire  ward  or  dormitory 
may  be  infected,  and  a  local  epidemic  may  be  the  result,  and  once  well 
under  way  this  may  last. for  months. 

In  infants  and  young  children  the  disease  is  seldom  acquired  by  sex- 
ual contact,  but  most  frequently  through  the  medium  of  napkins.  Other 
possible  means  of  infection  are  towels,  sponges,  wash-cloths,  undercloth- 
ing, bed-linen,  thermometers,  syringes,  bath-tubs,  bath  water,  or  the 
hands  of  the  nurse.  Even  when  the  most  careful  attention  has  been 
given  to  these  matters,  I  have  frequently  seen  ward  epidemics  continue 
unabated.  Atmospheric  infection  seems  unlikely.  The  most  probable 
explanation  under  these  circumstances  is  that  the  disease  is  spread  by 
nurses  in  washing,  feeding,  dressing,  or  bathing  children,  but  especially 
in  the  changing  of  napkins.  In  many  cases  it  was  found  impossible  to 
check  epidemics  until  both  the  patients  and  their  attendants  were  quar- 
antined. 

In  girls  from  six  to  twelve  years  old  other  means  of  contagion  must 
be  considered.    This  may  be  by  direct  contact,  manual  or  sexual,  or  sleep- 


1  See  author's  article  on  Gonococcus  Infections  in  Institutions,  New  York  Medical 
Journal,  March,  1905. 


638  DISEASES  OF  THE  UROGENITAL  SYSTEM. 

ing  with  parents  or  others  who  may  have  the  disease.  Pott  found  in 
ninety  per  cent. of  his  cases  that  the  mother  had  a  leucorrhoeal  discharge. 
The  mode  of  contagion  may  be  difficult  to  trace,  but  this  fact  should  cast 
no  doubt  upon  the  diagnosis. 

Symptoms. — In  infants  and  young  cliildren,  in  the  mild  cases,  the 
disease  is  limited  to  tlie  mucous  membrane  of  the  vagina.  There  is  a 
moderate  yellow  discharge  which,  by  microscopical  examination,  contains 
pus  cells  and  gonococci.  There  is  little  redness  and  no  symptoms  of  dis- 
comfort. In  more  severe  cases  the  discharge  is  copious,  often  thick  and 
of  a  yellow  or  yellowish-green  colour.  It  may  be  tinged  with  blood  from 
slight  erosions.  It  often  causes  excoriation  of  the  labia  or  thighs.  In 
some  cases  the  urethra  is  involved,  causing  frequent,  painful  micturition. 
The  inflammation  may  extend  to  the  bladder,  but  seldom  or  never  at 
this  age  to  the  mucous  membrane  of  the  uterus.  Occasionally  the  mucous 
membrane  of  the  rectum  is  involved.  The  symptoms  are  chiefly  local, 
but  there  may  be  a  slight  rise  of  temperature  to  100°  or  101°  F.  during 
the  period  of  most  acute  inflammation. 

In  girls  past  the  age  of  six  or  seven  years,  the  symptoms  resemble 
those  of  the  adult :  copious  secretion,  the  formation  of  crusts  on  the  labia, 
frequent,  painful  micturition  from  involvement  of  the  bladder  and 
urethra,  and  difficulty  in  locomotion.  There  may  be  slight  fever  and 
general  malaise.  The  inflammation  may  extend  to  the  lining  membrane 
of  the  uterus  and,  through  the  Fallopian  tubes,  to  the  pelvic  peritonaeum. 
Sanger  has  reported  such  a  case  in  a  child  of  three  years.  The  endome- 
tritis may  be  demonstrated  by  the  use  of  a  small  speculum,  by  which  the 
discharge  may  be  seen  coming  from  the  cervix.  Swelling,  and  very  rarely 
suppuration,  of  the  inguinal  glands  may  take  place. 

A  positive  diagnosis  between  simple  and  gonococcus  vaginitis  can  be 
made  with  certainty  only  by  a  microscopical  examination  of  tlie  discharge, 
though  in  default  of  such  examination  an  abundant  purulent  catarrh 
may  be  assumed  to  be  due  to  the  gonococcus.  In  simple  catarrh  the  dis- 
charge is  made  up  of  epithelial  and  pus  cells,  with  quite  a  wide  variety 
of  bacterial  forms,  chiefly  cocci  and  bacilli,  occasionally  a  few  diplococci. 
In  gonococcus  vaginitis  the  gonococci  are  found  in  large  numbers,  and 
are  usually  the  only  bacteria  present.  To  be  diagnostic,  they  should 
be  demonstrated  within  the  pus  cells  as  well  as  outside  them.  The  gono- 
coccus decolourises  when  stained  by  Gram's  method,  which  fact  distin- 
guishes it  from  the  other  organisms  likely  to  be  present  in  the  vagina. 
The  staining  is  quite  as  diagnostic  as  the  cultural  characteristics  of  this 
organism.  Cases  of  vaginitis  are  to  be  regarded  as  suspicious  if  pus  is 
found  and  few  organisms  are  detected ;  in  such  conditions  subsequent  ex- 
amination usually  reveals  the  gonococcus.  In  my  hospital  experience  the 
gonococcus  cases  have  outnumbered  the  simple  purulent  forms,  fully  ten 
to  one. 


DISEASES  OF  THE  FEMALE  GENITALS.  639 

In  infants,  when  tlie  amount  of  discharge  is  small  and  likely  to 
be  overlooked,  it  is  an  advantage  to  apply  between  the  labia  a  fold  of 
gauze  upon  which  the  yellow  stain  of  a  purulent  discharge  is  readily 
noticed. 

Gonococcus  vaginitis  may  be  complicated  by  conjunctivitis,  arthritis, 
endo-  or  pericarditis,  peritonitis,  and  proctitis.  Conjunctivitis  is  the 
most  frequent,  the  infection  usually  being  carried  by  the  hands.  Gono- 
coccus arthritis  is  not  uncommon  even  in  young  infants.  It  is  usually  a 
multiple  arthritis,  with  the  constitutional  symptoms  of  pyaemia.  The 
wrist,  ankle,  knee  and  elbow,  and  small  joints  of  the  fingers  and  toes  are 
most  frequently  involved.  These  cases  are  considered  more  fully  in  the 
chapter  on  Acute  Arthritis  in  Infants. 

The  diagnosis  in  all  the  complicating  conditions  is  based  upon  the 
presence  of  the  gonococcus. 

Prophylaxis. — The  highly  contagious  character  of  gonococcus  vagi- 
nitis makes  it  imperative  that  such  cases  should  not  be  received  into  the 
same  ward  or  dormitory  with  other  children.  Only  in  this  way  can 
house  epidemics  be  prevented.  Cases  which  are  mild  should  be  excluded, 
as  well  as  those  which  are  severe.  The  only  effective  measure  is  to  make 
the  microscopical  examination  of  vaginal  discharges  of  children  admitted 
to  an  institution  as  much  a  matter  of  routine  as  the  taking  of  throat 
cultures  if  there  is  a  tonsillar  exudate.  Cases  showing  the  gonococcus 
should  be  quarantined  or  excluded.  When  there  are  a  great  many  ad- 
missions every  month,  a  case  occasionally  escapes  detection.  The  rule 
which  we  have  followed  in  the  Babies'  Hospital  has  been  to  make  not 
only  an  examination  on  admission,  but  routine  examinations  of  all  pa- 
tients at  stated  intervals,  always  once  and  sometimes  twice  a  week.  Only 
'  by  this  means  has  it  at  times  been  possible  to  eradicate  the  disease. 

The  attendants,  both  day  and  night  nurses,  as  well  as  the  children, 
should  be  quarantined.  Napkins,  underclothing,  and  sheets  from  the 
beds  of  infected  children,  also  towels  and  wash-cloths,  should  not  go 
into  the  common  laundry,  but  should  be  first  soaked  in  a  strong  solution 
of  carbolic  acid,  and  afterward  boiled.  In  wards  or  institutions  where 
cases  have  occurred  washable  napkins  should  be  discontinued  and  old 
muslin  and  absorbent  cotton  used  in  their  place.  These  are  to  be  de- 
stroyed after  using.  All  articles  connected  with  the  children's  toilet,  also 
syringes,  thermometers,  etc.,  should  be  carefully  disinfected.  But  often 
this  is  not  enough.  Separate  articles  should  be  furnished  for  each  child. 
The  organism  is  one  that  is  fairly  easy  to  kill,  and  if  proper  precautions 
are  taken  epidemics  may  be  prevented.  The  essential  measure  is  a  prompt 
recognition  and  isolation  of  the  first  case  in  the  hospital.  Quarantine 
should  continue  not  only  until  the  catarrhal  inflammation  has  subsided 
and  the  organism  has  disappeared,  as  shown  by  a  single  negative  micro- 
scopical examination,  but  for  a  considerable  time  longer,  since  a  slight 


640  DISEASES  OF  THE  UROGENITAL  SYSTEM. 

discharge  containing  a  few  organisms  may  remain  for  weeks  after  the 
case  is  considered  cured.     Relapses  are  very  frequent. 

Treatment. — Cases  of  simple  vaginal  catarrh  should  be  irrigated  twice 
daily  with  a  warm  saturated  solution  of  boric  acid  or  1  to  5,000  bichlo- 
ride. Cleanliness  should  be  secured  by  frequent  bathing  and  the  skin 
protected  by  ointments.  In  more  severe  cases,  astringent  injections,  such 
as  sulphate  of  zinc  and  tannic  acid  (of  each  one  drachm  to  a  pint 
of  water)  should  be  used,  or  protargol  applied  in  solutions  of  from  one 
to  five  per  cent  strength.  The  general  health  should  be  built  up  liy 
iron,  cod-liver  oil,  and  other  tonics. 

In  gonococcus  vaginitis  more  energetic  treatment  is  necessary.  Every 
child  should  wear  a  napkin,  to  prevent  carrying  the  infection  to  the  eyes 
by  means  of  the  hands.  Irrigations  should  be  used  at  least  twice  a  day, 
and  stronger  antiseptics  employed  than  in  the  simple  cases.  The  best 
are  protargol,  in  solutions  from  one  to  ten  per  cent  strength,  and  argyrol, 
in  solutions  from  five  to  twenty-five  per  cent  strength.  Applications 
should  be  made  with  a  cotton  swab;  the  same  substances  may  be  used  in 
the  form  of  suppositories,  or  the  vagina  may  be  packed  with  gauze  wet 
in  these  solutions.  The  closest  attention  to  cleanliness  is  required  in  all 
cases.  The  course  of  the  disease  is  very  tedious;  many  weeks,  and  often 
months,  may  be  required  for  a  cure.  On  the  whole,  treatment  is  very 
unsatisfactory  on  account  of  the  difficulties  in  the  way  of  making  thor- 
ough local  applications.  When  the  disease  involves  the  bladder  and 
urethra,  the  same  general  measures  as  in  adults  are  indicated. 

The  precise  place  and  value  of  vaccines  in  the  treatment  of  gonococcus 
vaginitis  is  undetermined,  reported  results  with  this  method  being  far 
from  uniform.  When  practicable  I  believe  that  they  should  be  given  a 
trial  in  all  chronic  or  specially  resistent  cases.  I  have  personally  seen 
a  few  brilliant  results  from  their  use.  I  have  generally  employed  stock 
vaccines  made  from  many  strains  of  the  gonococcus.  Dosage  is  still  a 
matter  of  much  uncertainty.  Fifty  to  seventy-five  millions  may  be  used 
every  four  or  five  days  until  five  or  six  doses  have  been  given.  I  have 
seen  no  unfavourable  symptoms  in  any  case. 

Gangrenous  Vulvitis  (Noma). 

This  is  the  same  process  as  that  seen  in  the  mouth  and  known  as 
cancrum  oris.  It  usually  follows  one  of  the  infectious  diseases,  most 
frequently  measles,  occurring  in  patients  whose  general  vitality  has  been 
greatly  reduced.  There  is  first  noticed  a  tense,  brawny  induration,  the 
skin  being  shiny  and  swollen  over  a  circumscribed  area.  In  the  centre 
of  this  there  soon  appears,  usually  upon  one  of  the  labia  majora,  a  dark, 
circumscribed  spot.  Day  by  day  the  gangrenous  area  advances,  preceded 
by  the  induration.  It  may  involve  the  whole  labium,  extending  even  to 
the  mons  veneris  and  the  perinaeum.     These  cases  are  generally  fatal. 


ENURESIS.  641 

If  recovery  takes  place,  it  is  with  considerable  deformity  of  the  parts  in 
consequence  of  the  extensive  sloughing  and  cicatrisation.  As  sequelae, 
there  may  be  fistulae,  stenosis,  or  atresia  of  the  vagina.  The  only  radical 
treatment  is  early  excision,  and  the  application  of  the  actual  cautery, 
carbolic  or  nitric  acid. 

CHAPTER    IV. 
DISEASES  OF  THE  BLADDER. 

ENURESIS. 

{Incontinence  of  Urine;  Bed-wetting.) 

Enuresis  may  be  due  to  some  malformation  of  the  genital  tract,  such 
as  an  abnormal  opening  of  the  bladder  into  the  vagina,  to  extroversion 
of  the  bladder,  or  to  the  persistence  of  the  urachus;  in  the  latter  case 
the  urine  is  discharged  from  the  umbilicus.  It  also  occurs  in  organic 
diseases  of  the  central  nervous  system,  such  as  idiocy,  cerebral  palsy, 
acute  meningitis,  tumours  of  the  brain,  certain  forms  of  myelitis,  and 
in  injuries  of  the  cord.  In  many  of  these  conditions  there  is  associated 
incontinence  of  faeces.  Both  of  the  groups  of  cases  mentioned  are  quite 
distinct  from  the  ordinary  form  of  incontinence  of  urine  which  is  seen 
in  childhood.  The  latter  is  to  be  regarded  as  a.  neurosis,  and  is  the 
only  variety  which  will  be  considered  here. 

It  is  in  many  cases  possible  to  teach  infants  to  control  the  evacuation 
of  the  bladder  before  the  end  of  the  first  year ;  usually,  however,  control 
is  not  acquired  even  during  waking  hours  until  some  time  during  the 
second  year,  and  in  some  healthy  infants  not  before  the  end  of  the  second 
year.  The  time  depends  very  much  upon  the  training.  If  a  child  during 
its  third  year  can  not  control  the  evacuation  of  the  bladder  during  its 
waking  hours,  incontinence  may  be  said  to  exist. 

Etiology. — Incontinence  of  urine  may  be  due  to  a  continuance  of  the 
infantile  condition,  to  anything  which  increases  the  irritability  of  the 
spinal  centre,  or  which  interferes  with  the  cerebral  control  over  this 
centre,  or  to  anything  which  increases  the  irritability  of  the  terminal 
filaments  of  the  vesical  nerves  or  of  those  in  the  neighbourhood.  The 
causes  of  incontinence  thus  may  be  in  the  central  nervous  system,  in  the 
urine,  in  the  bladder,  or  in  any  of  the  adjacent  organs. 

The  causes  relating  to  the  central  nervous  system  are  in  the  main 
those  of  the  other  neuroses  of  childhood ;  these  are  anaemia,  malnutrition, 
an  inherited  nervous  constitution,  or  a  condition  of  extreme  nervousness 
or  neurasthenia,  the  result  of  the  child's  surroundings.  In  such  cases 
incontinence  is  often  associated  with  chorea,  epilepsy,  hysteria,  headaches, 
neuralgia,  and  other  nervous  symptoms.  In  these  conditions  there  may 
be  not  only  an  increased  irritability  of  the  nerve  centres,  but  also  of  the 
42 


642  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

peripheral  nerves,  accompanied  by  loss  of  tone  of  the  vesical  sphincter. 
A  similar  condition  may  exist  with  almost  any  form  of  acute  illness, 
usually,  however,  being  only  temporary. 

Incontinence  may  be  caused  either  by  a  highly  acid,  concentrated  urine 
when  an  insuflBcient  amount  of  fluid  is  taken,  or  by  the  opposite  condi- 
tion, where,  owing  to  the  drinking  of  a  large  quantity  of  water,  often 
only  a  matter  of  habit,  the  amount  of  urine  is  very  greatly  increased  and 
passed  at  frequent  intervals. 

In  the  bladder  itself,  cystitis  and  vesical  calculus,  although  infre- 
quent, should  not  be  overlooked  as  possible  causes.  In  a  few  cases,  where 
incontinence  has  existed  a  long  time,  the  bladder  becomes  so  contracted 
that  it  will  hold  only  an  ounce  or  two  of  urine.  This  condition,  although 
not  the  primary  cause  of  enuresis,  may  be  enough  to  continue  it. 

Local  irritation  in  the  neighbouring  organs  may  be  due  to  adherent 
prepuce,  balanitis,  phimosis,  or  to  a  narrow  meatus.  All  of  these  condi- 
tions are  frequently  associated  with  incontinence.  Rectal  irritation  may 
be  due  to  pinworms,  anal  fissure,  or  rectal  polypus;  and  vaginal  irrita- 
tion to  vulvo- vaginitis  or  adherent  clitoris;  but  these  are  rarely  the  only 
cause.  Often  we  have  incontinence  as  the  result  of  a  combination  of  sev- 
eral causes,  no  one  of  which  alone  would  have  been  sufficient  to  produce 
it.  Thus,  in  a  healthy  child  phimosis  may  give  rise  to  no  symptoms,  while 
in  one  who  is  anaemic  or  neurasthenic  it  may  produce  enough  local  irrita- 
tion to  cause  incontinence.  In  many  cases  heredity  seems  to  be  a 
factor  of  some  importance,  parents  often  having  suffered  in  their  child- 
hood from  the  same  condition;  quite  frequently  two  and  sometimes  even 
three  children  in  the  same  family  are  affected.  In  many  cases  the  con- 
dition seems  to  be  mainly  the  result  of  habit,  and  in  all  cases  habit  is 
a  potent  factor  in  continuing  the  incontinence,  sometimes  after  the  orig- 
inal exciting  cause  has  been  removed.  Frequently  no  adequate  cause 
can  be  found.  Both  sexes  are  about  equally  liable  to  enuresis,  and  it 
may  be  seen  in  all  ages  up  to  puberty. 

Symptoms. — Enuresis  may  be  nocturnal  or  diurnal,  or  both.  Of  184 
cases,  73  were  nocturnal,  9  diurnal,  and  102  were  both  nocturnal  and 
diurnal.  Cases  differ  greatly  in  severity.  Incontinence  may  be  habitual, 
occurring  every  night,  often  several  times  during  the  night,  and  fre- 
quently during  the  day ;  or  it  may  be  only  occasional  under  the  influence 
of  some  special  exciting  cause,  when  it  continues  a  few  days  or  weeks 
until  the  cause  is  removed.  In  a  considerable  number  of  cases,  the  condi- 
tion lasts  from  infancy  until  the  sixth  or  seventh  year.  It  may  even  con- 
tinue until  puberty;  but  it  generally  ceases  at  that  period,  unless  its  cause 
is  mechanical  or  depends  upon  some  organic  disease  of  the  brain  or  cord. 
In  ordinary  enuresis  there  is  never  dribbling  of  the  urine,  but  usually  a 
contraction  of  the  walls  of  the  bladder  follows  almost  immediately  upon 
the  desire  before  the  patient  can  make  his  wants  known  or  reach  a  con- 


♦      ENURESIS.  643 

venient  place  for  micturition.  At  night  the  same  thing  may  occur  with- 
out wakening  the  child,  the  contraction  being  of  purely  reflex  origin. 

Prognosis. — The  condition  is  usually  hopeless  when  it  depends  upon 
organic  disease  of  the  brain  and  cord ;  also  in  cases  due  to  malformation, 
unless  these  are  amenable  to  surgical  treatment.  In  the  ordinary  cases 
seen,  the  prognosis  depends  upon  the  age  of  the  child,  the  duration  of  the 
symptom,  and  the  nature  of  the  exciting  cause.  In  children  of  from 
three  to  five  years  a  cure  can  in  many  cases  be  accomplished  with  proper 
management.  Those  who  are  older  are  much  less  amenable  to  treatment, 
especially  if  the  condition  has  persisted  since  infancy ;  but  if  the  incon- 
tinence has  begun  after  seven  or  eight  years  of  age  and  lasted  a  few  weeks 
or  months,  the  outlook  is  much  more  encouraging.  When  some  cause  can 
be  discovered  which  can  be  removed,  the  prognosis  is  better  than  if  none 
can  be  found.  There  are,  however,  some  cases  in  which  no  other  cause 
than  habit  can  be  discovered  which  resist  all  treatment,  the  condition 
finally  ceasing  spontaneously  at  or  a  little  before  puberty;  in  very  few 
does  it  continue  beyond  this  period. 

Treatment. — The  first  indication  is  to  remove  the  cause,  when  one 
can  be  found.  If  there  are  preputial  adhesions,  they  should  be  broken 
up  and  irritating  smegma  removed.  If  phimosis  is  present,  it  should  be 
relieved  by  stretching  or  circumcision.  If  stone  in  the  bladder  is  sus- 
pected, as  it  should  be  when  the  incontinence  is  worse  by  day  and  ac- 
copipanied  by  straining  and  painful  spasm  of  the  bladder,  the  patient 
should  be  sounded  for  stone.  Pinworms  in  the  rectum  should  receive 
the  appropriate  treatment  by  injections.  While  the  local  conditions 
mentioned  should  always  be  attended  to,  the  fact  remains  that  few 
cases  are  cured  simply  by  relieving  them,  except  those  due  to  vesical 
calculi.  The  explanation  of  this  is  that  habit  is  a  very  important  factor 
in  keeping  up  incontinence  where  it  has  existed  a  long  time. 

A  concentrated  urine  of  high  acidity  with  deposits  of  uric  acid  is 
an  indication  for  alkalies  and  the  free  use  of  all  fluids,  especially  water. 
On  the  other  hand,  when  there  is  passed  a  large  quantity  of  urine  with 
low  specific  gravity,  the  amount  of  water  and  other  fluids  should  be 
restricted.  During  the  night  water  should  be  forbidden,  and  the  amount 
given  in  the  latter  part  of  the  day  greatly  reduced.  In  these  cases  the 
incontinence  is  often  simply  the  result  of  the  polyuria,  which  in  turn 
depends  upon  polydipsia. 

In  most  cases  the  condition  is  a  nervous  habit,  and  usually  associated 
with  other  habits  which  indicate  an  unstable  or  highly  susceptible 
nervous  system.  It  is  therefore  of  the  greatest  importance  that  a  proper 
general  regime  should  be  instituted  and  enforced.  Care  should  be  taken 
to  secure  for  the  child  a  simple,  natural  life,  preferably  in  the  country. 
There  should  be  no  overtaxing  of  the  nervous  system  at  home  or  in 
school.    Every  cause  of  unnatural  excitement  should  be  avoided.    Early 


644  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

hours  and  plenty  of  sleep  must  be  insisted  upon.  Certain  articles  of 
diet  are  to  be  avoided,  and  coffee,  tea,  and  beer  should  be  absolutely  pro- 
hibited. Sweets  and  all  highly  seasoned  food  should  be  very  sparingly 
allowed,  or  not  at  all.  Although  it  is  believed  by  many  that  a  diet  into 
which  meat  enters  largely  is  injurious,  from  personal  experience  I  have 
not  found  the  exclusion  of  meat  to  be  of  any  advantage.  The  diet  which 
succeeds  best  is  a  simple  one  composed  of  milk,  vegetables,  fruits,  meats, 
and  cereals.  With  most  patients  who  have  nocturnal  incontinence,  it 
is  well  to  allow  fluids  freely  during  the  early  part  of  the  day,  but  little 
or  none  after  3  or  4  p.m.,  a  dry  supper  being  given  just  before  retiring. 
The  child  should  be  taught  to  hold  his  water  as  long  as  possible  during 
the  day,  to  accustom  the  bladder  to  full  distention. 

Measures  directed  toward  improving  the  general  muscular  and 
nervous  tone  are  of  the  greatest  importance.  It  should  be  remembered 
that  incontinence  of  urine  is  a  neurosis,  depending,  like  most  neuroses  of 
childhood,  upon  disturbed  nutrition.  Anaemia,  chlorosis,  malnutrition, 
indigestion,  and  constipation  should  each  receive  careful  attention.  Any 
local  condition,  such  as  adenoid  growths  of  the  pharynx,  which  might 
serve  to  increase  the  general  nervous  irritability,  should  be  removed. 
Yet,  very  few  cases  are  cured  by  such  an  operation. 

Moral  treatment  is  also  important.  One  should  work  upon  the  child's 
pride  and  use  every  possible  means  to  strengthen  his  will.  Punishments, 
whether  corporal  or  otherwise,  do  little  good,  and  with  most  children 
they  are  absolutely  harmful.  With  children  in  whom  incontinence  is 
chiefly  a  matter  of  habit,  I  have  often  found  rewards  more  efficacious 
than  any  other  means  of  treatment.  One  should  first  find  out  what  it 
is  that  the  child  desires  most — a  new  doll,  a  bicycle — and  allow  him  to 
have  it  if  his  bed  is  dry,  taking  it  away  if  it  is  wet.  A  reward  of  five 
cents  for  every  dry  night  sometimes  works  marvels. 

The  measures  described — removal  of  local  causes,  building  up  of  the 
general  health,  institution  of  a  proper  regime,  and  mental  and  moral 
means — in  a  very  considerable  number  of  cases  suffice  for  a  cure.  They 
generally  constitute  the  most  important  part  of  the  treatment.  Drugs 
are  useful  as  accessories,  but  alone  seldom  accomplish  a  cure,  and,  on 
the  whole,  are  disappointing.  Of  those  employed,  belladonna  is  cer- 
tainly the  most  effective,  but  its  administration  should  be  continued  for 
a  long  time.  Atropine,  either  in  solution  or  in  tablet  form,  is  the  most 
convenient  method  of  administration.  For  nocturnal  incontinence,  tAt 
of  a  grain  for  each  year  of  the  child's  age  up  to  seven  years  is  a  suit- 
able initial  dose.  A  child  of  five  would  thus  be  taking  -^  oi  a  grain. 
At  first,  a  single  dose  should  be  given  at  bedtime;  after  a  few  days  a 
second  dose  may  be  given  three  or  four  hours  earlier.  To  push  the  drug 
much  further  than  this  causes  much  discomfort  and  is  of  doubtful  ad- 
vantage.    After  the  condition  is  under  control,  the  same  dose  should 


VESICAL  SPASM.  645 

be  continued  for  some  time  and  then  reduced,  the  atropine  being  given 
for  at  kast  two  montlis  in  gradually  diminishing  doses  after  the  incon- 
tinence has  ceased.  This  is  veiy  important  if  the  cure  is  to  be  perma- 
nent, as  there  is  a  strong  tendency  to  relapse. 

Strychnine  may  be  added  in  cases  not  yielding  to  the  atropine  alone. 
It  is  particularly  advantageous  when  there  is  diurnal  as  well  as  nocturnal 
incontinence,  for  under  these  conditions  there  is  usually  a  lack  of  tone  in 
the  sphincter,  as  well  as  increased  irritability  in  the  mucous  membrane 
of  the  bladder.  The  initial  dose  for  a  child  of  live  years  should  be  y^^ 
of  a  grain  twice  daily;  this  may  be  gradually  increased  to  ^V  of  a  grain 
three  times  a  day;  but  there  is  rarely  any  advantage  in  pushing  it  fur- 
ther. Ergot  is  sometimes  useful  in  conjunction  with  other  drugs,  but 
rarely  gives  relief  when  both  strychnine  and  atropine  have  failed.  Some 
obstinate  cases  are  reported  to  have  been  relieved  by  faradism;  the  posi- 
tive pole  is  attached  to  a  small  electrode  passed  into  the  rectum  and  the 
negative  pole  applied  over  the  bladder.  The  sitting  should  last  for  ten 
minutes,  and  be  repeated  three  times  a  week.  My  own  experience  with 
this  method  of  treatment  has  been  disappointing.  If  there  is  reason  to 
suspect  a  contracted  bladder,  as  when  the  incontinence  has  lasted  for 
years  and  the  bladder  will  never  hold  more  than  an  ounce  or  two  of 
urine,  cure  is  sometimes  accomplished  by  daily  distending  the  organ 
up  to  its  normal  capacity  with  warm  water.  A  few  obstinate  cases  in 
older  boys  which  had  resisted  all  other  methods  of  treatment  were  cured 
in  my  clinic  by  the  passage  of  sounds. 

Careful,  intelligent,  systematic  training  is  a  most  valuable  adjunct 
to  all  measures  employed  for  the  relief  of  this  very  annoying  condition. 

VESICAL  SPASM. 

This  is  quite  a  common  condition,  and  often  passes  under  the  name 
of  genital  irritation.  It  is  characterised  by  frequent,  sometimes  by  diffi- 
cult and  painful,  micturition.  It  occurs  in  children  of  all  ages,  even  in 
infants,  but  is  especially  frequent  between  the  ages  of  two  and  five  years. 
This  symptom  has  already  been  referred  to  in  connection  with  uric-acid 
infarctions  in  very  young  infants. 

The  usual  cause  is  the  irritation  of  the  bladder  by  a  concentrated, 
highly  acid  urine.  It  often  results  from  cold;  it  may  accompany  acute 
febrile  processes,  and  is  sometimes  merely  a  symptom  of  nervous  irrita- 
bility. The  cause  may  thus  be  in  the  bladder  or  in  the  urine.  It  may  be 
accompanied  by  enuresis,  but  usually  occurs  without  it.  It  is  sometimes 
symptomatic  of  disease  in  adjacent  parts,  as  in  the  rectum  or  the  pelvic 
peritonseum,  or  it  may  be  associated  with  inflammation  of  the  vulva  or 
urethra.    It  is  also  one  of  the  symptoms  of  vesical  calculus. 

The  symptoms  of  vesical  spasm  are  local  only.     The  child  passes 


646  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

water  very  frequently,  often  several  times  an  hour.  The  accompanying 
pain  may  be  intense,  not  infrequently  sufficient  to  cause  the  child  to 
cry  out.  Often  there  is  pain  and  severe  vesical  tenesmus  with  the  pas- 
sage of  only  a  few  drops  of  urine  at  a  time,  but  blood  is  not  present.  If 
the  condition  depends  upon  the  character  of  the  urine,  or  is  only  an 
expression  of  an.  extreme  vesical  irritability,  the  symptoms  are  generally 
of  short  duration,  possibly  a  day  or  two.  If  it  depends  upon  vesical 
calculus,  it  may  be  intermittent.  If  it  is  associated  with  disease  of  the 
adjacent  pelvic  viscera,  it  is  inconstant,  and  may  continue  for  a  con- 
siderable period,  depending  upon  the  nature  of  the  cause. 

The  treatment,  in  the  ordinary  cases,  consists  in  the  administration 
of  an  abundance  of  water,  with  alkaline  diuretics,  and  either  belladonna 
or  hyoscyamus.  The  tinctures  of  these  may  be  given  in  minim  doses 
every  two  hours  to  a  child  of  two  years. 

If  the  cause  is  outside  the  bladder,  it  should  receive  appropriate 
treatment. 

VESICAL  CALCULI. 

Vesical  calculus  is  a  very  rare  condition  in  children  in  New  York. 
The  nucleus  of  a  calculus  is  usually  a  renal  calculus  which  has  passed 
the  ureter,  but  has  been  prevented  by  its  size  from  going  farther.  Stone 
in  the  bladder  is  extremely  rare  in  infancy,  probably  owing  to  the  fluid 
diet,  but  it  is  not  infrequent  in  children  from  two  to  ten  years  of  age. 
The  most  common  variety  of  calculus  at  this  time  is  the  uric  acid. 

The  symptoms  in  children  are  somewhat  different  from  those  in 
adults,  and  the  condition  is  often  overlooked.  There  is  frequently  pain 
upon  micturition,  especially  at  the  close  of  the  act,  which  may  be  felt 
at  the  end  of  the  penis  or  in  the  perinaeum.  There  may  be  a  sudden 
stoppage  in  the  flow  of  urine.  The  straining  often  leads  to  rectal  tenes- 
mus and  even  to  prolapse.  This  complication  is  so  frequent  that,  in  a 
case  of  persistent  prolapse,  stone  should  always  be  suspected.  Incon- 
tinence of  urine  is  a  prominent,  and  often  the  principal  symptom;  in 
many  cases  it  is  noticed  only  during  the  day.  The  urinary  changes  are 
not  generally  marked;  haematuria  is  rare,  and  mucus  and  pus  are  in- 
frequent and  in  small  quantity.  The  genital  irritation  may  lead  to  the 
habit  of  masturbation.  A  stone  of  any  considerable  size  may  often  be 
felt  by  a  bimanual  examination,  one  flnger  being  placed  in  the  rectum 
and  the  other  hand  above  the  pubes.  This  is  easier  in  males  than  in 
females,  but  it  is  not  very  trustworthy,  and  not  conclusive  when  it  gives 
a  negative  result.  A  positive  diagnosis  is  made  only  by  exploring  the 
bladder  with  a  sound  or  by  the  Rontgen  ray. 

The  treatment  of  calculus  is  purely  surgical. 


SECTION    VII. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 


CHAPTER    I. 

INTRODUCTORY. 

The  Weight  of  the  Brain. — From  ninety-eight  observations  made  in 
the  post-mortem  room  of  the  New  York  Infant  Asylum,  the  following 
were  the  average  weights  noted: 

At  three  months 21      oz.  (602  grammes). 

At  six  months 25J^  "    (712         "       ). 

At  twelve  months 32 >^  "    (916         "       ). 

At  two  years 35       "    (990         "       ). 

The  following  are  the  figures  given  by  Boyd  and  Schaf er : 


Age. 

Males. 

Females. 

At  birth  (full  term) 

Ounces. 
11^ 

173^ 
21 
27 
33 
39 
40 
46 
.    48^ 

Grammes. 

330 

500 

602 

776 

941 

1,110 

1,138 

1,301 

1,374 

Ounces. 
10 

16 

20 

26 

30 

35 

40 

40H 

44 

Grammes. 
283 

Under  three  months 

450 

From  three  to  six  months 

From  six  to  twelve  months 

From  one  to  two  years 

From  two  to  four  years 

From  four  to  seven  years 

From  seven  to  fomleen  years 

From  fourteen  to  twenty  years. .  .    . 

560 

727 

843 

990 

1,135 

1,154 

1,244 

At  birth  the  weight  of  the  brain  to  that  of  the  body  is  nearly  1 : 8. 
During  infancy  and  childhood  the  following  is  the  ratio,  according  to 
Bischoff :  during  the  first  year,  1:6;  the  second  year,  1 :  14 ;  the  third 
year,  1 :  18 ;  at  the  fourteenth  year,  1 :  15  to  1 :  25 ;  in  adults,  1 :  43. 

The  Spinal  Cord. — The  weight  of  the  cord  to  the  weight  of  the  body 
at  birth  is  1 :  500 ;  in  adult  life  it  is  1 :  1500.  According  to  Kolliker,  the 
spinal  cord  and  the  vertebral  column  are  the  same  length  until  the  end  of 
the  third  month  of  foetal  life,  there  being  at  this  time  no  cauda  equina. 
At  the  ninth  month  the  lower  end  of  the  cord  is  opposite  the  third  lum- 
bar vertebra ;  in  the  adult  it  is  opposite  the  first. 

Some  Peculiarities  in  the  Diseases  of  the  Nervous  System  in  Infancy 
and  Childhood. — The  relatively  large  size,  the  rapid  growth,  and  the  im- 

647 


648  DISEASES  OF  THE   NERVOUS  SYSTEM. 

maturity  of  the  brain  and  cord  during  early  life,  explain  much  that  is 
peculiar  to  the  nervous  diseases  of  this  period. 

At  this  time,  apparently  trivial  causes  are  enough  to  produce  quite 
profound  nervous  impressions,  because  of  the  instability  of  the  nervous 
centres  and  the  greater  irritability  of  the  motor,  sensory,  and  vaso-motor 
nerves.  These  are  conditions  which  are  very  much  increased  by  all  dis- 
turbances of  nutrition.  These  disturbances  may  be  manifold  in  character, 
but  they  lie  at  the  root  of  very  many  of  the  neuroses  of  early  life,  e.  g., 
extreme  nervousness,  disorders  of  sleep,  stuttering,  chorea,  incontinence 
of  urine,  tetany,  and  convulsions.  The  great  liability  to  convulsions 
depends  not  only  upon  the  greater  irritability  of  the  peripheral  nerves, 
but  upon  the  instability  of  the  nervous  centres  and  the  lack  of  inhibition 
over  the  motor  ganglion  cells  of  the  spinal  cord.  The  nervous  centres  are 
more  easily  exhausted  than  later  in  life.  Prolonged  or  continuous  over- 
strain from  any  cause  whatsoever,  frequently  leads  to  headache  and 
chorea,  and  sometimes  even  to  epilepsy  and  insanity. 

Another  peculiarity  is  the  serious  consequences  which  often  follow 
reflex  irritation,  although  this  is  rarely  the  only  factor  in  the  case.  Con- 
ditions which  in  adult  life  produce  almost  no  effect  may  in  infancy  be 
the  cause  of  most  alarming  symptoms.  As  a  few  examples  may  be  cited^ 
reflex  S3'mptoms  due  to  phimosis  or  to  intestinal  worms,  convulsions  from 
disturbances  of  digestion,  nervous  symptoms  due  to  eye-strain,  or  to 
adenoid  growths  of  the  pharynx.  In  the  production  of  some  of  these, 
especially  attacks  of  convulsions,  there  are  several  factors,  such  as  the 
great  irritability  of  the  peripheral  nerves,  the  instability  of  the  nervous 
centres — often  a  result  of  disturbed  nutrition,  as  in  rickets — and  the  lack 
of  inhibitory  action  of  the  cortex  of  the  brain. 

As  a  third  point  of  importance  may  be  mentioned  the  grave  per- 
manent results  which  often  follow  relatively  small  organic  lesions.  A 
good  illustration  is  seen  in  the  lesions  which  produce  cerebral  birth-palsy. 
Here  the  damage  is  only  in  small  part  the  immediate  effect  of  the  haemor- 
rhage, for  this  often  is  not  great,  but  it  is  the  interference  with  the  devel- 
opment of  certain  parts  of  the  cortex  that  makes  this  condition  so  serious. 

From  what  has  been  said,  it  follows  that  the  hygiene  of  the  nervous 
system  is  of  the  utmost  importance  in  infancy  and  childhood.  It  is 
essential  for  the  healthy  development  of  the  nervous  system  that  all  stim- 
ulants should  be  avoided — not  only  tea,  coffee,  and  alcohol,  but  undue 
and  unnatural  excitement,  the  effect  of  which  in  infancy  is  almost  as . 
serious.  A  normal  development  can  take  place  only  in  the  midst  of  quiet 
and  peaceful  surroundings,  with  plenty  of  time  for  rest  and  sleep.  The 
conditions  of  modern  life,  especially  in  cities,  are  such  that  these  laws 
are  almost  invariably  violated,  and  the  consequences  of  this  are  seen 
in  the  marked  and  steady  increase  in  nervous  diseases  among  children. 


CONVULSIONS.  649 

CHAPTEK    II. 
GENERAL  AND  FUNCTIONAL  NERVOUS  Dh'iEASES. 

CONVULSIONS. 

All  young  children,  but  especially  infants,  are  extremely  prone  to 
convulsive  disorders,  which  are  manifested  clinically  in  great  variety.  In 
certain  infants,  particularly  those  who  are  rachitic,  this  susceptibility 
is  greatly  heightened.  To  this  condition  of  extreme  liability  to  con- 
vulsive attacks  the  term  spasmophilia  is  frequently  applied.  The  con- 
vulsive disorders  of  infancy  are:  (1)  attacks  of  eclampsia  or  general 
convulsions,  the  type  best  known;  (3)  tetany  with  carpo-pedal  spasm; 
(3)  laryngismus  stridulus  or  crowing  attacks;  (4)  the  less  typical,  hold- 
ing-breath spells,  which  are  apparently  a  minor  form  of  a  general  con- 
vulsion. Besides  these,  there  are  seen  in  infants  a  great  variety  of  at- 
tacks, which  recur  from  time  to  time,  over  quite  a  long  period  frequently, 
of  a  very  doubtful  character,  until  finally  they  develop  into  one  or  other 
of  the  types  just  mentioned.  All  these  convulsive  disorders  are  closely 
related  to  one  another  and  an  alternation  of  type  from  time  to  time  is 
common.  The  general  etiology  of  these  conditions  is  still  obscure.  Their 
association  with  rickets  is  certainly  very  close.  There  is  also  ground 
for  believing  that  in  many  of  these  children  there  is  a  disturbed  calcium 
metabolism. 

Under  the  head  of  convulsions  are  included  attacks  of  acute  transient 
nervous  disturbance,  characterised  by  involuntary  rhythmical  spasm  of 
the  muscles,  either  of  the  face,  trunk,  or  extremities,  or  all  of  them,  usu- 
ally accompanied  by  loss  of  consciousness.  They  may  be  regarded  as 
"  motor  discharges  "  from  the  cortex  of  the  brain. 

Etiology. — The  principal  predisposing  causes  are  infancy,  conditions 
affecting  the  nutrition  of  the  brain,  and  hereditary  influences.  Of  all 
these  factors,  the  most  important  one  is  the  instability  of  the  nerve 
centres  which  is  characteristic  of  infancy  and  is  associated  with  the  non- 
development  of  the  voluntary  centres  of  the  cortex.  The  brain  grows 
more  during  the  first  year  than  in  all  later  life,  and  this  rapidity  of 
growth  is  in  itself  an  important  predisposing  cause  of  functional  derange- 
ment. After  infancy,  attacks  of  convulsions  are  much  less  frequent,  and 
after  seven  years  they  are  relatively  rare.  While  convulsions  occasionally 
occur  in  children  previously  healthy,  the  majority  of  attacks  are  in  those 
in  whom  there  is  at  least  some  disturbance  of  the  nutrition  of  the  brain — 
the  cerebral  instability  of  infancy  being  greatly  exaggerated  by  such 
nutritive  disorders.  The  most  frequent  one  is  rickets,  which  may  be  re- 
garded as  altogether  the  most  important  predisposing  cause  of  infantile 
convulsions.     They  are  often  one  of  the  earliest  symptoms  of  that  dis- 


650  DISEASES  OF  THE   NERVOUS  SYSTEM 

ease,  and  when  convulsions  ot-eur  in  infancy  without  evident  cause, 
rickets  should  always  be  looked  for.  Any  disturbance  of  nutrition,  such 
as  is  seen  in  status  lymphaticus,  syphilis,  anaiuiia,  malnutrition,  and  ex- 
haustion resulting  from  any  acute  disease,  especially  one  of  the  digestive 
tract,  may  predispose  to  convulsions.  Children  who  inherit  from  their 
parents  a  peculiarly  nervous  temperament  are  more  liable  to  convulsions 
than  are  others.  This  predisposition  is  often  seen  in  several  members  of 
the  same  family.  The  younger  the  child  the  greater  the  susceptibility. 
Females  are  rather  more  frequently  affected  than  males. 

The  exciting  causes  include  a  wide  variety  of  pathological  conditions, 
among  which  disturbances  of  digestion  take  the  first  place.  Where  the 
susceptibility  is  very  great,  the  exciting  cause  may  be  a  trivial  one.  These 
causes  may  be  grouped  under  three  general  heads:  (1)  direct  irritation 
of  the  cortex  of  the  brain;  (2)  reflex  irritation;  (3)  toxic  influences. 

Under  the  head  of  direct  irritation  may  be  included  all  convulsions 
occurring  with  the  various  forms  of  cerebral  disease;  the  most  frequent 
are  meningitis,  meningeal  or  cerebral  haemorrhage,  tumour,  abscess, 
hydrocephalus,  embolism,  and  thrombosis.  As  examples  of  reflex  irri- 
tation may  be  classed  the  convulsions  following  severe  injuries,  renal  or 
intestinal  colic,  retention  of  urine,  phimosis,  or  a  foreign  body  in  the 
ear.  A  case  has  been  reported  to  me  in  which  the  application  of  cold  to 
the  skin  repeatedly  induced  convulsions.  Other  conditions  classed  under 
this  head  are  dentition  and  worms,  but  both  must  be  regarded  as  ex- 
ceedingly rare  causes  of  convulsions.  The  exciting  cause  is  very  fre- 
quently the  presence  in  the  stomach  or  intestines  of  undigested  food; 
such  attacks  are  sometimes  ascribed  to  reflex  irritation,  but  the  majority 
are  better  regarded  as  toxic.  Acute  and  chronic  indigestion  are  to  be 
ranked  among  the  most  frequent  causes  of  convulsions,  both  in  infants 
and  older  children.  In  either  there  may  be  but  one  attack,  or  attacks 
may  recur  at  intervals  of  a  few  months  with  a  repetition  of  the  cause. 
Of  toxic  origin  may  be  considered  not  only  the  convulsions  resulting 
from  conditions  like  uraemia  and  asphyxia,  but  also  those  which  occur 
at  the  onset  or  in  the  course  of  various  infectious  diseases,  sometimes 
classed  as  febrile  convulsions.  They  are  very  frequent  at  the  onset  of 
certain  diseases,  particularly  pneumonia,  scarlet  fever,  malaria,  acute  in- 
digestion, and  gastro-enteric  intoxication.  In  these  cases  the  convulsions 
seem  due  partly  to  the  intensity  of  the  poison  and  partly  to  the  sudden- 
ness with  which  it  affects  the  nervous  system.  Convulsions  occurring 
late  in  the  course  of  many  diseases  may  be  due  to  toxic  influences,  espe- 
cially when  associated  with  exhaustion  of  the  nerve  centres,  from  the 
prolonged  disturbances  of  nutrition  accompanying  the  febrile  condition. 

In  pertussis,  which  of  all  infectious  diseases  is  the  one  in  which  con- 
vulsions are  most  frequent,  several  factors  may  be  present :  asphyxia 
due  to  a  severe  paroxysm,  cerebral  congestion  or  haemorrhage  resulting 


CONVULSIONS.  651 

from  such  a  paroxysm,  or  simply  from  the  pecuhar  susceptibility  of  the 
patient  brought  about  by  the  disease  itself. 

Convulsions  ending  fatally  are  not  infrequently  associated  with  en- 
largement of  the  thymus  gland.  I  have  seen  several  such  where  there 
was  found  at  autopsy  great  enlargement  of  the  thymus,  which  weighed 
from  one  to  one  and  a  half  ounces.  Some  of  these  infants  were  pre- 
viously healthy;  some  were  rachitic.  Tlie  similarity  of  all  these  cases 
indicated  that  the  convulsions  were  in  some  way  due  to  the  enlarged 
thymus,  but  the  exact  explanation  is  not  yet  understood. 

Frequently  recurring  convulsions  in  infancy  are  very  often  associated 
with  tetany.  The  symptoms  of  the  latter  condition  may  be  so  slight  as 
to  be  readily  overlooked;  or  there  may  be  no  symptoms  present  except 
the  characteristic  electrical  reactions. 

One  attack  of  convulsions,  whatever  the  cause,  renders  the  patient 
more  liable  to  a  second,  and  where  there  have  been  several,  they  occur 
from  causes  which  are  less  and  less  marked. 

An  important  element  in  the  convulsions  of  infancy,  according  to 
Hughlings  Jackson,  is  the  lack  of  development  of  the  higher  cerebral 
functions,  in  consequence  of  which  they  do  not  exert  the  controlling  in- 
fluence over  the  discharge  of  nerve  force  which  they  do  in  later  life. 

The  condition  of  the  brain  in  the  beginning  of  an  attack  of  convul- 
sions is  one  of  ansemia;  this  is  shortly  followed  by  venous  hyperaemia 
which  may  be  very  intense.  In  infants  who  die  during  convulsions  the 
brain  and  its  meninges  are  usually  found  intensely  congested.  They 
may  be  the  seat  of  punctate  haemorrhages,  and  sometimes  of  more  ex- 
tensive ones.  The  lungs  are  also  deeply  congested,  and  the  right  heart 
is  generally  distended  with  dark  clots.  The  other  lesions  found  are 
accidental. 

Symptoms. — In  some  cases  prodromal  symptoms  are  present,  such  as 
extreme  restlessness,  irritability,  slight  twitchings  of  the  muscles  of  the 
face,  hands,  feet,  or  eyelids.  More  frequently,  however,  the  attack  comes 
quite  suddenly  with  little  warning.  Usually  the  first  thing  noticed  is 
that  the  face  is  pale,  the  eyes  fixed,  sometimes  rolled  up  in  their  orbits ; 
in  a  moment  or  two  convulsive  twitchings  begin  in  the  muscles  of  the 
eye  or  face,  or  in  one  of  the  extremities,  which  usually  rapidly  extend 
until  all  parts  of  the  body  participate.  In  most  cases  the  convul- 
sions become  general,  but  they  may  remain  unilateral  even  when  not 
due  to  a  local  cause— a  point  which  is  often  forgotten.  The  contraction 
of  the  facial  muscles  causes  a  succession  of  grimaces ;  the  neck  is  thrown 
back;  the  hands  are  clenched;  the  thumbs  buried  in  the  palms;  and  a 
quick  spasmodic  contraction  of  the  extremities  occurs.  There  may  be 
some  frothing  at  the  mouth,  and  in  all  true  convulsions  there  is  loss  of 
consciousness.  Eespiration  is  feeble,  shallow,  and  may  be  spasmodic. 
The  pulse  is  weak;  it  may  be  slow  or  rapid;  often  it  is  irregular.    The 


652  DISEASES  OF  THE   NERVOUS  SYSTEM. 

forehead  is  covered  with  cold  perspiration.  The  face  is  first  pale,  then 
becomes  slightly  blue,  especially  about  the  lips.  Unnatural  rattling 
sounds  may  be  produced  in  the  larynx.  The  bladder  and  rectum  may  be 
evacuated.  The  convulsive  movements  consist  in  an  alternation  of  flexion 
and  extension  occurring  rhythmically.  All  varieties  of  tonic  and  clonic 
spasm  may  be  seen,  and  in  all  degrees  of  severity.  The  contractions  of 
the  two  sides  of  the  body  are  usually  synchronous.  After  a  variable  time, 
from  a  few  moments  to  half  an  hour,  the  convulsive  movements  are 
gradually  less  frequent,  and  finally  cease  altogether,  usually  leaving  the 
patient  in  a  condition  of  stupor.  They  may  recur  after  a  short  time  or 
there  may  be  but  one  attack.  A  period  of  general  relaxation  usually  fol- 
lows the  convulsive  seizures,  frequently  accompanied  by  marked  evidences 
of  prostration.  Transient  paralysis,  apparently  due  to  exhaustion  of  the 
nerve  centres,  is  not  an  uncommon  sequel. 

Death  may  take  place  from  a  single  attack;  this,  however,  is  rare  ex- 
cept in  very  young  infants,  especially  those  who  are  rachitic  or  are  suf- 
fering from  status  lymphaticus.  There  may  be  no  sequel  to  the  con- 
vulsions if  the  cause  is  a  temporary  one,  or  tliey  may  produce  some  serious 
brain  lesion,  particularly  meningeal  haemorrhage.  Death  from  convul- 
sions is  generally  due  to  asphyxia,  or  to  exhaustion  from  the  rapidly 
recurring  attacks.  Many  cases  recover  in  which  the  children  for  several 
minutes  had  the  appearance  of  being  moribund. 

One  attack  of  convulsions  is  very  apt  to  be  followed  by  others;  for 
the  occurrence  of  the  first  one  usually  reveals  a  peculiar  susceptibility 
of  the  nervous  system,  and  each  succeeding  attack  comes  from  a  less 
powerful  exciting  cause  than  the  previous  one.  The  longer  the  interval 
which  has  passed,  the  less  likely  is  there  to  be  a  repetition,  especially  if 
the  child  has  passed  its  third  year.  The  number  of  attacks  may  be  very 
great.  In  one  case  that  I  saw,  an  infant  during  the  latter  part  of  its 
second  year  had  during  six  months  over  thirty-five  hundred  distinct 
attacks  of  convulsions.  For  a  considerable  period  they  reached  the  almost 
incredible  number  of  eighty  a  day,  and  yet  the  mental  condition  of  the 
child  in  tlie  interval  was  apparently  normal. 

Diagnosis. — There  can  rarely  be  any  difficulty  in  recognising  an  at- 
tack of  convulsions.  The  difficulty  consists  in  determining  with  which 
of  the  many  possible  exciting  causes  we  have  to  do  in  tlie  case  before  us. 
If  it  comes  with  acute  symptoms  does  it  depend  upon  a  cerebral  lesion, 
or  does  it  mark  the  onset  of  some  other  acute  disease?  Is  it  reflex,  and 
if  so  to  what  is  it  due?  If  there  are  no  acute  symptoms,  is  it  epilepsy? 
To  answer  these  questions  a  careful  history  must  be  obtained,  and  all 
the  circumstances  surrounding  the  patient,  the  character  of  the  con- 
vulsions, and  all  the  other  symptoms  present  must  be  taken  into  con- 
sideration. 

In  infancy,  epilepsy  is  the  least  probable  diagnosis.     In  older  chil- 


CONVULSIONS.  653 

dren  the  important  points  indicating  that  disease  are:  the  presence  of 
some  of  the  stigmata  of  degeneration,  a  history  of  previous  attacks,  a 
distinct  aura  preceding  the  seizure,  or  a  sudden  onset  with  a  cry  or  fall, 
biting  of  the  tongue,  a  tonic  spasm  preceding  the  clonic,  a  deep  sleep 
following  the  seizure,  and,  finally,  perfect  recovery  in  the  course  of  a 
few  hours.  Convulsions  which  come  on  with  high  fever,  even  though 
a  patient  may  have  repeated  attacks,  are  seldom  epileptic.  However,  in 
some  cases  only  prolonged  observation  can  enable  one  to  decide  posi- 
tively whether  or  not  epilepsy  is  present. 

Convulsions  occurring  in  brain  disease,  except  acute  meningitis,  are 
not  as  a  rule  accompanied  by  any  marked  rise  in  temperature.  Focal 
symptoms  are  often  present,  such  as  localised  paralysis  or  rigidity, 
changes  in  the  pupils,  and  strabismus.  The  convulsive  movements  are 
frequently  limited  to  one  side  of  the  body.  It  should,  however,  be  borne 
in  mind  that  unilateral  conv'ulsions,  even  when  repeated,  do  not  always 
mean  a  local  lesion,  as  I  have  seen  proved  by  autopsy  more  than  once. 
In  haemorrhage  or  meningitis,  convulsions  are  likely  soon  to  recur.  In 
tumour  they  may  recur  after  a  longer  interval. 

Convulsions  may  be  thought  to  indicate  the  onset  of  some  acute  dis- 
ease when  they  occur  in  a  child  over  two  years  old,  and  when  they  come 
on  suddenly  or  with  only  slight  premonition  in  a  child  previously  well; 
but  the  most  important  point  is  that  they  are  accompanied  by  a  high 
temperature — 104°  to  106°  F.  Acute  meningitis  is  the  only  other  con- 
dition likely  to  produce  these  S3^mptoms.  Whether  the  convulsions  mark 
the  onset  of  lobar  pneumonia,  scarlet  fever,  or  some  other  disease,  can 
be  determined  only  by  carefully  watching  the  patient's  symptoms  for 
twenty-four  or  thirty-six  hours. 

In  infants,  derangements  of  the  digestive  tract  should  first  be  sus- 
pected; in  very  young  infants  relatively  slight  disorders  may  cause 
severe  and  repeated  convulsions.  In  the  first  weeks  of  life  one  may 
often  be  in  great  doubt  as  to  the  cause  of  convulsions.  Such  attacks  may 
be  due  to  some  disorder  of  the  digestive  tract,  to  a  recent  cerebral  lesion 
like  haemorrhage  or  to  a  defective  brain  development.  Sometimes  noth- 
ing but  the  progress  of  the  case  will  definitely  clear  up  the  diagnosis. 

Examination  of  the  urine  should  not  be  omitted  in  any  case  of  con- 
vulsions of  doubtful  origin.  Asphyxia  may  be  suspected  in  the  case  of 
con\ailsions  occurring  in  the  newly  born,  late  in  pneumonia,  in  some 
cases  of  pertussis,  in  spasmodic  or  membranous  laryngitis,  or  in  laryn- 
gismus stridulus.  Dentition  and  worms  should  be  considered  among 
the  least  probable,  never  as  the  most  probable,  causes  of  reflex  irritation, 
and  should  not  be  so  accepted  without  positive  evidence.  Worms  are 
so  rare  in  infancy  that  at  this  period  they  may  be  practically  ignored. 
Dentition  seldom  causes  convulsions  except  in  patients  who  are  markedly 
rachitic.     In  all  cases  of  convulsions  of  doubtful  or  obscure  origin  oc- 


654  DISEASES  OF  THE  NERVOUS  SYSTEM. 

curring  in  infants,  rickets  should  be  suspected  as  the  underlying  cause, 
and  the  child  carefully  examined  for  other  evidences  of  that  disease. 
The  close  association  of  convulsions  with  tetany  should  not  be  for- 
gotten. 

Prognosis. — This  depends  upon  the  age  of  the  patient  and  the  cause 
of  the  convulsions.  Idiopathic  or  reflex  convulsions  are  rarely  danger- 
ous to  life  except  in  very  young  or  in  rachitic  infants.  CouNoilsions  as- 
sociated with  enlarged  thymus  are  often  fatal.  Convulsions  occurring 
at  the  onset  of  acute  febrile  diseases  are  seldom  fatal,  and  not  often 
serious;  they  may  not  even  indicate  an  unusually  severe  type  of  the  dis- 
ease. Especially  fatal  are  the  convulsions  of  pertussis  and  of  asphyxia 
when  they  occur  late  in  any  form  of  laryngeal  or  pulmonary  disease.  In 
nephritis,  while  always  serious,  convulsions  are  by  no  means  invariably 
fatal.  The  conditions  during  an  attack  which  should  lead  one  to  make 
a  bad  prognosis  are  when  the  conMilsions  are  prolonged  or  recur  fre- 
quently; also  the  presence  of  very  great  prostration,  a  feeble  pulse  with 
cyanosis,  or  deep  stupor. 

In  the  prognosis  one  must  take  into  account  not  only  the  immediate 
result  of  the  attack,  but  its  possible  outcome.  In  a  highly  nervous  or 
susceptible  child  a  con\'ulsion  often  means  very  little.  Permanent  injury 
to  the  brain,  simply  as  a  result  of  an  attack,  I  believe,  to  be  very  rare. 
The  possibility  of  epilepsy  is  to  be  borne  in  mind  in  all  cases  where  chil- 
dren over  two  years  old  have  occasional  attacks  of  convulsions,  although 
it  is  unusual  that  this  result  is  seen.  The  farther  apart  the  attacks  are 
and  the  more  definite  the  exciting  cause,  the  less  likely  is  this  to  be 
the  case. 

Treatment. — Summoned  to  a  child  in  convulsions,  a  physician  should 
go  at  once  and  remain  until  the  attack  has  subsided.  He  should  take 
with  him  chloroform,  a  hypodermic  syringe  with  morphine,  a  soft  cath- 
eter or  rectal  tube,  and  a  solution  of  chloral.  In  order  to  treat  convul- 
sions intelligently  one  must  have  in  mind  the  prominent  pathological 
conditions.  These  are:  acute  cerebral  hyperaemia,  a  more  or  less  severe 
asphyxia  with  pulmonary  congestion,  an  overtaxed  right  heart,  and 
a  tendency  to  congestion  of  all  the  internal  organs.  The  nervous 
centres  are  in  a  condition  of  such  unnatural  excitability  that  the  slight- 
est irritation  may  bring  on  convulsive  movements  when  they  have  tempo- 
rarily subsided.  The  patient  should  therefore  be  kept  perfectly  quiet, 
and  every  unnecessary  disturbance  avoided.  Cold  should  be  applied  to 
the  head — best  by  means  of  an  ice  cap  or  cold  cloths — and  dry  heat  and 
counter-irritation  to  the  surface  of  the  body  and  extremities.  The  time- 
honoured  mustard  bath  causes  so  much  disturbance  of  the  patient  that 
it  can  usually  be  dispensed  with  and  the  mustard  pack  substituted.  The 
feet  may  be  placed  in  mustard  water  while  the  child  lies  in  its  crib.  The 
mustard  pack  and  footbath  should  be  continued  until  the  skin  is  well 


CONVULSIONS.  655 

reddened.     The  degree  to  which  counter-irritation  of  the  skin  should  he 
carried  will  depend  upon  the  condition  of  the  pulse  and  the  cyanosis. 

In  controlling  convulsions  the  three  remedies  which  may  be  depended 
upon  are  the  inhalation  of  chloroform,  morphine  hypodermically,  and 
chloral.  Chloroform  is  undoubtedly  the  most  reliable  remedy  for  an 
immediate  effect,  and  should  be  used  even  in  the  youngest  infant.  At 
the  same  time  that  it  is  being  administered,  chloral  should  be  given 
per  rectum.  The  initial  dose  should  be,  at  six  months,  four  grains;  at 
one  year,  six  grains;  at  two  years,  eight  grains,  dissolved  in  one  ounce 
of  warm  milk.  It  should  be  injected  high  into  the  bowel  through  a 
catheter,  and  prevented  from  escaping  by  pressing  the  buttocks  together. 
It  may  be  repeated  in  an  hour  if  necessary.  The  effect  of  the  drug  is 
generally  obtained  in  twenty  minutes.  If,  in  spite  of  the  chloral,  the 
convulsions  show  a  marked  tendency  to  continue  as  soon  as  the  chloro- 
form is  withdrawn,  or  if  the  enema  of  chloral  has  been  expelled,  morphine 
should  be  given  hypodermically.  When  the  heart's  action  is  weak,  this 
is  probably  the  best  of  all  remedies.  Objections  are  urged  against  it 
only  by  those  who  have  had  no  experience  with  its  use.  To  a  well- 
grown  child  two  years  ol^,  -^  grain  may  be  given;  one  year  old,  -^ 
grain ;  six  months  old,  ^  grain.  This  dose  may  be  repeated  in  half  an 
hour  if  no  effect  is  seen.  The  tolerance  of  opium  in  cases  of  convulsions 
is  very  marked,  and  sometimes  double  the  doses  mentioned  may  be  re- 
quired. The  only  other  agent  of  much  value  is  oxygen.  I  have  seen  con- 
vulsions which  continued  in  spite  of  all  other  means  yield  immediately 
to  oxygen.  This  is  most  likely  to  be  valuable  in  cases  of  convulsions  due 
to  asphyxia. 

When  once  under  control,  the  recurrence  of  the  convulsions  may  be 
prevented  by  keeping  the  patient  for  two  or  three  days  under  the  influ- 
ence of  chloral  with  bromide  of  sodium,  the  amount  of  chloral  being 
gradually  reduced.  If  it  is  badly  borne  by  the  stomach  and  not  easily 
retained  by  the  rectum,  either  antipyrine  or  phenacetine  may  be  used 
with  the  bromide.  Where  there  is  a  strong  tendency  to  recurrence  of 
the  convulsions,  urethan  is  sometimes  even  more  efficient  than  chloral. 
It  may  be  given  in  the  same  or  in  slightly  larger  doses. 

As  soon  as  the  convulsions  have  ceased,  the  cause  should  be  sought 
and  treated.  In  infancy  it  is  wise  in  every  case  to  irrigate  the  colon 
thoroughly  with  warm  water,  to  remove  any  possible  source  of  irritation. 
If  there  is  reason  to  suspect  the  presence  of  undigested  food  in  the 
stomach,  this  may  be  washed  out.  Much  more  frequently  it  is  in  the 
intestines,  and  free  purgation  by  calomel  is  advisable.  If  there  is  high 
temperature,  this  should  be  reduced  by  the  cold  bath  or  pack.  Sec- 
ondary attacks  are  to  be  prevented  by  careful  feeding,  by  improving  the 
general  nutrition  by  means  of  fresh  air,  iron,  cod-liver  oil,  and  phos- 
phorus.   The  last  two  are  especially  valuable  in  cases  due  to  rickets. 


656  DISEASES  OF  THE  NERVOUS  SYSTEM. 

TETANY. 

Tetany  is  a  condition  characterised  by  extreme  nervous  and  muscular 
irritability  with  tonic  muscular  spasm,  which  may  be  intermittent  or 
continuous.  It  usually  affects  the  muscles  of  the  extremities,  especially 
the  hands  and  feet,  more  rarely  the  neck,  face,  and  trunk.  When  limited 
to  the  hands  and  feet  it  is  known  as  carpo-pedal  spasm  or  arthrogryposis ; 
and  although  sometimes  classed  separately,  this  is  really  only  one  mani- 
festation of  the  same  general  condition.  In  infants,  tetany  is  very  fre- 
quently associated  with  laryngismus  stridulus,  this  being  present  in  fully 
two-thirds  of  the  cases;  but  in  older  children  this  association  is  quite 
rare.  General  convulsions  occur  in  from  twenty  to  thirty  per  cent  of 
the  cases.  Although  tetany  is  not  a  very  common  disease  in  America,  I 
believe  that  it  is  very  often  overlooked.  In  my  hospital  service  I  seldom 
see  fewer  than  a  dozen  cases  a  year. 

Etiology. — While  tetany  may  occur  at  any  age,  it  is  most  frequent  in 
infancy.  Fully  two-thirds  of  the  cases  are  seen  in  the  first  two  years  of 
life.  It  is  most  common  between  the  fourth  and  tentli  month.  Most  of 
the  attacks  are  seen  in  the  winter  months.  In  infancy,  males  are  much 
more  frequently  affected.  At  this  age  it  is  rarely  seen  except  when 
associated  with  rickets.  It  may  follow  broncho-pneumonia,  pertussis, 
typhoid  fever,  rheumatism,  or  measles.  There  is  usually  present  some 
derangement  of  the  digestive  tract.  There  may  be  acute  diarrhoea  or 
chronic  gastric  or  intestinal  indigestion.  It  is  seen  in  rare  cases  with 
intestinal  worms  and  with  intussusception.  The  most  common  exciting 
cause  appears  to  be  an  intoxication  from  the  digestive  tract  or  the  irrita- 
tion of  undigested  food.  Attacks  in  older  children  are  very  uncommon 
in  this  country.  In  girls,  tetany  may  occur  at  the  time  of  puberty, 
especially  when  menstruation  is  delayed.  In  animals  and  in  man 
tetany  regularly  follows  the  complete  removal  of  the  parathyroid  glands. 
Some  pathologists  consider  the  essential  cause  to  be  an  absence  of  the 
secretion  of  the  parathyroid  or  some  disturbance  of  its  function.  While 
this  may  be  accepted  as  one  of  the  causes  of  tetany,  it  is  by  no  means 
established  that  it  is  the  only  cause.  Considerable  evidence  has  ac- 
cumulated that  tetany  is  in  some  way  associated  with  disturbances  of 
calcium  metabolism;  but  in  what  way  has  not  yet  been  proven.  Much 
regarding  the  nature  and  cause  of  tetany  remains  to  be  solved  by  further 
investigation. 

Pathology. — Up  to  the  present  time  the  only  constant  anatomical 
lesions  demonstrated  in  tetany  are  in  the  parathyroid  glands.  The  most 
frequent  one  is  haemorrhage  which  may  be  recent,  or  if  old,  other  changes 
are  present  such  as  the  formation  of  small  cysts  and  pigmentation. 
While  parathyroid  changes  have  been  found  in  many  cases  they  are  not 
uniformly  present. 


TETANY. 


G57 


Symptoms. — The  spasm  may  develop  abruptly,  or  it  may  be  pre- 
ceded by  sensory  disturbances,  such  as  pain,  nuni])ness,  or  tinii^linff.  The 
upper  extremities  are  usually  first  affected,  the  s])asm  gradually  becom- 
ing more  severe  and  finally  involving  the  lower  extremities.  Both  sides 
of  the  body  are  equally  affected.     The  position  assumed  by  the  hands 


Fig.  104.— Tetany,  showing  the  Characteristic  Position  of  the  Hands  and  Feet. 

In  a  child  two  years  old. 

is  very  characteristic :  The  fingers  are  flexed  at  the  metacarpo-phalangeal 
joints  and  the  phalanges  extended;  the  thumbs  are  adducted  almost  to 
the  little  finger;  the  wrist  is  flexed  at  an  acute  angle,  and  the  whole 
hand  drawn  somewhat  to  the  ulnar  side.  If  the  spasm  is  very  marked 
no  motion  is  allowed  at  the  wrist,  but  movements  at  the  elbow  and 
43 


658  DISEASES  OF  THE  NERVOUS  SYSTEM. 

slioulder  are  usually  normal.  The  feet  are  strongly  extended,  sometimes 
in  the  position  of  typical  equino-varus.  The  first  phalanges  of  the  toes 
are  flexed,  and  the  second  and  third  rows  extended;  the  plantar  surface 
is  strongly  arched,  and  the  dorsum  of  the  foot  is  very  prominent,  stand- 
ing out  like  a  cushion.  The  typical  position  of  the. hands  and  feet  is 
well  shown  in  Fig.  104.  The  tendo-Achillis  stands  out  prominently. 
Motion  at  the  hip  and  knee  is  generally  free.  The  spasm  in  many  cases 
is  limited  to  the  hands  and  feet;  more  rarely  the  muscles  of  the  thigh, 
usually  the  adductors,  may  be  involved.  In  very  rare  cases  the  muscles 
of  the  trunk,  the  face,  or  the  eye  may  be  affected. 

The  knee-jerk  and  the  cutaneous  reflexes  are  exaggerated,  and  there 
is  abnormal  response  to  mechanical  irritation.  Light  percussion  upon 
a  nerve  trunk  often  induces  marked  contraction  of  the  muscles  supplied 
by  the  nerve.  This  is  particularly  striking  in  the  face.  The  contraction 
of  the  facial  muscles  following  such  irritation  is  known  as  "  Chvostek's 
symptom  "  or  the  facial  phenomenon.  A  spasm  causing  the  characteristic 
position  of  the  hands  or  feet  may  be  excited  by  pressure  upon  the  nerve 
trunks,  or  by  constricting  the  limb  so  as  to  cut  off  the  circulation.  This 
is  known  as  "  Trousseau's  symptom."  The  most  diagnostic  feature  of 
tetany  is  the  electrical  reaction.  It  is  best  obtained  in  the  peroneal 
nerve.  Under  normal  conditions  there  may  be  no  contraction  to  the 
cathodal  closure  with  a  current  of  less  than  five  milliamperes.  In  tetany 
such  a  contraction  is  regularly  obtained  with  a  current  of  this  strength 
and  often  with  a  much  weaker  one.  Also,  a  reaction  highh'  suggestive 
of  tetany  is  an  anodal  opening  contraction  with  a  current  of  less  than 
five  milliamperes,  and  less  than  one  causing  an  anodal  closure  contrac- 
tion. The  most  diagnostic  reaction,  however,  is  a  cathodal  opening 
contraction  with  a  current  of  less  than  five  milliamperes  or  a  tonic  con- 
traction with  cathodal  closure  with  less  than  five  milliamperes. 

Evidences  of  pain  owing  to  the  spasm  are  frequently  present.  It 
may  be  so  severe  as  to  cause  children  to  cry  out.  Pain  is  induced  b}' 
any  attempt  to  overcome  the  spasm,  and  sometimes  it  is  constant.  There 
is  no  loss  of  consciousness  and  no  fever.  The  muscular  contraction  is 
generally  continuous,  although  there  may  be  periods  of  remission  or 
even  of  intermission.  When  associated  with  laryngismus  stridulus,  the 
spasm  is  much  increased  during  these  attacks. 

The  duration  of  tetany  is  from  a  few  days  to  several  weeks.  The 
mild  form,  which  is  usually  seen  in  infants,  in  many  cases  passes  away 
spontaneously  in  one  or  two  weeks,  although  there  may  be  relapses  and 
recurrences  at  variable  intervals.  The  most  important  complication  is 
general  con\'ulsions.  These  may  come  on  at  any  time  in  the  course  of 
the  attack.  Spasm  of  the  glottis  may  either  precede  or  follow  tetany, 
and  by  many  is  regarded  as  part  of  the  disease.  AVhen  associated  they 
generally  cease  at  the  same  time. 


LARYNGISMUS   STRIDULUS.  659 

Diagnosis. — The  diagnostic  features  of  tetany  are  bilateral  spasm — 
in  infants  usually  limited  to  the  hands  and  feet — without  loss  of  con- 
iciousness,  the  spasm  heing  increased  or  excited  by  pressure  upon  the 
arteries  or  nerves,  exaggerated  reflexes,  and  the  characteristic  electrical 
reaction.  Evidences  of  rickets  are  usually  ])resent.  While  the  other 
symptoms  of  tetany  are  subject  to  considerable  variation,  the  peculiar 
electrical  reactions  are  always  present  and  therefore  diagnostic.  Accept- 
ing this  reaction  as  the  pathognomonic  sign  of  the  disease,  it  will  be 
found  that  tetany  is  often  present  when  not  suspected,  and  that  many 
obscure  nervous  symptoms  are  due  to  this  disease  which  otherwise  might 
be  misinterpreted. 

The  severe  form  of  tetany  has  been  taken  for  tetanus;  but  that  dis- 
ease is  very  rare  except  in  the  newly  born,  and  trismus  is  generally  the 
first  symptom.  Trismus  is  extremely  rare  in  tetany.  From  meningitis 
and  other  forms  of  cerebral  disease  tetany  is  distinguished  by  the  absence 
of  cerel^ral  symptoms. 

Prognosis. — Tetany  per  se  is  not  fatal,  but  death  may  result  from 
the  development  of  general  convulsions  or  in  infants  from  the  condition, 
usually  some  serious  disturbance  of  digestion,  which  tetany  complicates. 
If  recovery  occurs  it  is  usually  complete. 

Treatment. — The  first  indication  is  to  discover  and  if  possible  re- 
move the  cavise,  and  this  in  most  cases  is  found  in  the  digestive  tract. 
If  rickets  is  present  it  should  receive  the  usual  treatment,  both  dietetic 
and  medicinal.  For  the  relief  of  the  spasm,  the  hot  bath  is  a  valuable 
remedy.  This  may  be  repeated  two  or  three  times  a  day.  Drugs  which 
have  the  power  of  allaying  spasm  should  be  given — bromides,  chloral,  or 
antipyrine. 

The  specific  treatment  of  tetany  by  parathyroid  extract  has  not  in 
my  hands  been  followed  by  any  appreciable  benefit.  I  have  seen  it  tried 
only  in  infants.  Those  who  hold  the  cause  to  be  a  disturbance  of  calcium 
metabolism,  would  treat  tetany  by  withholding  calcium  salts,  or  by 
administering  them,  according  to  their  view  of  the  part  which  calcium 
plays  in  etiology.  Whether  calcium  is  given  or  withheld,  seems  to  me 
to  have  no  special  influence  upon  the  disease.  I  have  seen  no  advantage 
in  excluding  milk  and  have  seen  the  most  satisfactory  results  when  the 
feeding  was  carried  on  according  to  the  indications  afforded  by  the 
child's  digestive  symptoms,  disregarding  the  tetany.  In  prolonged  cases 
there  is  no  doubt  that  the  administration  of  cod-liver  oil  and  phosphorus 
is  beneficial.    They  are  to  be  used  as  in  rickets. 

LARYNGISMUS  STRIDULUS— LARYNGO-SPASM. 

Laryngismus  stridulus  is  a  rather  rare  condition  and  belongs  espe- 
cially to  infancy,    It  is  most  frequently  seen  in  children  who  are  rachitic. 


660  DISEASES  OF  THE   NERVOUS  SYSTEM. 

and  is  associated  with  carpo-pedal  spasm  and  with  general  convulsions. 
It  is  not  to  be  confounded  with  ordinary  spasmodic  croup  or  catarrhal 
spasm  of  the  lar^'nx. 

Spasm  of  the  larynx  may  be  seen  in  several  conditions  quite  different 
from  laryngismus  stridulus.  It  forms  one  of  the  essential  features  of 
pertussis.  It  occurs  both  in  infants  and  in  older  children  from  pressure 
upon,  or  irritation  of,  the  pneumogastric  or  the  recurrent  laryngeal  nerve 
by  a  tumour  in  the  mediastinum,  usually  a  tuterculous  lymph  node,  or 
a  retro-cesophageal  al)scess.  There  is  a  form  of  spasm  which  occurs  in 
the  newly  born  accompanied  by  crowing  inspiration ;  this  is  not  frequent, 
and  is  rarely  serious. 

Laryngismus  stridulus  is  quite  different  from  any  of  these  conditions. 
It  is  peculiar  to  infancy,  the  great  proportion  of  cases  occurring  be- 
tween the  sixth  and  eighteenth  months.  Males  appear  to  be  more 
susceptible  than  females.  The  constitutional  condition  with  which  it  is 
most  often  associated  is  rickets.  In  a  large  number  of  cases,  but  not 
in  all,  there  is  cranio-tabes.  Many  writers  believe  that  laryngismus  is 
invariably  of  rachitic  origin.  Of  fifty  cases  observed  by  Gee,  there  were 
found  in  all  but  two  unmistakable  evidences  of  rickets.  The  disease 
occurs  in  delicate  infants  who  have  been  closely  confined  in  warm  rooms, 
and  it  is  probably  on  this  account  that  it  is  more  often  seen  in  the 
winter  and  early  spring  than  at  other  seasons.  The  exciting  causes  of 
this  spasm  may  be  a  breath  of  cold  air,  or  any  form  of  nervous  excite- 
ment, such  as  passion,  fright,  or  crying. 

Symptoms. — Tiie  disease  is  often  unnoticed  by  the  parents  until  the 
attacks  have  become  quite  frequent,  the  first  ones  being  mild,  and  the 
later  ones  more  and  more  severe.  Occasionally  the  very  first  paroxysms 
may  be  severe.  Such  an  attack  comes  on  suddenly.  The  child  throws 
back  his  head,  the  face  becomes  pale,  then  livid,  and  for  the  time  there 
is  complete  arrest  of  respiration.  This  continues  for  a  few  moments, 
during  which  the  cyanosis  deepens,  and  the  child  seems  in  great  distress, 
making  violent  efforts  to  breathe.  If  the  paroxysm  is  a  very  severe  one, 
the  asphyxia  may  be  so  great  as  to  lead  to  loss  of  consciousness,  and  it 
may  even  Ije  fatal,  or  the  attack  may  terminate  in  general  convulsions. 
In  milder  attacks,  after  fifteen  or  twenty  seconds  the  muscular  spasm 
relaxes,  the  glottis  opens,  and  a  long,  deep  inspiration  occurs,  with  the 
production  of  a  crowing  sound.  The  "  crowing  attacks  "  of  infants  are 
usually  of  this  nature  but  milder,  and  the  arrest  of  respiration  is  only 
momentary.  Such  forms  of  spasm  often  come  on  without  any  evident 
cause,  and  may  be  repeated  from  two  or  three  to  twenty  times  a  day. 
Between  them  the  condition  of  the  child  may  be  normal  or  carpo- 
pedal  spasm  and  other  evidences  of  tetany  may  be  present.  Not  all  the 
paroxysms  in  the  same  case  are  equally  severe.  A  child  may  have  in 
the  course  of  a  day  a  great  many  mild  attacks,  but  only  a  few  severe 


HOLDING-BREATH   SPELLS.  661 

ones.  General  convulsions  arc  seen  in  over  one-third  of  tlie  cases,  and 
carpo-pedal  spasm  or  tetany  coni])licat('s  a  still  lari^cr  proportioji.  If 
tetany  is  present  in  the  interval,  it  is  always  increased  durin^^  the 
attacks. 

The  duration  of  the  disease  varies  fi-om  a  few  days  to  several  weeks, 
or  even  months.  In  cases  whicli  terminate  in  recovery  thei-e  is  a  gradual 
diminution  in  the  frequency  and  severity  of  the  paroxysms,  until  they 
finally  cease  altogether.  The  outlook  is  good,  unless  thei'e  are  general 
convulsions.     The  cases  in  which  fatal   asphyxia  occurs  are  very  rare. 

Diagnosis. — This  is  to  he  made  from  catarrhal  spasm  of  the  larynx. 
The  differential  points  have  l)een  mentioned  under  the  latttn-  disease. 
Owing  to  the  occurrence  of  the  paroxysms  and  the  crowing  sounds,  the 
disease  may  be  mistaken  for  whooping-cough,  and  in  fact  this  diagnosis 
is  not  infrequently  made.  A  careful  examination  of  the  patient  during 
the  attacks,  the  absence  of  cough,  and  the  frequent  association  of  tetany, 
are  sufficient  to  differentiate  this  from  pertussis. 

Treatment. — During  the  attack  the  object  is  to  break  the  spasm.  In 
mild  cases  this  may  be  done  by  sprinkling  water  in  the  face.  In  severe 
cases  inhalations  of  chloroform  may  l)e  required,  and  even  intubation. 
Between  the  attacks  the  patient  should  be  given  either  bromide  and 
chloral,  or  antipyrine.  Sodium  bromide,  gr.  v,  and  chloral,  gr.  i,  may 
be  given  every  three  or  four  hours  to  a  child  a  year  old  until  the  fre- 
quency and  severity  of  the  attacks  are  conti-olled  ;  afterward  three  times 
a  day.  My  own  experience  with  antipyrine  in  this  disease  leads  me  to 
the  belief  that  it  is  more  effective  than  bromide  and  chloral.  When  the 
symptoms  are  severe,  two  grains  of  antipyrine  may  be  given  every  four 
hours  to  a  child  a  year  old,  the  dose  being  gradually  diminished  as  the 
symptoms  improve. 

Calcium  chloride  in  some  cases  produces  striking  results.  In  others 
it  is  without  apparent  benefit.  It  should  be  given,  in  full  doses,  e.  g., 
gr.  vi,  four  or  five  times  a  day  to  a  child  of  twelve  months. 

The  general  treatment  of  the  child  is  quite  as  important  as  drugs 
directed  toward  relieving  the  spasm.  Cold  sponging  should  be  used 
unless  it  occasions  so  much  fright  as  to  increase  the  number  of  paroxysms. 
Careful  attention  should  be  given  to  the  diet.  Cliildren  shoukl  be  kept 
in  the  open  air  as  much  as  possible.  Cod-liver  oil  is  needed  in  most 
cases,  and  rachitic  cases  are  sometimes  much  l)enefited  by  phosphorus. 
In  all  cases  the  treatment  should  be  continued  for  several  weeks  after 
the  paroxysms  have  subsided. 

HOLDING-BREATH  SPELLS. 

Attacks  closely  related  to  those  which  have  just  been  described  are 
met  with  which  may  perhaps  be  variations  of  the  same  disorder.     To 


662  DISEASES  OF  THE  NERVOUS  SYSTEM. 

them  the  term  "  holding-breath  spells  "  has  been  applied.  They  are  seen 
most  frequently  in  the  latter  part  of  the  first  and  during  the  second 
year,  and  affect  children  of  the  extremely  nervous  type.  Most  of  tlieni 
are  rachitic.  The  attacks  may  occur  five  or  six  times  a  day,  or  at  in- 
tervals of  several  days.  Beginning  in  infancy  they  may  recur  from  time 
to  time  until  the  age  of  four  or  five  years.  In  susceptible  children  almost 
any  form  of  excitement  may  precipitate  an  attack.  By  far  the  most 
frequent  are  temper  and  fright.  If  anything  is  attempted  to  which  the 
child  strongly  objects,  e.  g.,  a  cold  bath,  inspection  of  the  throat,  or  tak- 
ing away  a  toy,  an  attack  may  ensue.  The  child's  face  becomes  flushed, 
then  livid;  there  is  general  rigidity  of  the  trunk  and  extremities,  but 
rarely  clonic  spasm.  This  rigidity  is  followed  by  complete  relaxation 
with  loss  of  consciousness.  The  entire  attack  usually  lasts  about  lialf 
a  minute.  There  may  be  a  crowing  sound  as  the  child  catches  his  breath 
or  there  may  be  none.  After  a  few  minutes  of  quiet  the  child  gets  up 
and  in  a  short  time  is  apparently  as  well  as  ever.  Most  of  those  who 
are  subject  to  attacks  of  this  sort  sooner  or  later  have  one  or  more  gen- 
eral convulsions.  Although  in  infancy  these  seizures  may  recur  with 
alarming  frequency,  and  extend  over  a  period  of  several  years,  in  most 
cases  with  time  and  with  improvement  in  general  health  they  gradually 
become  less  and  less  frequent  until  finally  they  cease  altogetlier.  I 
have  not  seen  these  attacks  accompanied  by  tetany,  nor  followed  by 
epilepsy. 

In  this  condition  there  is  apparently  no  effort  on  the  part  of  the 
child  to  control  his  impulses,  he  simply  "  lets  himself  go."  Parents, 
witnessing  attacks  coming  on  after  correcting  or  disciplining  a  child, 
soon  fall  into  the  habit  of  indulging  him  in  everj^thing  with  the  hope 
of  avoiding  them.  Such  advice,  indeed,  is  often  given  by  physicians.  I 
believe  it  to  be  unwise.  A  much  better  plan  seems  to  be  to  teach  the 
child  to  control  himself  in  everything  no  matter  how  small.  While  it  is 
impossible  to  assert  that  the  attacks  can  be  brought  on  at  will,  such  cer- 
tainly seems  at  times  to  be  the  case,  and  the  development  of  the  will 
power  by  every  form  of  self-control  seems  to  exert  an  influence  in  pre- 
venting these  attacks,  certainly  in  children  who  have  reached  the  age 
of  four  or  five  years. 

The  treatment  of  these  children  is  first  addressed  to  the  general 
nutrition;  many  of  them  are  ansmic  and  under  weight.  The  feeding 
and  general  roirtine  should  therefore  be  the  first  concern.  A  life  as 
much  as  possible  in  the  open  air  and  in  the  country  is  most  desirable 
with  freedom  from  every  form  of  nervous  excitement  or  undue  nervous 
stimulation.  They  should  be  controlled,  taught  self-control,  and  treated 
tenderly,  but  with  great  tact  and  firmness.  Drugs  directed  specifically 
to  the  control  of  the  attacks  have  in  my  experience  been  of  little 
value. 


EPILEPSY.  663 


EPILEPSY. 


Epilepsy  may  be  defined  as  a  disease  in  wliicli  tliere  is  an  estab- 
lished disposition  to  convulsions  of  a  certain  tyi^e,  with  loss  of  con- 
sciousness, which  have  recurred  until  a  habit  of  convulsions  has  become 
fixed. 

A  distinction  must  be  made  between  cases  of  so-called  "idiopathic" 
epilepsy  and  those  which  are  secondary  to  a  definite  lesion  of  the  brain, 
such  as  tumour,  sclerosis,  or  abscess.  Convulsions  of  the  latter  char- 
acter are  designated  as  "symptomatic"  epilepsy,  and  are  discussed  in 
connection  with  the  various  diseases  in  which  tliey  occur.  The  nature 
of  the  attack  may,  however,  be  identical  in  both  varieties,  and  may  not 
differ  from  an  ordinary  attack  of  convulsions  or  eclampsia. 

The  proportion  of  idiopatliic  cases  in  children  is  not  so  large  as  was 
formerly  supposed;  many  of  these  have  been  shown  to  depend  upon 
lesions  once  overlooked,  particularly  mild  infantile  cerebral  paralyses. 

Etiology. — From  a  consideration  of  1,450  cases  of  epilepsy,  Gowers 
states  that  twelve  per  cent  begin  in  the  first  three  years  of  life,  and 
forty-six  per  cent  between  ten  and  twenty  years.  The  greatest  tend- 
ency to  the  development  of  the  disease  is  shown  about  the  time  of 
puberty.  Females  are  rather  more  liable  to  be  affected  than  males, 
although  the  difference  in  sex  is  slight.  Heredity  plays  an  impor- 
tant role  in  the  production  of  the  disease.  In  one-third  of  the  cases, 
according  to  Gowers,  there  is  a  family  history  either  of  epilepsy  or 
insanity. 

Not  very  infrequently  epilepsy  may  be  traced  to  convulsions  occurring 
during  infancy.  Infantile  convulsions  are  very  common,  and  usually 
the  cause  which  produces  them  is  a  transient  one.  The  proportion  of 
such  cases  which  develop  epilepsy  later  in  life  is  certainly  very  small. 
One  frequently  meets  with  children  from  two  to  five  years  old  who  have 
occasional  attacks  of  convulsions,  often  from  apparently  trivial  causes. 
In  my  experience,  the  great  majority  of  these  also  recover  completely 
with  proper  treatment;  a  very  few  become  epileptic.  The  first  seizure 
is  sometimes  traceable  to  fright,  great  excitement,  heat-stroke,  or  blows 
or  falls  upon  the  head  even  without  any  gross  lesion.  As  reflex  causes 
may  be  mentioned  intestinal  worms,  phimosis,  adenoid  vegetations  of 
the  pharynx,  delayed  or  difficult  menstruation,  and  masturbation.  Most 
of  these  are  rare  causes,  but  they  may  be  sufficient  to  produce  the  dis- 
ease where  a  strong  predisposition  exists. 

Among  the  most  important  factors  in  producing  a  paroxysm,  is  in- 
testinal putrefaction  associated  with  chronic  constipation  and  chronic 
intestinal  indigestion.  I  believe  it  to  be  one  of  the  most  important 
etiological  factors  in  cases  occurring  in  children,  particularly  as  an  ex- 
citing cause  of  the  first  attacks. 


664  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Pathology. — It  is  not  within  the  scope  of  this  work  to  discuss  the 
various  theories  which  have  been  advanced.  The  following  are  the  con- 
clusions reached  by  Gowers : 

"  The  muscular  spasm  is  to  be  regarded  as  the  result  of  the  sudden 
overaction  (discharge)  of  nerve  cells,  the  violent  liberation  of  nerve 
force,  and  the  sensations  which  the  patient  experiences  before  losing  con- 
sciousness must  be  due  directly  or  indirectly  to  the  same  cause.  The 
disease  which  excites  convulsions  is  most  frequently  at  the  cortex,  and 
when  organic  disease  causes  convulsions  that  begin  locally,  the  disease 
is  almost  invariably  at  the  cortex.  In  idiopathic  epilepsy  the  convulsions 
sometimes  begin  in  this  wa}^  and  this  suggests  very  strongly  that  in  such 
cases  the  change  occurs  in  the  cortex.  Epilepsy  must  then  be  regarded 
as  a  disease  of  the  gray  matter,  most  frequently  of  the  gray  matter  of 
the  cortex." 

While  there  is  pretty  general  agreement  that  the  seat  of  the  morbid 
changes  in  true  epilepsy  is  in  the  cortex,  but  little  is  yet  definitely  known 
as  to  the  nature  of  these  changes.  It  is  probable  that  a  great  variety  of 
lesions,  many  of  which  are  apparently  slight,  may  produce  this  disease. 

Symptoms. — Two  distinct  types  of  epileptic  seizures  are  met  with: 
the  major  attacks,  or  grand  mal,  in  which  there  are  severe  convulsions 
lasting  from  two  to  ten  minutes,  with  loss  of  consciousness,  etc. ;  and 
minor  attacks,  or  petit  mal,  in  which  the  convulsive  movements  are 
slight  and  may  be  absent,  and  in  which  the  loss  of  consciousness  is  often 
but  momentary.     Between  these  two  extremes  all  gradations  are  seen. 

Grand  Mal. — The  onset  may  be  sudden,  without  premonition,  or  it 
may  be  preceded  by  certain  prodromal  symptoms  known  as  the  aura. 
The  aura  may  be  motor,  such  as  a  local  spasm  of  the  hand,  face,  or  leg; 
or  sensory,  such  as  numbness  and  tingling  in  any  part  of  the  body,  or 
some  abnormal  sensation  rising  gradually  to  the  head,  at  which  time 
loss  of  consciousness  occurs.  The  variety  of  sensations  described  by 
patients  as  indicating  an  attack  is  endless.  There  may  be  a  sensation 
in  one  finger,  in  the  face,  tongue,  eye,  or  in  any  part  of  the  body ;  or  the 
warning  may  be  of  a  general  character,  like  a  tremor  or  a  shivering 
sensation,  or  a  feeling  of  faintness.  There  has  also  been  described  a 
visceral  or  pneumogastrie  aura,  in  which  there  is  epigastric  pain,  some- 
times nausea,  and  a  sensation  of  a  ball  in  the  throat;  or  there  may  be 
palpitation,  or  cardiac  distress.  There  may  be  general  giddiness  or 
vertigo,  or  a  sensation  of  fulness  in  the  head;  or  feelings  of  strangeness, 
or  a  dreamy,  dazed  condition;  and,  finally,  the  aura  may  have  reference 
to  any  of  the  special  senses,  most  frequently  to  sight.  Sparks  may  appear 
before  the  eyes,  or  flashes  of  light  or  colour,  or  strange  objects  may  be 
seen ;  or  there  may  be  a  momentary  loss  of  hearing ;  or  strange  sounds 
may  be  heard.     In  most  cases  the  aura  is  peculiar  to  the  individual. 

At  the  beginning  of  the  seizure  the  face  becomes  pale,  the  pupils 


EPILEPSY.  665 

widely  dilated,  the  eyes  rolled  up  in  their  orl)its  and  fixed.  Speedily 
there  is  loss  of  consciousness.  Simultaneously  with  these  symptoms,  or 
immediately  following  them,  there  occurs  a  violent  tonic  muscular  spasm 
to  which  are  due  the  characteristic  symptoms  of  the  early  part  of  the 
seizure,  viz.,  the  fall,  cry,  biting  of  the  tongue,  cyanosis,  and  evacuation 
of  the  bladder  or  rectum.  The  fall  is  forcilde,  violent;  in  fact,  the 
patient  is  precipitated  usually  forward,  and  frequently  suffers  injury, 
never  sinking  down  as  in  a  faint.  The  head  is  often  strongly  rotated  to 
one  side.  The  position  of  the  hands  is  frequently  that  assumed  in  tetany. 
The  cry  is  a  hoarse,  inarticulate  sound,  not  very  loud,  and  is  due  to 
forcible  expiration,  owing  to  spasm  of  the  muscles  of  respiration  with 
the  glottis  partially  closed.  The  cyanosis  is  the  result  of  tonic  spasm 
of  the  muscles  of  respiration;  it  may  be  quite  intense,  so  that  the  face 
is  livid,  bloated,  and  the  features  distorted.  The  spasm  of  the  muscles 
of  mastication  causes  the  biting  of  the  tongue.  Evacuation  of  the  bladder 
and  rectum  may  result  from  contraction  of  their  walls,  or  from  spasm  of 
the  abdominal  muscles.  The  violence  of  the  muscular  spasm  in  this 
stage  may  be  very  great;  it  has  caused  fracture  of  bones,  rupture  of 
muscles,  and  even  dislocation  of  Joints. 

The  stage  of  tonic  spasm  may  be  only  momentary,  the  patient  passing 
almost  at  once  into  the  stage  of  clonic  convulsions.  The  usual  duration 
is  from  ten  seconds  to  half  a  minute.  In  the  stage  of  clonic  spasm 
which  follows,  the  symptoms  are  those  of  an  ordinary  attack  of  con- 
vulsions. The  muscular  contractions  are  violent,  and  there  is  often 
frothing  at  the  mouth.  Gradually  the  muscles  of  respiration  relax,  air 
enters  the  lungs,  and  the  cyanosis  passes  off.  After  the  clonic  spasm 
has  continued  for  a  variable  time — from  two  or  three  minutes  to  half  an 
hour — the  muscular  contractions  become  less  and  less  frequent,  and 
finally  cease  altogether.  In  a  few  minutes  the  patient  may  regain  con- 
sciousness, look  vacantly  around,  and  in  a  dazed  way  perhaps  ask  what 
has  happened,  he  being  completely  oblivious  to  all  that  has  occurred. 
More  frequently,  however,  he  passes  at  once  into  a  deep  sleep,  which 
continues  for  an  hour  or  more,  but  from  which  he  can  be  aroused.  From 
this  he  usually  wakens  with  a  severe  headache,  which  may  continue  for 
several  hours.  After  this  he  often  feels  better  than  for  several  days 
preceding  the  attack.  During  the  seizure  the  temperature  may  be 
elevated  one  or  two  degrees,  but  rarely  more.  The  attack  may  be  fol- 
lowed by  a  slight  temporary  paresis,  or  aphasia,  hysterical  phenomena, 
vomiting,  and  intense  hunger.  In  very  rare  cases  the  urine  may  contain 
a  trace  of  sugar. 

Petit  Mai— The  minor  attacks  of  epilepsy  may  present  a  very  great 
variety  of  symptoms,  and  at  times  it  is  almost  impossible  to  decide  that 
these  are  epileptic,  except  from  their  periodical  occurrence.  They  pass 
under  the  names  of  "  spells,"  "  attacks  of  dizziness,"  "  fainting  turns," 


666  DISEASES  OF  THE  NERVOUS  SYSTEM. 

etc.  The  most  striking  thing  which  stamps  them  as  epileptic  is  the  loss 
of  consciousness,  and  this  may  be  of  short  duration,  sometimes  only 
momentary,  and  so  pass  unnoticed.  In  some  cases  it  is  absent  altogether. 
There  is  no  fall,  but  there  may  be  a  slight  dropping  of  the  head,  a  fixed 
stare  for  a  moment  or  two,  and  that  is  all.  This  may  or  may  not  be 
preceded  by  an  aura.  After  such  a  mild  attack  the  patient's  mind  may 
be  somewhat  confused,  and  he  may  do  or  say  strange  things.  All  sorts 
of  curious  acts  have  been  performed  in  an  automatic  way  by  patients  in 
the  condition  which  follows  an  attack  of  epilepsy,  which  may  perhaps 
be  regarded  as  part  of  the  attack.  In  rare  instances  even  acts  of  violence 
may  be  done. 

The  Mental  Condition  of  Epileptics. — A  careful  distinction  should 
be  made  between  cases  in  which  epilepsy  is  secondary  to  some  organic 
brain  disease,  and  the  mental  disturbances  seen  in  cases  of  idiopathic 
epilepsy.  The  children  who  are  the  subjects  of  the  latter  disease,  and 
who  are  perfectly  normal  mentally,  are  certainly  few.  All  degrees  of 
disturbance  may  be  seen,  from  those  who  are  simply  dull,  apathetic,  back- 
ward in  development,  and  uncontrollable  in  temper,  to  those  who  are 
melancholic,  idiotic,  and  even  maniacal.  The  earlier  in  childhood  epi- 
lepsy develops,  the  greater  is  usually  the  mental  disturbance  seen,  because 
of  the  effect  of  the  seizures  upon  the  brain  during  its  period  of  active 
growth. 

Symptomatic  Epilepsy. — This  occurs  most  frequently  in  children  as 
a  sequel  of  cerebral  palsy,  usually  with  hemiplegia,  and  it  may  follow 
either  the  congenital  or  acquired  form.  Epilepsy  may  come  on  at  any 
time  after  the  onset  of  the  paralysis — from  a  few  months  to  five  or  six 
years.  At  first  the  attacks  may  be  separated  by  long  intervals,  but  they 
gradually  become  more  frequent  as  time  passes.  The  convulsions  in 
post-hemiplegic  epilepsy  begin,  as  a  rule,  on  the  paralysed  side,  and  for 
a  long  time  they  may  be  confined  to  that  side ;  but  later  they  may  become 
general,  in  which  case  they  are  indistinguishable  from  attacks  of  idio- 
pathic epilepsy.  Severe  seizures  are  more  likely  to  be  seen  than  are  the 
mild  ones. 

Course  of  the  Disease. — In  most  cases  seizures  at  first  occur  at  long 
intervals,  of  perhaps  a  year,  but  later  they  become  more  and  more  fre- 
quent. Either  the  mild  or  the  severe  attacks  may  be  first  seen,  and  may 
remain  throughout  as  the  only  type  present,  or  they  may  be  associated 
in  the  same  case.  There  are  most  frequently  seen  occasional  major 
attacks  with  a  large  number  of  minor  ones.  The  interval  between  the 
epileptic  seizures  in  most  cases  is  from  two  to  four  weeks,  although  they 
may  be  of  daily  occurrence.  Sometimes  three  or  four  seizures  will  follow 
one  another  closely,  and  then  there  will  occur  a  long  interval  of  im- 
munity. The  seizures  may  come  on  either  during  sleep  or  in  the  waking 
hours,  and  in  some  cases  for  a  long  time  they  may  occur  only  in  sleep. 


EPILEPSY.  667 

Such  cases  present  peculiar  difficulties  in  diagnosis,  and  are  often  long 
unrecognised  as  epileptic.  The  general  liealtli  of  patients  may  be  quite 
normal. 

Death  rarely,  if  ever,  results  from  epilepsy,  except  from  some  accident 
at  the  time  of  the  seizures,  or  from  the  condition  known  as  the  status 
epilepticus;  in  this  the  attacks  come  on  with  great  frequency  and  sever- 
ity, the  patient  at  times  passing  rapidly  from  one  convulsion  into  an- 
other, the  temperature  rising  to  105°  or  106°  F.,  and  death  occurring 
either  from  exhaustion  or  in  coma. 

Diagnosis. — In  most  cases  there  is  little  difficulty  in  recognising  the 
major  attacks  when  they  occur  by  day.  Nocturnal  attacks  may  be  diag- 
nosticated by  the  cry,  the  biting  of  the  tongue,  blood  upon  the  pillow, 
sub-conjunctival  extravasation,  evacuation  of  the  bladder  or  rectum,  and 
the  severe  headache.  Minor  attacks  present  the  greatest  difficulties,  and 
a  positive  diagnosis  is  often  impossible  until  the  patient  has  been 
watched  for  a  long  time.  The  most  important  points  to  be  noted  are 
sudden  pallor,  dilatation  of  the  pupils,  temporary  loss  of  consciousness, 
or  simply  mental  confusion,  and  sometimes  the  evacuation  of  the  bladder. 

It  is  not  always  possible  to  distinguish  between  secondary  or  symp- 
tomatic epilepsy  and  the  idiopathic  or  hereditary  form,  particularly  if 
the  case  comes  under  observation  late  in  the  course  of  the  disease.  The 
points  which  go  to  establish  the  first  form  are :  that  the  convulsive  move- 
ments are  partial,  or  limited  to  one  side;  that  when  they  are  general, 
they  always  begin  in  the  same  part  of  the  body ;  or  that  there  is  a  history 
of  partial  or  unilateral  attacks  for  some  time  before  the  occurrence  of 
any  general  convulsions.  It  is  important  in  all  cases  to  examine  the 
patient  carefully  for  signs  of  an  old  hemiplegia,  the  symptoms  of  which 
may  be  so  slight  as  to  be  readily  overlooked.  A  marked  increase  in  the 
reflexes  of  one  side  is  quite  as  conclusive  evidence  as  is  a  distinct  weakness 
of  the  arm  or  leg.  In  idiopathic  epilepsy  some  of  the  stigmata  of  degen- 
eration are  usually  present.  The  sudden  development  of  epileptiform 
seizures  in  a  child  previously  healthy,  and  in  whom  there  is  no  hereditary 
history  of  the  disease,  should  always  arouse  the  suspicion  of  organic 
brain  diseases,  especially  tumour. 

Prognosis. — The  danger  to  life  in  epilepsy  is  very  slight.  Death  is 
generally  due  to  some  accident,  particularly  drow^ning,  at  the  time  of  a 
seizure.  The  tendency  to  spontaneous  cessation  of  the  attacks  is  small, 
while  the  tendency  to  recurrence  is  very  great. 

The  prognosis  in  any  given  case  depends  upon  the  cause  of  the  dis- 
ease and  the  duration  of  the  symptoms.  When  the  cause  can  be  re- 
moved, and  when  the  symptoms  have  lasted  less  than  a  year,  the 
prospects  of  permanent  cure  are  fairly  good.  This  is  particularly  true 
of  cases  in  which  the  epilepsy  clearly  depends  upon  gross  errors  in  diet, 
with  chronic  intestinal  indigestion.     If  an  hereditary-  tendency  to  the 


668  DISEASES  OF  THE  NERVOUS  SYSTEM. 

disease  is  marked,  if  the  epileptic  seizures  have  developed  apart  from  any 
adequate  exciting  cause,  and  if  they  have  continued  untreated  or  in 
spite  of  treatment  for  two  or  three  years,  the  symptoms  may  perhaps 
be  relieved,  but  there  is  little  prospect  of  permanent  cure.  In  the  cases 
also  whicli  are  due  to  local  irritation,  like  that  resulting  from  an  old 
meningeal  haemorrhage,  the  prognosis  is  invariably  bad,  and  only  tem- 
porary relief  is  to  be  expected.  A  few  cases  of  traumatic  epilepsy  have 
been  cured  and  many  have  teen  greatly  improved  by  a  surgical  operation. 

Treatment. — The  first  indication  is  to  remove  the  exciting  cause 
where  one  can  be  found.  Particular  attention  should  be  given  to  the 
digestive  organs.  The  most  hopeful  cases  are  those  associated  with  dis- 
turbances of  digestion,  especially  chronic  intestinal  indigestion  with 
constipation.  These  cases  are  to  be  managed  like  others  of  the  same  sort 
in  which  epileptic  attacks  are  not  present.  Meat  should  be  allowed  once 
a  day  and  in  moderate  quantity.  Milk  should  be  given,  diluted  if  neces- 
sary, also  buttermilk  and  kumyss.  Green  vegetables,  peas  and  beans, 
may  be  given  freely;  also  all  fresh  fruits.  Tea,  coffee,  and  alcohol  in 
every  form  must  be  absolutely  prohibited.  The  most  careful  attention 
should  be  given  to  the  bowels.  Under  no  circumstances  should  a  condi- 
tion of  chronic  constipation  be  neglected.  A  dose  of  calomel  once  a  week 
and  intestinal  irrigation  two  or  three  times  a  week  are  of  great  value 
in  many  cases.  When  the  symptoms  of  intestinal  putrefaction  are 
marked,  borax  is  at  times  of  value — two  grains  three  times  a  day  to 
a  child  of  five  years — or  salicylate  of  sodium,  salol,  or  the  benzoate  of 
sodium  may  be  given ;  the  dose  of  each  being  from  two  to  ten  grains, 
according  to  the  age  of  the  child,  after  each  meal.  The  general  hygiene 
of  the  patient  must  receive  careful  attention.  He  should  lead  a  simple, 
regular  life,  as  much  as  possible  out  of  doors,  away  from  all  sources 
of  excitement. 

All  the  foregoing  means  of  treatment  are  of  equal  importance  with 
the  use  of  special  drugs.  The  most  common  mistake  is  to  rely  only  upon 
drugs,  ignoring  the  other  measures  mentioned.  It  not  infrequently 
happens  that  drugs  are  without  any  effect  wlien  they  are  the  only  means 
of  treatment  employed,  whereas  in  conjunction  with  other  measures 
marked  improvement  is  seen. 

The  bromides  are  unquestionably  the  best  means  of  combating  the 
epileptic  habit.  Either  the  sodium  salt  alone  or  a  combination  of  the 
sodium  and  ammonium  or  strontium  bromide  is  to  be  preferred.  Tbe 
purpose  should  be  to  give  the  smallest  doses  which  will  control  the 
seizures.  Children  require  proportionately  larger  doses  than  .adults,  and 
in  most  cases  a  child  of  five  years  will  need  from  twenty-five  to  fifty 
grains  a  day.  The  method  of  administering  the  bromides  is  of  some 
importance.  The  larger  part  of  the  quantity  for  twenty-four  hours 
should  be  given  shortly  before  the  time  when  the  seizures  have  usually 


CHOREA.  669 

occurred;  in  the  interval  mnch  smaller  doses.  Tn  most  cases  it  is  desir- 
able to  give  a  full  dose  at  bedtime.  Bromides  should  always  he  given 
largely  diluted — in  from  six  to  eight  ounces  of  water. 

Cases  of  petit  rnal  are  especially  difficult  to  control.  For  such  there 
is  often  an  advantage  in  combining  belladonna  with  the  bromides.  In 
all  cases  the  treatment  must  be  continued  for  a  long  time  if  anything 
is  accomplished.  The  bromides  should  be  gradually  reduced  after  the 
attacks  are  controlled,  but  must  be  given  in  moderately  large  doses  for 
at  least  two  years  after  the  seizures  have  ceased.  Sometimes  the  combina- 
tion of  chloral  or  antipyrine  with  bromides  is  advantageous,  particularly 
if  the  latter  are  badly  borne  or  cause  an  annoying  amount  of  acne. 
Seguin  states  that  he  has  been  able  to  control  the  acne  in  many  cases  by 
giving  at  the  same  time  moderate  doses  of  arsenic. 

Cases  have  been  reported  of  very  striking  benefit  following  the  use 
of  calcium  lactate.  It  should  be  given  in  full  doses,  at  least  thirty  grains 
a  day  for  a  considerable  period. 

The  surgical  treatment  of  epilepsy  has  of  late  attracted  much  atten- 
tion. An  operation  is  to  be  considered  in  cases  in  which  the  paroxysms 
are  very  frequent  and  severe,  and  when  there  is  present  a  definite  local 
cause,  such  as  an  old  fracture  of  the  skull,  or  when  epilepsy  has  followed 
an  injury  to  the  head  even  without  fracture. 

The  education  of  epileptic  children  is  a  subject  of  great  difficulty  and 
is  often  neglected.  There  are  many  reasons  why  it  is  impracticable  to 
send  them  to  ordinary  schools,  and  it  is  therefore  very  desirable  that 
special  schools  and  colonies  for  them  should  be  established. 

The  Management  of  the  Attack. — Abortive  measures  are  sometimes 
successful  in  cases  with  a  distinct  aura,  the  most  reliable  being  the  inha- 
lation of  nitrite  of  amyl.  While  the  seizure  lasts,  the  patient  should  be 
prevented  from  injuring  himself.  The  clothing  should  be  loosened,  a 
spool  or  cork  should  be  placed  between  his  teeth  to  protect  the  tongue, 
but  no  effort  made  to  restrain  his  movements  unless  he  is  likely  to  do 
violence  to  himself.  An  epileptic  child  should  never  be  without  some 
companion. 

CHOREA. 

(Saint  Vitus's  Dance.) 
Chorea  is  a  functional  nervous  disease  characterised  by  aimless,  irreg- 
ular movements  of  any  or  all  the  voluntary  muscles.    Choreic  movements 
are  of  a  somewhat  spasmodic  character,  often  accompanied  by  an  ap- 
parent or  real  loss  of  power  in  the  groups  of  muscles  affected,  and  by 
•  a  mental  condition  of  extreme  irritability. 

Etiology. — Chorea  is  most  frequently  seen  between  the  ages  of  seven 
and  fourteen  years.  Of  146  cases,  6  were  under  five  years,  72  between 
five  and  nine  years,  and   68   between  ten   and  fourteen  years.     The 


670  DISEASES  OF  THE   NERVOUS  SYSTEM. 

youngest  case  of  which  I  have  record  was  that  of  a  child  four  years  old. 
It  is  extremely  rare  before  the  third  year,  although  it  may  occur  even 
in  infancy.  My  own  observations  coincide  with  those  of  nearly  all  writ- 
ers, that  the  disease  is  more  than  twice  as  frequent  in  females  as  in  males. 
While  chorea  may  be  seen  at  all  seasons,  it  is  much  more  frequent  in  the 
spring  months.  Of  717  attacks  studied  by  Lewis  (Philadelphia),  the 
largest  number  began  in  March,  and  the  next  largest  number  in  May; 
in  my  own  cases  May  stood  first. 

The  relation  of  chorea  to  rheumatism  is  of  much  importance.  The 
investigations  of  different  writers  have  given  results  which  are  somewhat 
contradictory.  Some  have  found  evidences  of  rheumatism  in  but  a  small 
proportion  of  the  cases — in  not  more  than  five  or  ten  per  cent — while 
the  statistics  of  others  have  placed  the  percentage  with  rheumatism  as 
high  as  fifty  or  even  sixty  per  cent.  The  question  hinges  largely  upon 
what  is  to  be  admitted  as  evidence  of  rheumatism  in  a  child;  if  cases  of 
acute  articular  inflammation  only,  then  the  number  will  be  very  small ;  if 
subacute  cases  with  joint  swellings  are  included,  the  proportion  will  be 
considerably  larger ;  while  if  we  admit  cases  of  acute  endocarditis  without 
articular  symptoms,  and  those  of  articular  pains  and  joint  stiffness  but 
without  swelling,  the  proportion  will  be  very  much  increased.  My  own 
belief  is  that  there  is  a  very  close  connection  between  chorea  and  the 
rheumatic  diathesis  as  manifested  by  all  the  symptoms  above  noted,  and 
accompanied  by  a  family  history  of  rheumatism.  There  seems  to  be  a  large 
group  of  cases,  therefore,  which  may  be  classed  distinctly  as  rheumatic. 
There  are,  however,  a  few  others  in  which  no  such  element  can  be  found. 

My  former  associate.  Dr.  F.  M.  Crandall,  has  analysed  146  cases  of 
chorea  treated  by  us  in  an  out-patient  clinic  and  in  private  practice,  with 
the  following  results:  Of  111  cases  in  which  the  question  of  rheumatism 
was  investigated  there  was  a  definite  history  of  it  in  63.  In  41,  rheu- 
matism occurred  before  the  chorea;  in  13,  the  first  evidence  of  rheu- 
matism was  coincident  with  the  chorea;  and  in  9  it  first  occurred  subse- 
quently to  the  chorea,  usually  within  three  months.  In  about  one-third 
of  the  cases,  attacks  of  rheumatism  occurred  during  or  subsequent  to  the 
chorea  as  well  as  before  it.  It  may  then  be  stated  that  previous  rheu- 
matism was  evident  in  37  per  cent,  concurrent  rheumatism  in  2-4  per 
cent,  and  subsequent  rheumatism  in  15  per  cent  of  the  cases.  Excluding 
cases  mentioned  twice,  and  also  all  those  in  which  there  was  a  history 
only  of  "  growing  pains,"  there  was  evidence  of  articular  rheumatism  in 
56.7  per  cent  of  the  cases.  Many  of  these  patients  have  now  been  under 
observation  for  several  years,  and  it  has  been  interesting  to  see,  as  time 
has  passed,  how  the  evidences  of  rheumatism  have  multiplied  the  longer 
the  cases  have  been  followed. 

In  the  above  statistics  only  articular  symptoms  have  been  accepted 
as  evidence  of  rheumatism.    If  the  cases  of  endocarditis  without  articular 


CHOREA.  671 

symptoms  were  included,  as  I  think  they  might  fairly  he,  it  would  raise 
the  proportion  of  rheumatic  cases  still  higher.  Tlie  great  proportion 
of  cardiac  murmurs  persisting  after  chorea,  if  not  all  of  theni,  should, 
I  believe,  be  classed  as  rheumatic,  even  if  no  articular  symptoms  have 
been  present. 

Overpressure  in  school  is  often  an  important  element  in  the  produc- 
tion of  chorea.  Anaemia,  if  not  an  essential  factor,  is  certainly  a  very 
important  one,  and  the  great  proportion  of  cases  present  very  distinct 
evidences  of  it.  Chorea  may  develop  as  a  sequel  of  any  of  the  infectious 
diseases,  more  particularly  scarlet  and  typhoid  fevers.  Among  the  reflex 
causes  may  be  mentioned  phimosis,  either  lumbricoids  or  pinworms, 
dela3^ed  menstruation,  and  ocular  defects,  although  the  latter  more  fre- 
quently cause  a  local  spasm  of  the  muscles  of  the  eyes,  which  can  hardly 
be  considered  choreic.  Hereditary  influence  is  of  considerable  importance 
in  the  production  of  chorea.  It  is  much  more  frequent  in  children  of 
neurotic  families,  and  very  often  several  successive  generations,  or  sev- 
eral children  in  the  same  family,  may  suffer  from  the  disease. 

The  exciting  cause  of  chorea  in  a  certain  proportion  of  cases  is  fright ; 
occasionally  it  arises  from  imitation,  and  the  disease  has  been  known  to 
occur  epidemically  in  institutions. 

The  role  of  bacteria  in  the  production  of  rheumatic  chorea  is  still 
undecided.  The  organism  which  Poynton  and  Paine  have  described 
as  the  cause  of  acute  articular  rheumatism  has  been  found  in  the 
meninges  of  the  brain  in  a  few  fatal  cases  of  chorea. 

Pathology. — The  exact  pathology  of  chorea  is  at  the  present  time  not 
settled.  The  seat  of  the  morbid  process  is  undoubtedly  the  central 
nervous  system,  probably  the  motor  areas  of  the  cortex.  The  cases  asso- 
ciated with  rheumatism  are  now  generally  regarded  as  of  infectious 
origin.  In  some  severe  cases  which  were  fatal,  owing  to  association  with 
acute  endocarditis,  capillary  emboli  have  been  found  in  the  brain.  How- 
ever, it  is  by  no  means  established  that  this  is  the  condition  present  in 
most  of  the  rheumatic  cases.  The  fact  that  in  the  great  majority  of  such 
cases  complete  recovery  occurs  in  the  course  of  a  few  weeks  or  months, 
speaks  strongly  against  any  important  structural  change  in  the  nervous 
centres.  In  cases  not  rheumatic,  the  most  probable  explanation  of  the 
symptoms  is  to  be  found  in  vascular  changes,  having  their  origin  in 
disturbances  of  nutrition. 

Symptoms. — An  attack  of  chorea  generally  comes  on  gradually.  At 
first  the  child  may  be  considered  simply  as  unusually  nervous;  if  at 
school,  there  may  be  noticed  a  difficulty  in  writing,  drawing,  or  in  using 
the  hands  for  other  delicate  operations.  At  home,  the  child  is  con-, 
tinually  dropping  things,  has  difficulty  in  feeding  himself,  sometimes  in 
buttoning  his  clothes,  and  very  frequently  he  is  not  brought  to  the 
physician  until  the  symptoms  have  lasted  a^  week  or  two.     Sometimes 


672  DISEASES  OF  THE   NERVOUS  SYSTEM. 

the  legs  are  first  affected,  and  a  history  is  given  of  frequent  falls,  a 
stumbling  gait,  difficulty  in  going  upstairs,  etc.  At  other  times  the 
spasm  is  first  seen  in  the  facial  muscles,  with  disturbance  of  articulation, 
twitchings  of  the  eye  muscles,  and  the  child  may  be  punished  for  making 
grimaces.  In  most  cases  the  spasmodic  movements  soon  extend  to  all 
parts  of  the  body.  They  remain  limited  to  one  side  of  the  body  (hemi- 
chorea)  in  about  one-third  of  the  cases.  When  fully  developed,  the  move- 
ments of  chorea  are  quite  unmistakable.  They  are  irregular,  jerking, 
spasmodic,  never  rhythmical,  rarely  symmetrical,  and  vary  in  intensity 
from  an  occasional  muscular  contraction  to  almost  constant  motion.  The 
movements  are  not  under  the  control  of  the  patient's  will,  and  are  usu- 
ally intensified  by  efforts  to  repress  them.  They  are  increased  by  excite- 
ment, embarrassment,  or  fatigue,  but  do  not  continue  during  sleep. 

Very  often  there  is  weakness  of  the  affected  muscles,  which  may  be 
so  great  as  to  lead  to  the  suspicion  that  actual  paralysis  exists.  Xot 
infrequently  I  have  had  patients  brought  to  the  clinic  for  supposed 
paralysis,  either  of  one  extremity  or  of  one  side  of  the  body,  where  the 
choreic  movements  have  not  been  severe  enough  to  attract  the  attention 
of  the  mother.  This  paralysis  usually  disappears  in  the  course  of  a 
few  weeks. 

In  severe  forms  of  chorea  the  patient  may  be  unable  to  walk,  to  speak 
intelligibly  or  even  to  sit  up  in  bed.  Control  of  the  bladder  or  rectum 
may  also  be  lost.  The  symptoms  may  be  so  intense  as  even  to  endanger 
life.  Such  cases,  however,  are  dangerous,  not  from  the  choreic  move- 
ments, but  from  the  acute  endocarditis  with  which  they  are  frequently 
associated. 

The  mental  condition  of  choreic  patients  is  one  of  marked  irritability. 
They  are  fretful,  emotional,  easily  provoked  to  tears  or  laughter,  and 
difficult  to  control.  In  extreme  cases  a  mental  disturbance  bordering 
upon  acute  mania  has  been  observed.  In  other  cases  the  facial  expression 
and  manner  of  speech  strongly  suggest  beginning  imbecility.  All  degrees 
of  speech  disturbances  are  seen  from  the  slight  difficulty  in  articulation 
due  to  inability  properly  to  control  the  movements  of  the  tongue  and  lips, 
to  a  condition  in  which  speech  is  almost  impossible.  In  severe  cases 
speech  may  be  temporarily  lost. 

Cardiac  murmurs  are  frequent  in  chorea.  Some  of  these  are  of 
anaemic  origin,  some  possibly  are  due  to  chorea  of  the  cardiac  muscle  it- 
self— although  this  is  a  matter  of  some  uncertainty — but  a  large  nunil)er, 
probably  the  majorit}-,  are  due  to  concurrent  endocarditis,  as  is  sliown 
by  the  fact  that  they  are  permanent,  and  are  followed  by  all  the  signs 
of  organic  heart  disease.  During  every  attack  the  heart  should  be 
closely  watched,  especially  in  children  in  whom  there  is  a  strong  pre- 
disposition to  rheumatism. 

The  general  condition   of  choreic  patients   is   usually   much   below 


CHOREA.  673 

normal.  They  arc  anaemic;  the  appetite  is  poor,  often  capricious;  they 
sleep  very  badly;  they  suffer  frequently  from  headaches;  they  are  easily 
fatigued  by  slight  muscular  exertion;  and  in  short  they  have  all  the 
symptoms  of  a  greatly  disturbed  nutrition. 

Course- and  Duration. — The  ordinary  form  of  chorea  tends  to  spon- 
taneous recovery  in  from  six  to  ten  weeks.  Exceptionally  it  may  last  for 
three  or  four  months.  In  a  small  number  of  cases  the  disease  may  be- 
come chronic  and  continue  indefinitely.  Certain  forms  of  local  spasm, 
particularly  choreiform  movements  of  tlie  muscles  of  tlie  face,  eyes,  or 
neck,  may  be  permanent.  In  any  case  of  chorea  wliicli  lasts  longer  than 
the  usual  time,  the  patient  should  be  carefully  examined  for  some  cause 
of  peripheral  irritation.  The  tendency  to  relapses  and  second  attacks  is 
very  marked.  Later  attacks  are  likely  to  occvir  in  the  spring  succeed- 
ing the  first  illness,  and  in  a  small  number  of  patients  attacks  may  come 
every  year  for  four  or  five  years. 

Diagnosis. — There  is  little  difficulty  in  recognising  chorea  from  the 
sudden,  irregular,  spasmodic  contraction  of  the  nmscles  coming  on  under 
the  circumstances  indicated.  No  other  movements  of  childhood  are 
likely  to  be  confounded  with  it.  The  form  of  chorea  following  hemi- 
plegia is  usually  more  athetoid  than  choreic,  yet  at  times  it  closely  simu- 
lates ordinary  chorea.  The  difficulty  in  distinguishing  between  the  two 
is  often  increased  by  the  fact  that  tbe  weakness  of  simple  chorea  may,  if 
unilateral,  closely  simulate  hemiplegia.  The  existence  of  rigidity,  con- 
tractions, and  increased  reflexes  belongs  exclusively  to  hemiplegic  cases, 
and  these  will  usually  suffice  to  clear  up  all  doubt  with  reference  to  the 
diagnosis. 

Prognosis. — As  a  rule,  this  is  favourable,  and  complete  recovery  can 
usually  be  predicted,  the  exceptions  being  few  in  number.  Parents  should 
always  be  warned  of  the  tendency  of  the  disease  to  return  in  succeeding 
years,  and  the  fact  should  be  stated  that  in  a  certain  proportion  of  cases 
the  disease  may  be  permanent.  The  prognosis  of  the  cardiac  murmurs 
occurring  in  chorea  should  always  be  guarded,  although  some  of  these 
are  functional  and  disappear  with  recovery  from  the  chorea;  but  the 
number  of  those  which  do  not  disappear  is  sufficiently  large  to  make  one 
always  apprehensive  as  to  the  ultimate  result.  Acute  chorea  accompanied 
with  endocarditis  may  be  fatal;  a  number  of  such  cases  are  on  record 
in  which  there  was  no  other  evidence  of  rheumatism. 

Treatment. — The  general  management  of  the  case  is  equally  im- 
portant with  the  administration  of  drugs.  A  child  with  chorea  should  at 
once  be  taken  from  school,  and  should  never  be  subjected  to  punishment 
or  to  ridicule  on  account  of  the  movements.  Special  attention  should 
be  given  to  the  patient's  diet  and  general  nutrition.  Tonics,  especially 
iron,  are  indicated  in  most  cases.  The  food  should  be  simple  and  nutri- 
tious, and  all  stimulants,  particularly  tea  and  coffee,  should  be  absolutely 
44 


674  DISEASES  OF  THE   NERVOUS   SYSTEM. 

projiibited.  While  fresh  air  is  desirable,  exercise  should  be  prescribed 
with  great  caution  and  its  effect  should  be  carefully  watched.  A  cer- 
tain amount  of  moral  restraint  is  indispensable ;  tlms  it  often  happens 
that  choreic  patients  do  very  badly  at  liome  where  they  are  indulged 
and  receive  sympathy,  while  in  a  hospital,  where  they  are  under 
restraint  and  made  to  control  themselves,  they  begin  to  improve  im- 
mediately. In  all  severe  cases  the  "  rest  treatment  "  should  be  employed. 
It  is  equally  beneficial  in  the  milder  ones;  the  patient  is  put  to  bed, 
and  complete  mental  and  physical  rest  secured.  This  may  be  combined 
with  gentle  massage  for  fifteen  or  twenty  minutes  a  day.  The  daily 
use  of  warm  baths,  either  alone  or  in  conjunction  with  massage,  is  de- 
cidedly beneficial.  In  other  cases  the  regular  use  of  cold  douches  is 
of  value. 

With  reference  to  the  use  of  drugs,  it  is  advisable  to  separate  from 
other  cases  those  in  wiiich  the  connection  with  rheumatism  is  very  close. 
In  the  rlieumatic  cases,  salicylate  of  soda  is  often  efficient,  while  the 
drugs  usually  employed  may  be  absolutely  without  effect.  In  the  non- 
rheumatic  cases,  arsenic  is  undoubtedly  a  valuable  remedy.  Beginning 
with  four  drops  of  Fowler's  solution  three  times  a  day  for  a  child  of 
eight  years,  the  daily  quantity  may  be  increased  by  one  drop  every  two 
or  three  days  until  eight  drops  are  given  at  each  dose.  One  should  stop 
short  of  this  if  digestion  is  disturbed,  or  there  is  puffiness  of  the  face 
or  albumin  in  the  urine.  Arsenic  should  always  be  given  after  meals, 
and  largely  diluted.  The  possibility  of  arsenical  poisoning  should  be 
remembered,  although  it  is  rare.  Semple  has  reported  a  case  in  which 
multiple  neuritis  and  general  pigmentation  of  the  skin  occurred  after 
four  weeks'  administration  of  the  drug. 

Antipyrine  and  strychnine  sometimes  succeed  where  arsenic  fails. 
From  fifteen  to  twenty  grains  of  antipyrine  should  be  given  daily  in 
divided  doses  to  a  child  of  eight  years.  To  a  child  of  eight  years  strych- 
nine should  be  given  in  doses  of  ^V  of  ^  grain  three  times  a  day,  the 
dose  being  gradually  increased  until  double  this  quantity  is  given. 
Acute  chorea  of  great  severity  may  require  opiuiti,  or  bromides  and 
chloral. 

In  estimating  the  value  of  drugs  in  the  treatment  of  chorea,  the  natu- 
ral course  of  the  disease  should  be  kept  in  mind,  since  those  drugs  which 
are  taken  after  the  third  or  fourth  week  are  much  more  likely  to  be 
thought  beneficial  than  those  used  in  the  early  period  of  tlie  attack. 

Chorea  has  a  strong  tendency  to  recur,  especially  in  the  spring 
months.  Children  who  have  had  one  attack  should  be  closely  watched, 
particularly  with  reference  to  their  work  in  school.  They  should  not  be 
crowded  in  their  studies,  they  should  have  long  vacations,  and  the  nerv- 
ous system  should  not  be  put  upon  any.  severe  tension  for  a  long  time. 


OTHER  SPASMODIC   AFFECTIONS.  675 

OTHER  SPASMODIC   AFFECTIONS. 

Habit  Spasm. — This  term  is  used  to  (lescril)e  certain  spasmodic  mus- 
cular movements  which  at  first  are  only  occasionally  noticed,  but  which 
may  persist  until  they  become  habitual  and  almost  entirely  involuntary. 
The  movements  usually  affect  the  muscles  of  the  face,  tnit  they  may  be 
seen  in  almost  any  part  of  the  body.  The  most  frequent  varieties  consist 
of  blinking  or  sudden  frowning,  raising  the  eyebrows,  or  some  peculiar 
grimace.  At  other  times  there  is  sudden  twisting  of  the  head,  shrugging 
of  the  shoulders,  or  jerking  of  the  hands.  It  is  not  often  seen  in  the 
lower  extremities,  but  the  muscles  of  respiration  are  quite  frequently 
affected.  There  may  be  a  half-sigh,  a  sort  of  sob,  or  a  peculiar  dry, 
laryngeal  cough. 

These  movements  are  at  first  infrequent :  ])nt  as  tlie  habit  l)ecomes 
more  firmly  fixed  the, spasm  recurs  every  few  minutes,  and  in  severe 
cases  it  may  be  almost  continuous.  The  form  of  spasm  is  not  always 
the  same;  one  may  disappear  and  another  take  its  place.  The  condition 
may  last  for  months  or  years,  and  it  may  even  be  permanent. 

Habit  spasm  is  really  little  more  than  exaggerated  nervousness  con- 
tinuing in  some  definite  form  until  by  repetition  a  fixed  habit  is  estab- 
lished. It  is  different  in  cause,  course,  prognosis,  and  treatment  from 
chorea,  with  which,  however,  -it  is  often  confounded. 

The  causes  are  those  of  neuroses  in  general.  In  tlie  beginning,  at 
least,  the  general  health  is  usually  below  the  normal.  The  patients 
are  nervous  children  of  neurotic  antecedents.  There  may  be  a  history 
of  some  definite  exciting  cause,  such  as  illness  or  overwork  in  school. 
There  may  be  some  local  cause  of  which  the  spasm  is  merely  a  reflex. 
Common  ones  affecting  the  facial  muscles  are  visual  defects,  adenoids, 
and  carious  teeth. 

Habit  spasm  is  to  be  differentiated  from  chorea ;  this  is  usually  easy, 
from  the  limitation  of  the  movements  to  one  part  or  group  of  muscles 
and  from  the  duration  of  the  disease. 

Treatment  is  quite  unsatisfactory  after  the  habit  has  become  fixed, 
hence  it  is  of  very  great  importance  that  it  should  be  arrested  at  the 
earliest  possible  age.  Punishments  are  of  no  avail,  and  usually  aggravate 
the  condition.  Eewards  are  much  more  effectual.  The  general  health 
should  receive  attention  and  nerve  tonics  should  be  given,  especially 
strychnine. 

Athetosis  and  Athetoid  Movements. — These  terms,  introduced  by  Ham- 
mond, are  used  to  doscril)e  a  chronic  form  of  spasm  usually  seen  in  the 
hand,  but  sometimes  also  in  the  foot,  and  even  the  face.  It  may  affect 
both  sides,  but  in  most  cases  it  is  unilateral.  The  movement  is  slow, 
irregular,  and  incoordinate — a  sort  of  "  mobile  spasm,"  it  has  been 
called — and  there  may  be  associated  a  certain  amount  of  muscular  rigid- 


676  DISEASES  OF  THE   NERVOUS  SYSTEM. 

ity.  Such  movements  rarely  occur  in  persons  apparently  healthy,  hut 
are  usually  seen  as  a  sequel  of  cerebral  palsies,  generally  hemiplegia. 
Becovery  from  the  paralysis  may  be  so  nearly  complete  that  tlie  athetoid 
movements  are  looked  upon  as  primary.  In  some  cases  the  movements 
are  more  rapid  and  somewhat  resemble  those  of  chcrrea,  the  condition 
being  sometimes  classed  as  post-hemiplegic  chorea.  Athetosis  is  not  in- 
fluenced by  treatment. 

Rotary  and  Nodding  Spasm  of  the  Head. — These  are  rare  forms  of 
irregular  movements  usually  observed  in  infancy.  The  condition  was 
described  long  ago  by  Henoch.  The  most  frequent  is  the  rotary  spasm, 
which  consists  in  a  side-to-side  oscillation  of  the  head,  which  may  be 
slow  or  rapid,  and  in  some  cases  is  almost  continuous.  Some  children 
have  at  times  the  nodding  spasm  also,  and  in  others  this  is  the  only 
movement  seen.  Nystagmus  is  frequently  associated,  and  may  affect  one 
or  both  ej'es.  In  a  few  of  the  reported  cases  convergent  strabismus  was 
present. 

The  causes  of  the  condition  are  extremely  obscure.  It  is  usually  seen 
in  infancy  between  the  third  and  eighteenth  months,  and,  like  most  nerv- 
ous symptoms  of  this  period,  has  been  ascribed  to  dentition,  but  without 
any  special  reason.  In  three  of  the  cases  reported  by  Hadden,  it  followed 
an  injury  to  the  head,  and  might  perhaps  be  regarded  as  a  result  of  cere- 
bral concussion. 

As  a  rule,  the  condition  lasts  for  several  months  and  improves,  recov- 
ery generally  taking  place.  The  prognosis  is  therefore  usually  favour- 
able. 

Nystagmus. — This  term  is  applied  to  rhythmical,  involuntary,  oscil- 
latory movements  usually  of  both  e3'es.  They  are  caused  by  the  alter- 
nate contraction  of  opposing  muscles.  Nystagmus  may  be  either  vertical 
or  horizontal.  It  is  most  often  seen  in  infants  a  few  months  old,  and  is 
a  symptom  of  irritation  which  may  be  general  or  local.  In  some  cases 
the  movement  is  almost  continuous,  occurring  even  in  sleep;  in  others, 
it  is  only  noticed  at  times  of  special  excitement. 

The  etiology  of  nystagmus  is  obscure,  and  it  may  occur  in  quite  a 
variety  of  conditions — sometimes  referable  to  the  eye,  at  other  times  to 
the  central  nervous  system.  On  the  part  of  the  eye,  nystagmus  may  be 
due  to  blindness  from  any  cause,  to  congenital  cataract,  corneal  opacity, 
disease  of  the  choroid  or  retina,  or  to  errors  of  refraction.  It  may  be 
seen  in  almost  any  organic  disease  of  the  nervous  system,  both  with  focal 
and  diffuse  lesions,  especially  in  chronic  hydrocephalus,  insular  sclerosis, 
tuberculous  meningitis,  and  in  diseases  in  which  sight  is  impaired. 
Nystagmus  may  be  of  reflex  origin,  as  in  a  case  recently  occurring  in  the 
Babies'  Hospital,  where  an  infant  with  a  severe  diarrhoea  had  repeated  at- 
tacks, which  disappeared  each  time  after  intestinal  irrigation.  While  it  is 
of  no  importance  as  a  localising  symptom^  nystagmus  usually  indicates 


OTHER  SPASMODIC  AFFECTIONS.  677 

something  more  than  functional  disturbance.  An  exception  to  this  may 
perhaps  be  made  when  it  follows  cerebral  concussion.  In  such  cases  it  is 
usually  temporary,  disappearing  in  a  few  days  or  weeks.  Under  most 
other  conditions  it  may  continue  indefinitely. 

The  condition  of  the  eyes  should  be  investigated  in  every  case  of 
nystagmus;  it  is  only  when  the  cause  is  here,  and  can  be  removed,  that 
habitual  nystagmus  is  amenable  to  treatment. 

Hiccough  (Singultus).— This  is  a  spasm  of  the  diaphragm  which  is 
usually  seen  in  young  infants.  In  them  it  is  in  most  cases  due  to  some 
irritation  in  the  stomach.  It  is  seen  after  eating,  and  may  depend  upon 
overfilling  of  the  stomach  with  food,  swallowing  of  air,  etc.  In  other 
cases  it  has  no  relation  to  the  taking  of  food,  and  is  to  be  regarded  as 
a  form  of  reflex  spasm,  which  may  occur  from  a  variety  of  causes,  such  as 
cold  feet,  chilling  of  the  surface  during  the  bath,  or  suddenly  taking  an 
infant  from  a  warm  bed  into  a  cold  room.  In  cases  like  the  above, 
hiccough,  though  sometimes  annoying,  is  of  little  importance.  It  may 
be  associated  with  gastric  indigestion,  with  intestinal  flatulence  or  inflam- 
mation, with  peritonitis  or  intestinal  obstruction.  With  the  last  two 
conditions  it  is  always  an  unfavourable  symptom.  In  older  children 
hiccough  sometimes  occurs  as  a  pure  neurosis. 

The  object  of  treatment  is  to  remove  the  cause.  In  infants  this  is 
to  aid  in  the  expulsion  of  the  gas  from  the  stomach  by  manipulation,  by 
position,  or  the  other  means  useful  in  gastric  colic.  When  it  is  a  nervous 
symptom  only,  it  may  be  arrested  by  holding  the  breath,  by  prolonged 
forced  expiration,  as  in  blowing  a  trumpet,  and  sometimes  it  may  be  re- 
lieved by  drugs  which  control  muscular  spasm,  e.  g.,  antipyrine  or  chloral. 

Thomsen's  Disease  (Congenital  Myotonia). — This  rare  disease  is  usu- 
ally congenital.  It  may  occur  in  several  members  of  the  same  family, 
and  is  often  hereditary.  The  characteristic  symptoms  are  a  peculiar 
rigidity  of  the  muscles  which  is  observed  when  they  are  first  brought 
into  action  after  repose.  This  rigidity  is  spasmodic,  and  usually  con- 
tinues but  a  few  moments.  It  may  recur  when  voluntary  movements 
are  again  attempted.  If,  however,  muscular  effort  is  persisted  in,  it 
soon  passes  off.  It  is  increased  by  apprehension,  excitement,  or  cold,  and 
by  observation.  The  legs  are  most  frequently  affected,  the  condition 
being  often  noticed  when  the  patient  starts  to  walk ;  any  of  the  voluntary 
muscles,  however,  may  be  involved.  It  may  be  greater  upon  one  side  of 
the  body  than  upon  the  other.  The  muscles  are  abnormally  sensitive 
to  mechanical  stimulation,  and  often  to  galvanism.  They  are  above 
normal  size,  and  the  fibres  themselves  are  enlarged. 

The  pathology  of  this  disease  is,  according  to  Gowers,  an  altered 
functional  condition  of  the  muscle  fibres,  and  an  abnormal  functional 
state  of  the  nerve  cells  of  the  cord  and  the  cortex.  It  is  incurable, 
although  the  symptoms  may  be  improved  by  active  muscular  exercise. 


678 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


Cervical  Opisthotonus. — This  is  usually  a  symptom  of  disease  at  the 
base  of  the  brain,  occurring  with  cerebro-spinal,  tuberculous,  and  chronic 
basilar  meningitis,  sometimes  with  tumours  of  the  posterior  fossa  of  the 
skull.  However,  in  certain  cases  it  occurs  as  a  form  of  reflex  spasm, 
particularly  in  young  infants  who  are  suffering  from  diarrhceal  diseases 
or  marasnms.  In  these  cases  it  may  last  for  days  or  weeks.  The  de- 
formity is  produced  by  a  contraction  of  tlie  superior  fibres  of  the  trapezius 
and  by  the  posterior  group  of  cervical  muscles. 

Torticollis — Wry-neck. — Torticollis  is  usually  produced  by  a  tonic 
spasm  of  one  sterno-mastoid  nuiscle,  with  wliich  may  be  associated  spasm 
of  the  posterior  cervical  muscles,  including  the  trapezius.  In  recent 
cases  there  is  simply  a  condition  of  muscular  spasm ;  in  those  of  long 
standing  there  may  be  permanent  shortening  of  the  affected  muscle, 
atrophy,  and  partial  paralysis.  A  somewhat  similar  deformity  may  be 
caused  by  cicatricial  contraction  of  the  tissues  of  the  neck  following 
burns. 

The  deformity  varies  somewhat  according  as  the  sterno-mastoid 
muscle  is  alone  affected,  or  the  posterior  muscles  also,  and  as  to  which 

predominates.  In  simple  ster- 
no-mastoid spasm  the  iiead  is 
inclined  to  the  affected  side  and 
rotated  toward  the  opposite 
side;  the  chin  is  raised,  and 
the  ear  approaches  the  clavicle. 
When  otiier  muscles  are  in- 
volved the  deformity  is  modi- 
fied. If  the  tra])ezius  is  af- 
fected (Fig.  105)  there  is  less 
rotation  of  the  head,  but  it  is 
drawn  to  the  affected  side  and 
somewhat  backward,  while  the 
shoulder  is  raised  and  the  spine 
curved.  Both  of  these  symp- 
toms may  be  seen  to  a  slight 
degree  in  almost  any  marked 
case  of  sterno-mastoid  spasm. 
Sometimes  the  spasm  of  tlie 
posterior  muscles  affects  both 
sides;  the  head  is  then  drawn 
backward  and  lield  rigidly  but  without  rotation.  In  most  of  the  recent 
cases  the  deformity  can  be  partially  or  entirely  overcome  by  passive  force ; 
but  after  a  time  this  is  impossible,  owing  to  muscular  shortening.  In 
recent  cases  localised  pain  and  tenderness  are  also  frequently  present, 
and  sometimes  they  are  severe. 


Fig.  105.  —  Spasmodic  Torticollis.  Trape- 
zius and  sterno-mastoid  of  the  left  side  arie 
affected. 


OTHER   SPASMODIC   AFFECTIONS.  679 

Etiology. — Spasmodic*  torticollis  may  he  produced  by  anything  caus- 
ing irritation  of  the  trunk  or  the  branches  of  the  spinal  accessory  nerve; 
the  source  may  be  in  the  spinal  canal,  in  the  cranium,  along  the  course 
of  the  nerve  trunk,  or  of  any  of  its  peripheral  fibres. 

Torticollis  may  be  congenital  or  ac(iuiri'(l.  licgarding  the  cause  of 
congenital  torticollis  there  is  some  dis])ute.  Such  cases  have  often  been 
attributed  to  the  contraction  resulting  from  luvmatoma  of  the  sterno- 
mastoid.  It  is  my  belief  that  this  is  rarely  if  ever  the  case.  While  it 
is  possible  that  the  deformity  is  sometimes  the  conseipience  of  injury 
received  during  delivery,  the  cause  of  most  of  the  congenital  cases  goes 
back  to  conditions  existing  before  birth.  It  may  be  compared  to  club- 
foot, and  may  be  due  to  a  faulty  position  of  tlic  child  //;  iitero,  or  it  may 
come  from  more  serious  conditions,  such  as  malformations,  or  unequal 
development  of  the  two  sides  of  the  body. 

A  frequent  cause  in  the  acquired  cases  is  irritation  of  the  spinal  ac- 
cessory nerve  by  an  enlarged  cervical  lymph  gland ;  such  is  the  usual 
etiology  of  torticollis  following  scarlet  fever,  measles,  or  diphtheria.  I 
have  seen  it  in  the  early  stage  of  quinsy,  and  it  may  occur  in  cellulitis 
of  the  neck.  A  cause  which  the  physician  should  always  have  in  mind  is 
cervical  Pott's  disease;  torticollis  may  be  tlie  earliest,  and  for  several 
weeks  sometimes  almost  the  only,  objective  symptom  of  this  disease. 
Torticollis  coming  on  acutely  is  most  frequently  due  to  cold  (rheu- 
matism?), occasionally  to  malaria.  I  have  notes  of  eight  cases  clearly 
traceable  to  malaria,  and  have  seen  at  least  a  dozen  others.  In  the  so- 
called  rheumatic  torticollis,  muscular  pain  and  soreness  are  rather  more 
prominent  than  in  the  other  forms. 

Prognosis. — The  result  in  a  case  of  torticollis  depends  upon  the 
cause,  the  severity,  and  the  duration  of  the  deformity.  Most  of  the 
acute  cases  recover,  under  appropriate  treatment,  in  the  course  of  a 
few  weeks,  sometimes  in  a  few  days.  The  congenital  cases  with  slight 
deformity  are  usually  amenable  to  mechanical  or  postural  treatment  if 
I'egun  early.  There  is,  however,  in  most  of  the  other  varieties  a  dis- 
position of  the  deformity,  if  untreated,  to  persist,  and  even  to  increase. 
If  it  has  lasted  several  months  the  probabilities  of  spontaneous  recovery 
or  even  of  improvement  are  small. 

Treatment. — The  first  indication  is  to  remove  or  treat  the  cause 
when  one  can  be  found.  Malarial  cases  require  quinine;  rheumatic 
cases  are  benefited  by  rest  in  bed,  hot  applications,  counter-irritation, 
friction,  and  sometimes  by  anti-rheumatic  remedies.  Cases  which  have 
lasted  a  month  usually  require  some  orthopedic  head-support,  and  those 
which  have  lasted  six  months  or  more  are  rarely  cured  without  a  surgi- 
cal operation.  This  may  be  either  a  subcutaneous  tenotomy  or  myotomy 
of  the  sterno-mastoid,  or  an  open  incision.  Whitman  gives  the  result 
of  thirty-two  hospital  cases,  as  follows:  In  seventeen  in  which  the  de- 


680  DISEASES  OF  THE   NERVOUS  SYSTEM. 

formity  had  lasted  less  than  six  months,  ten  were  cured,  the  average 
duration  of  treatment  being  three  months;  four  were  improved,  and 
three  not  improved,  the  average  duration  of  treatment  in  these  cases 
being  eleven  months.  Of  fifteen  cases  in  which  the  deformity  had 
lasted  over  six  months,  none  were  cured  and  only  six  improved,  after  an 
average  of  about  eight  months'  treatment.  In  the  foregoing  series  of 
cases  the  treatment  consisted  mainly  in  the  use  of  orthopsedic  apparatus ; 
later  results  from  incision  have  been  considerably  more  favourable.  But 
these  figures  show  how  serious  a  matter  is  an  old  case  of  torticollis,  and 
emphasise  the  importance  of  resorting  to  radical  measures  early  in  the 
disease. 

HYSTERIA. 

This  is  not  a  disease  of  childhood,  but  one  which  is  occasionally 
seen  in  early  life.  All  that  will  be  attempted  in  this  chapter  is  to  point 
out  the  most  common  manifestations  of  hysteria  when  it  occurs  in  chil- 
dren.   After  puberty  it  is  essentially  the  same  as  in  adults. 

Etiology. — Hysteria  is  very  rare  before  the  seventh  or  eighth  year, 
and  most  of  the  cases  seen  in  children  occur  after  the  tenth  year.  As  to 
sex,  there  is  no  such  predominance  of  females  as  in  later  life,  although 
even  in  childhood  they  are  more  frequently  affected  than  males.  Hered- 
itary influences  play  an  important  part  in  the  production  of  this  disease. 
It  is  seen  in  children  who  inherit  a  nervous  constitution,  or  in  whose 
parents  nervous  diseases,  such  as  insanity,  or  hysteria,  or  alcoholism  have 
been  present.  Of  the  other  etiological  factors  the  most  important  are  a 
disordered  nutrition,  frequently  with  anaemia  or  chlorosis,  and  over- 
pressure in  schools.  Masturbation  or  phimosis  may  act  as  an  exciting 
cause,  or,  indeed,  anything  which  leads  to  an  exalted  nervous  irritability 
and  depreciation  of  the  general  health.  It  may  follow  any  of  the  acute 
infectious  diseases;  or  it  may  be  excited  by  injury,  fright,  or  imitation. 

Symptoms. — There  is  scarcely  any  disease  in  which  the  clinical  pic- 
ture presented  is  so  varied  as  in  hysteria.  It  may  simulate  almost  any 
form  of  organic  disease  of  the  brain,  lungs,  digestive  organs,  bones,  or 
joints.  The  most  common  symptoms  may  be  grouped  under  four  general 
heads.  These  are,  however,  seen  in  almost  every  conceivable  combi- 
nation. 

1.  Psychical  Symptoms. — When  these  predominate  there  may  be  seen 
periods  of  mental  depression  of  longer  or  shorter  duration,  a  change 
in  disposition,  an  indifference  to  surroundings,  a  capricious  humour,  or  a 
nervous  condition  of  extreme  irritability  with  irregular  paroxysms  of 
laughter  or  weeping  without  cause.  There  may  be  great  excitability  of 
temper,  and  fits  of  passion  almost  maniacal  in  their  severity.  There 
may  be  various  hallucinations.  Sleep  is  frequently  disturbed,  some- 
times by  attacks  resembling  ordinary  night-terrors;  sometimes  somnam- 


HYSTERIA.  681 

bulism  is  present.  There  is  often  a  disposition  to  deception  about  tlie 
most  trivial  matters,  which  may  last  for  weeks.  There  is  a  tendency  to 
imitate  the  symptoms  of  various  diseases,  which  the  patients  may  liave 
witnessed  in  otliers  or  about  which  tliey  liave  read. 

2.  Sensory  Symptoms. — These  are  the  most  frequent  manifestations 
of  hysteria  in  early  life.  There  is  often  general  or  local  hypera^stliesia, 
which  may  be  so  great  as  to  simulate  inflammation  of  tlie  various 
internal  organs.  Anaesthesia  is  mucli  less  common,  although  it  may 
be  seen  in  children  as  young  as  eiglit  or  nine.  Headache  is  an  occasional 
symptom,  and  is  sometimes  associated  with  great  tenderness  of  the  scalp. 
There  may  be  neuralgias  in  the  different  parts  of  the  body,  or  sharp 
epigastric  pain,  sometimes  accompanied  by  vomiting.  Sometimes  the 
special  senses  are  affected,  giving  rise  to  hysterical  blindness  or  deafness, 
usually  of  short  duration. 

3.  Joint  Symptoms. — These  are  really  a  variety  of  sensory  dis- 
turbances. They  are  not  uncommon,  and  are  often  most  puzzling.  The 
symptoms  may  be  referable  to  the  spine,  or  to  any  of  the  large  Joints, 
particularly  those  of  the  lower  extremity.  All  forms  of  organic  disease 
of  these  joints  may  be  sinmlated.  They  are  usually  seen  between  the 
ages  of  ten  and  fourteen  years,  and  occur  in  both  sexes.  There  may  be 
lameness  referred  to  one  of  the  large  joints,  curvature  of  the  spine,  or 
torticollis.  The  symptoms  are  most  frequently  referred  to  the  hip,  and 
next  to  the  knee,  the  ankle,  or  the  spine.  The  pain  is  often  acute.  It 
is  increased  by  motion,  and  by  attempts  at  overcoming  the  deformity, 
if  any  is  present.  There  is  a  marked  hyperaesthesia  of  the  whole  limb, 
and  sometimes  of  .the  body.  In  nearly  every  case  there  is  marked  tender- 
ness of  the  spine  upon  pressure,  especially  in  the  dorsal  region.  The 
deformity  may  be  very  slight  from  spasm  of  the  flexors  "only,  or  it  may 
be  severe,  and  followed  by  contracture,  so  that  the  thighs  may  be  flexed 
tightly  against  the  abdomen  with  the  heels  against  the  buttocks.  Such 
deformities  may  last  for  months.  There  may  be  considerable  muscular 
atrophy,  but  only  that  which  comes  from  disuse.  A  special  difficulty  in 
diagnosis  arises  from  the  circumstance  that  these  symptoms  occasionally 
follow  an  injury. 

Organic  disease  of  bones  and  joints  may  usually  be  excluded  by 
attention  to  the  following  points:  The  mode  of  onset  is  more  abrupt 
than  is  seen  in  bone  disease,  and  the  course  of  the  disease  is  quite  ir- 
regular. The  degree  of  deformity  is  greater  than  is  seen  in  bone  dis- 
ease of  the  same  duration.  There  is  general  hyperaesthesia  of  the  limb, 
acute  tenderness  of  the  spine  upon  pressure,  and  undue  sensitiveness  to 
heat  or  cold.  The  deformity  varies  from  time  to  time,  being  always  more 
marked  when  examination  is  attempted.  If  the  patients  are  closely 
watched,  other  evidences  of  hysteria  may  be  seen.  Under  complete  anaes- 
thesia the  contractures  may  disappear  entirely.    There  is  no  enlargement 


682  DISEASES  OF  THE   NERVOUS  SYSTEM. 

of  the  articular  ends  of  the  hones,  no  swelling  of  the  soft  parts,  and  no 
evidence  of  active  inflammation  or  of  suppuration.  All  the  symptoms 
except  the  deformity  are  suhjective.  Under  proper  treatment  there  is 
in  most  cases  perfect  recovery,  often  in  a  surprisingly  short  time. 

4.  Motor  and  Convulsive  Symptoms. — In  the  milder  forms  there  are 
seen  many  varieties  of  tonic  or  clonic  spasm.  There  may  be  local 
spasm  of  the  eyes,  face,  or  mouth,  spasm  of  the  muscles  of  the  neck 
producing  torticollis,  of  the  muscles  of  respiration  causing  dyspnoea, 
which  may  be  constant  or  paroxysmal.  There  may  be  hiccough,  or  spasm 
of  the  larynx  causing  hysterical  aphonia.  A  very  common  symptom  is 
hysterical  cough,  which  may  be  so  frequent  and  so  severe — even  accom- 
panied by  haemoptysis — that  grave  disease  of  the  lungs  is  suspected ;  the 
chest,  however,  is  free  from  the  physical  signs  of  disease.  There  may  be 
frequent  attacks  of  vomiting  with  eructations;  these  may  be  continued 
sometimes  even  for  months,  and  in  .rare  instances  blood  has  been  vom- 
ited. There  may  be  d3^sphagia  from  spasm  of  the  oesophagus,  or  regur- 
gitation of  food  on  attempts  at  swallowing.  In  more  severe  cases  we  may 
have  the  symptoms  of  chorea  major  and  attacks  of  hystero-epilepsy.  The 
latter  are  rare  in  children  and  do  not  differ  essentially  from  such  attacks 
in  older  patients.  There  are  usually  prodromal  symptoms.  The  con- 
vulsive movements  are  exceedingly  varied  in  type.  There  are  painful 
sensations  and  sensitive  areas,  by  pressure  upon  which  hysterical  syuij)- 
toms  may  be  increased  or  even  convulsions  excited.  The  respiration 
may  be  rapid  or  irregular.  All  variations  in  tonic  and  clonic  spasm  may 
be  seen.  Opisthotonus  is  frequent.  Consciousness  is  not  fully  lost,  but  is 
disturbed,  and  hallucinations  are  present.    The  temperature  is  normal. 

Hysterical  paralysis  is  not  common  in  children,  but  it  may  be  seen 
even  in  the  very  young.  Other  symptoms  occasionally  seen  in  hysteria 
are  persistent  anorexia,  polyuria,  sometimes  incontinence  of  urine,  dis- 
turbance of  the  secretion  of  saliva  or  perspiration. 

The  general  condition  of  hysterical  patients  is  usually  below  the  nor- 
mal. They  are  poorly  nourished  and  anaemic;  they  sleep  badly;  they 
have  capricious  appetites  and  feeble  digestion. 

Diagnosis. — Hysteria  is  apt  to  be  overlooked  because  its  occurrence  in 
children  is  not, considered  as  often  as  it  should  be.  In  most  cases  the 
diagnosis  is  easy  if  hysteria  is  suspected.  A  combination  of  vague  dis- 
connected symptoms  is  usually  present  which  admits  of  no  other  ex- 
planation. Organic  disease  can  be  excluded  only  by  careful  and  repeated 
examinations.  It  is  to  be  borne  in  mind,  however,  that  hysteria  not 
infrequently  complicates  organic  or  constitutional  disease.  Mucli  im- 
portance is  to  be  attached  to  a  family  history  of  hysteria  or  of  other 
neuroses. 

Prognosis. — This  is  better  than  in  adults,  especially  if  the  cases  are 
taken  in  hand  early,  before  the  disease  has  become  deeply  seated.    Very 


HEADACHES.  683 

much  depends  upon  ]iow  well  tlie  directions  for  treatment  can  be  carried 
out.  The  prognosis  is  less  favourable  wben  Ibe  bereditary  tendency  is 
strongly  marked.     In  many  cases  there  are  relapses  later  in  life. 

Treatment. — Propliylaxis  is  of  nmcb  imi)ortance.  When  a  bered- 
itary tendency  to  nervous  diseases  exists  in  a  family,  or  whenever  very 
nervous  children  are  placed  under  the  physician's  care,  every  means 
should  be  taken  toward  muscular  development,  keeping  tlie  nervous  sys- 
tem in  the  background.  Such  children  should  lead  an  out-of-door  life 
as  much  as  possible,  preferably  in  the  country.  Tbey  should  keep  early 
hours,  have  regular  exercise,  and  their  education  should  be  directed  with 
moderation  and  judgment,  special  attention  being  paid  to  regularity  of 
work  and  the  prevention  of  overpressure  in  schools.  Theatres  and  ex- 
citing books  should  be  avoided.  All  stimulants,  including  tea  and 
coffee,  should  be  absolutely  forbidden.  The  diet  should  be  plain  and 
nutritious.  It  is  highly  important  that  such  children  should  be  re- 
moved from  association  with  an  hysterical  motber,  when  tins  is  possible. 
The  best  results  are  usually  obtained  when  the  child  is  taken  from  his 
home  surroundings  and  placed  in  some  quiet  retreat  in  charge  of  an 
intelligent  nurse. 

In  the  general  management  of  a  case  of  hysteria,  it  is  of  the  first 
importance  that  the  child  should  be  cared  for  by  a  person  of  firnmess, 
who  can  exercise  proper  control.  Hysterical  children  are  always  man- 
aged more  easily  when  they  are  removed  from  their  homes  and  placed 
under  the  charge  of  a  good  nurse.  Sometimes  they  can  be  managed  in 
no  other  way.  Isolation  is  absolutely  essential  in  many  cases.  The 
general  health  should  be  carefully  looked  after,  and  arsenic,  iron,  cod- 
liver  oil,  and  other  tonics  given  according  to  indications.  Horseback 
exercise  and  other  out-of-door  sports  should  be  encouraged,  and  every 
means  taken  to  interest  the  child  in  something  which  requires  physical 
exercise.  In  cases  of  simulated  disease,  the  child  should  be  put  to  bed, 
no  books  or  toys  allowed,  and  no  effort  made  toward  his  amusement. 
No  sympathy  should  be  exhibited,  but  the  child  should  be  treated  with 
kindness  and  firmness.  This  moral  treatment  is  quite  as  important  as 
any  other  part  of  the  therapeutics.  In  cases  with  hysterical  joint  symp- 
toms the  most  valuable  thing  is  counter-irritation  to  the  spine,  prefer- 
ably by  the  Paquelin  cautery.  Under  no  circumstances  should  mechan- 
ical force  be  used  to  overcome  deformity.  Many  cases  of  hysteria 
improve  under  hydrotherapy;  the  cold  douche,  the  cold  pack,  or  the 
shower  bath  may  be  used.  This  is  valuable  in  conjunction  with  massage 
and  the  "  rest  treatment." 

HEADACHES. 

Headaches  are  not  common  in  little  children  except  in  connection 
with  disease  of  the  brain  or  meninges;  in  older  children  they  occur  from 


684  DISEASES  OF  THE  NERVOUS  SYSTEM. 

causes  similar  to  those  seen  in  adult  life.     The  most  frequent  headaches 
may  be  grouped  in  the  following  classes: 

1.  Toxic  Headaches. — Such  are  the  headaches  resulting  from  uraMuia, 
from  malaria,  and  those  seen  in  many  acute  infectious  diseases.  But 
the  largest  number  are  associated  with  chronic  indigestion  and  con- 
stipation. 

2.  Headaches  from  Anaemia,  Malnutrition,  and  Nerve  Exhaustion. — 
These  are  most  frequently  seen  in  girls  from  ten  to  fourteen  years  old. 
Some  are  intellectually  bright,  and  have  been  crowded  in  their  school 
work;  others  are  dull  and  learn  only  with  difficult}^  and  in  consequence 
worry  over  their  work  until  their  health  becomes  undermined.  They 
sleep  badly,  lose  appetite,  and  often  become  choreic.  The  anaemia  may 
be  either  the  cause  or  the  result  of  these  symptoms. 

3.  Headaches  of  Nervous  Origin. — These  may  occur  in  children  who 
are  highly  neurotic,  either  from  their  inheritance  or  surroundings,  and 
in  those  who  are  the  subjects  of  epilepsy  or  hysteria,  and  they  may  be 
symptomatic  of  organic  disease  of  the  brain,  such  as  tumour  or  tuber- 
culous or  syphilitic  meningitis.  True  facial  neuralgia  is  rare  in  child- 
hood except  from  carious  teeth;  from  this  cause,  however,  it  is  not  in- 
frequent. 

4.  Headaches  due  to  Disease  of  some  of  the  Organs  of  Special  Sense. 
— In  connection  with  the  eyes  there  may  be  conjunctivitis,  keratitis, 
iritis,  errors  of  refraction,  or  strabismus;  connected  with  the  nose  there 
may  be  polypi,  hypertrophic  rhinitis,  or  adenoid  vegetations  of  the 
pharynx;  connected  with  the  ears  there  may  be  otitis  or  foreign  bodies 
in  the  canal.     Each  one  of  these  conditions  requires  special  treatment. 

5.  Headaches  due  to  Inherited  Gout  or  Rheumatism. — These  are  not 
very  frequent,  but  they  may  be  severe,  and  may  at  times  simulate  the 
onset  of  meningitis.  They  are  often  accompanied  by  pains  in  the  joints, 
muscles,  or  nerve  trunks. 

6.  Disturbances  of  the  genital  tract  are  rarely  a  cause  of  headaches  in 
children,  although  this  may  be  the  case  in  girls  about  the  time  of  pu- 
berty, especially  where  menstruation  is  delayed  or  difficult. 

Diagnosis. — The  diagnosis  of  headaches  includes  the  discovery  of  the 
cause,  and  this  is  often  difficult.  In  an  infant  or  a  young  child,  organic 
disease  of  the  nervous  system  should  always  be  suspected  as  a.  cause  of 
severe  headaches.  In  older  children  the  important  things  to  be  con- 
sidered, because  the  most  frequent,  are  digestive  disturbances,  nervous 
exhaustion,  malnutrition,  and  visual  disorders.  An  absolute  diagnosis 
in  a  case  of  persistent  headache  can  be  made  only  by  a  careful  physical 
examination,  not  omitting  a  study  of  the  urine;  often  there  must  be  a 
close  observation  of  the  patient  for  some  time. 

Treatment. — The  only  successful  treatment  is  that  which  is  directed 
toward  a  removal  of  the  cause.     Each  one  of  the  different  groups  above 


DISORDERS  OF  SPEECH.  685 

mentioned  is  to  be  managed  differently,  according  to  the  principles  else- 
where laid  down  regarding  the  treatment  of  these  conditions.  For  the 
relief  of  the  symptom,  cold  to  the  head,  a  hot  foot-bath,  and  phenaeetine 
in  moderate  doses  are  perhaps  the  most  certain  of  all  remedies. 


DISORDERS  OF  SPEECH. 

In  this  chapter  will  be  discussed  only  functional  speech  defects,  those 
depending  upon  organic  conditions  being  considered  in  connection  with 
diseases  of  the  brain.  The  most  common  varieties  are  stuttering,  stam- 
mering, lisping,  alalia,  backwardness,  and  functional  aphasia.  All  forms 
are  much  more  frequent  in  boys  than  in  girls,  the  proportion  being  more 
than  four  to  one. 

Stuttering. — This  is  the  most  common  form  of  speech  disturbance. 
Articulation  is  distinct  and  the  separate  sounds  are  properly  produced, 
but  there  is  a  difficulty  in  connecting  the  consonant  with  the  succeeding 
vowel ;  this  seems  like  an  obstacle  to  be  overcome.  Occasional  stuttering 
is  seen  in  very  many  children.  It  is  more  frequent  in  the  third  and 
fourth  years,  before  speech  is  thoroughly  mastered.  At  this  age  it  is 
aggravated  or  produced  by  disturbances  of  nutrition,  but  is  usually 
of  temporary  duration,  lasting  for  a  few  weeks  or  months.  Only  recently 
a  little  boy  of  four  was  under  my  care,  who  became  very  ansemic,  slept 
poorly,  and  suffered  from  malnutrition  as  a  result  of  the  confinement 
incident  to  a  home  in  the  city.  He  soon  began  to  stutter,  and  in  a  short 
time  it  became  painfully  marked.  After  a  few  weeks  in  the  country  he 
improved  very  much  in  his  general  condition,  gained  four  or  five  pounds 
in  weight,  and  his  stuttering  completely,  and  I  think  permanently,  dis- 
appeared. Such  disturbances  as  this  are  analogous  to  chorea.  In  other 
cases  stuttering  follows  some  acute  illness,  and  under  such  conditions 
also  it  is  usually  of  short  duration. 

Most  children  who  become  habitual  stutterers  do  not  begin  until  they 
are  six  or  seven  years  old,  and  sometimes  even  later.  Stuttering  may 
arise  from  imitation,  and  inheritance  is  an  important  etiological  factor. 
It  is  frequently  a  mark  of  degeneration. 

It  is  important  that  all  such  cases  receive  early  treatment  before 
the  habit  becomes  firmly  fixed.  The  prognosis  is  good  for  spontaneous 
recovery  in  nearly  all  the  cases  seen  in  very  young  children,  and  also  in 
those  coming  on  after  acute  illness.  Other  cases  in  which  the  condition 
has  become  habitual  should  have  the  benefit  of  systematic  training  under 
a  competent  teacher  in  breathing  and  vocal  gymnastics. 

Stammering.— This  term  is  sometimes  used  synonymously  with  stut- 
tering. Kussmaul  makes  the  distinction  between  them  that,  in  stam- 
mering, individual  sounds  are  difficult  of  production,  while  in  stuttering 
it  is  syllabic  combinations.     Stammering  is  often  accompanied  by  some 


686  DISEASES  OF  THE   NERVOUS  SYSTEM. 

defect  in  the  organs  of  articulation — the  teeth,  lips,  tongue,  or  palate — 
which  is  not  present  in  stuttering. 

The  treatment  consists  in  careful  training  and  in  the  correction  of 
whatever  abnormal  local  conditions  may  exist. 

Lisping. — In  this  there  is  an  imperfect  production  of  certain  sounds, 
owing  usually  to  a  faulty  position  of  the  organs  of  articulation.  The 
sounds  may  be  so  indistinct  that  they  can  not  be  understood.  In  this 
condition  also  there  may  be  defective  formation  of  some  of  the  organs 
of  articulation,  although  in  the  milder  forms  this  is  not  the  case.  The 
treatment  is  similar  to  that  of  stammering. 

Alalia. — This  consists  in  a  total  inability  to  articulate.  It  is  seen  in 
all  young  infants  during  their  earliest  attempts  at  talking.  In  older 
children  it  is  usually  associated  with  some  mental  defect. 

Backwardness. — Backwardness  is  carefully  to  be  distinguished  from 
a  late  development  of  speech  due  to  mental  defects.  At  two  years  old 
children  not  deaf  are  almost  invariably  able  to  speak.  Speech  may  be 
late  in  consequence  of  prolonged  or  very  severe  illness,  and  when  it  has 
once  been  acquired  it  may  be  lost  from  similar  causes. 

Functional  Aphasia. — The  term  has  been  applied  to  a  temporary  loss 
of  speech  which  sometimes  occurs  in  chorea,  and  sometimes  from  severe 
fright  or  anything  else  which  has  produced  a  marked  nervous  impression. 
West  records  an  instance  in  a  girl  of  eight  years,  who  was  suffering  from 
an  attack  of  chorea  induced  by  fright.  Speech  first  became  difficult  and 
then  was  lost  altogether.  For  a  month  the  child  could  say  only  "  Yes  " 
and  "  No."  The  case  improved  very  slowly,  but  at  the  end  of  nine  weeks 
had  recovered  completely.  Loss  of  speech  sometimes  follows  the  acute 
infectious  diseases,  especially  typhoid  fever. 

In  all  disorders  of  speech,  the  functional  cases  are  to  be  distinguished 
from  those  which  depend  upon  deafness  and  mental  deficiency.  The 
frequency  with  which  these  disorders  are  due  to  disturbances  of  general 
nutrition,  and  to  local  causes  in  the  mouth  and  throat,  should  be  borne 
in  mind,  and  these  conditions  should  receive  their  appropriate  treatment 
early,  before  the  habit  of  defective  speech  becomes  firmly  established. 
For  the  latter  class  of  unfortunates,  special  training  at  the  hands  of  a 
competent  teacher  should  be  advised,  preferably  in  an  institution. 

DISORDERS  OF  SLEEP. 

Disturbed  Sleep,  Sleeplessness. — Disturbed  or  restless  sleep  is  much 
more  common  in  infancy  and  childhood  than  is  true  insomnia,  although 
the  causes  of  the  two  conditions  may  be  the  same. 

Etiology. — In  infancy  these  symptoms  are  most  frequently  due  to 
hunger  or  to  indigestion  resulting  from  overfeeding  or  improper  feeding. 
Very  often  disturbed  sleep  is  the  result  of  bad  habits,  such  as  rocking 


DISORDERS  OF  SLEEP.  687 

during  sleep  or  night-feeding.  Sometimes  it  arises  from  dentition,  or 
the  pain  of  colic  or  otitis ;  at  other  times  it  may  be  simply  tlie  expression 
of  a  condition  of  extreme  nervous  irritability,  the  result  of  inheritance 
or  of  the  child's  surroundings.  It  is  often  caused  by  the  persistent  activ- 
ities of  a  fussy  nurse  or  mother. 

In  later  childhood  the  first  thing  to  be  suspected  when  sleep  is  much 
disturbed  is  some  derangement  of  the  digestive  organs;  in  this  will  be 
found  the  explanation  of  fully  half  the  cases.  The  most  frequent  type, 
when  the  symptom  is  of  long  duration,  is  clironic  intestinal  indigestion, 
often  associated  with  indicanuria,  a  condition  in  which  formerly  the 
usual  diagnosis  was  intestinal  worms.  Other  cases  are  due  to  obstructed 
respiration  from  adenoid  growths  of  the  pharynx  or  enlarged  tonsils, 
sometimes  to  nocturnal  attacks  of  asthma.  A  lack  of  fresh  air  in  the 
sleeping  room,  excessive  or  insufficient  bedclothing,  and  cold  feet,  are 
other  frequent  causes.  Disturbed  sleep  with  "  starting  pains  "  is  one  of 
the  earliest  symptoms  of  hip-joint  disease.  In  the  nervous  exhaustion 
resulting  from  overpressure  in  schools,  and  in  malnutrition  and  anaemia, 
disturbances  of  sleep  are  well-nigh  constant.  They  are  also  seen  in 
organic  cardiac  disease  and  in  all  pulmonary  conditions  accompanied  by 
dj'spncea  or  cough.  Sleep  m.ay  be  disturbed  in  consequence  of  bad  dreams 
which  have  their  origin  in  exciting  stories  lieard  or  read  just  before 
bedtime,  or  in  too  violent  or  exciting  play.  To  discover  the  cause  in 
almost  any  case  it  is  necessary  to  investigate  carefully  the  whole  routine 
of  the  child's  life. 

Symptoms. — The  condition  may  be  one  of  real  insomnia  which  may 
last  for  weeks  or  months ;  or  the  sleep  may  be  simply  disturljed  and  rest- 
less, the  child  waking  many  times  during  the  night,  and  when  asleep 
will  not  lie  quietly,  but  constantly  changes  his  position.  Sometimes 
children  wake  suddenly  with  a  scream,  but  immediately  drop  off  to  sleep 
again. 

Treatment. — The  essential  treatment  consists  in  the  discovery  and 
removal  of  the  cause  of  the  disturbance.  This  will  often  involve  a  radical 
change  in  the  manner  of  feeding,  in  the  hygiene  of  the  nursery,  and  in 
all  the  surroundings  of  the  child.  A  change  of  nurses  sometimes  results 
in  a  speedy  cure.  Under  no  circumstances  should  the  physician  coun- 
tenance the  use  of  drugs  to  promote  sleep  in  children,  except  in  the  case 
of  severe  acute  disease.  Soothing  syrups  and  all  nostrums  for  "teeth- 
ing "  should  be  absolutely  forbidden ;  also  the  sucking  of  a  "  pacifier." 
Many  mothers  and  nurses  fall  into  the  habit  of  using  them,  because  the 
injurious  effects  are, not  appreciated.  When  the  cause  of  sleeplessness  is 
found  and  removed  the  child  will  sleep,  but  compulsory  sleep  obtained 
under  other  conditions  is  usually  productive  of  more  harm  than  good; 
If  food,  diet,  and  all  bad  habits  have  been  corrected,  nervous  causes 
should  be  investigated.    When  no  cause  can  be  discovered  the  treatment 


688  DISEASES  OF  THE   NERVOUS  SYSTEM. 

should  consist  in  putting  the  child  upon  the  simplest  possible  diet,  and 
in  attention  to  such  general  conditions  as  anaBmia,  malnutrition,  and 
neurasthenia,  some  of  which  are  almost  certain  to  be  present.  In  many 
cases  a  warm  bath  at  bedtime  will  be  found  beneficial.  A  quiet,  darkened 
room,  plenty  of  fresh  air,  and  the  stopping  of  both  eating  and  drinking 
during  the  night,  are  essential  to  a  cure  in  most  cases.  When  the  con- 
dition accompanies  some  acute  disease,  the  drugs  which  are  most  useful 
are  codeine  and  trional.  A  child  of  two  years  may  take  gr.  -^  of  codeine 
or  two  grains  of  trional  as  an  initial  dose,  to  be  increased  if  necessary. 

Night  Terrors — Pavor  Noctumus. — Two  classes  of  cases  have  been 
grouped  under  this  head,  both  having  this  in  common,  that  sleep  is  dis- 
turbed by  fright. 

The  condition  in  the  first  group  partakes  of  the  nature  of  nightmare. 
It  may  be  due  to  partial  asphyxia  from  adenoid  growths  of  the  pharynx, 
or  to  other  causes  mentioned  under  disturbed  sleep,  or  it  may  be  gastric 
or  intestinal  in  its  origin.  These  cases  are  quite  frequent.  Sleep  may 
be  disturbed  from  the  outset,  and  the  attack  may  be  merely  the  culmina- 
tion of  such  disturbance.  The  child  wakes  in  a  state  of  fright  and  ex- 
citement, and  often  says  he  has  had  a  bad  dream.  His  mind  is  clear,  he 
recognises  those  about  him,  but  it  may  be  a  long  time  before  he  is  suffi- 
ciently calm  to  sleep  again.  The  attack  may  be  remembered  perfectly 
the  next  day.  Cases  like  this  are  to  be  managed  in  the  same  general  way 
as  those  of  disturbed  sleep  above  mentioned. 

In  the  second  group  are  the  only  cases  to  which  the  term  "  night  ter- 
rors "  should  really  be  applied.  These  are  relatively  rare,  but  the  condi- 
tion is  a  much  more  serious  one.  The  symptom  is  generally  due  to  some 
disturbance  of  the  central  nervous  system.  It  occurs  especially  in  those 
of  neurotic  antecedents,  or  those  who  have  previously  suffered  from 
infantile  convulsions,  and  it  is  often  the  precursor  of  other  nervous  at- 
tacks— migraine,  hysteria,  epilepsy,  and  even  insanity.  The  attack  usu- 
ally comes  suddenly  where  a  child  has  previously  been  sleeping  quietly, 
and  more  frequently  in  the  early  part  of  the  night  than  later.  He  is 
generally  found  sitting  upright  in  his  bed  in  a  bewilderment  of  terror, 
being  "  afraid  of  the  dog,"  or  "  the  bear,"  or  there  is  some  other  vision 
or  hallucination  which  has  produced  the  fright.  Often  this  is  associated 
with  something  of  a  red  colour.  The  child  does  not  recognise  those 
about  him,  does  not  know  where  he  is,  and  may  go  to  sleep  again  with- 
out coming  to  full  consciousness.  The  next  day  there  is  no  recollection 
of  what  has  happened.  Usually  no  after-effects  are  seen,  but  sometimes 
a  large  amount  of  pale  urine  is  passed.  The  attacks  may  be  repeated 
at  intervals  of  a  few  months,  or  they  may  occur  every  few  nights;  but 
whatever  the  peculiar  nature  of  the  vision,  it  is  likely  to  be  repeated  in 
nearly  the  same  form.  Such  attacks  have  something  in  common  with 
epileptic  seizures,  and  the  diagnosis  between  them  may  at  times  be  dif- 


INJURIOUS  HABITS  OF  INFANCY  AND   CHILDHOOD.         689 

ficult.  They  are  to  be  regarded  seriously,  not  only  on  account  of  what 
they  are  in  themselves,  but  on  account  of  what  may  follow. 

Treatment. — All  mental  and  nervous  strain  should  be  most  carefully 
avoided,  and  when  the  attacks  are  fie<iuent  the  bromides  should  be  given 
at  bedtime.  Some  person  should  sleep  in  the  same  room  with  the  child, 
or  in  an  adjoining  one  with  the  door  open. 

Excessive  Sleep. — It  is  rare  that  either  infants  or  children  sleep  an 
unnatural  amount  of  the  time  unless  one  of  two  causes  is  present — or- 
ganic brain  disease,  most  frequently  tuljerculous  meningitis,  or  the  use 
of  drugs.  The  latter  is  always  to  be  suspected  if  with  the  sleep  there  is 
associated  obstinate  constipation.  Opium  in  the  form  of  "  soothing 
syrup  "  or  paregoric  is  the  drug  which  has  usually  been  given. 

INJURIOUS  HABITS  OF   INFANCY  AND   CHILDHOOD. 

On  account  of  the  close  connection  of  such  habits  with  disturbances 
of  the  nervous  system,  they  may  be  properly  considered  with  the  func- 
tional nervous  diseases.  Although  some  of  these  habits  may  not  be  of 
serious  importance,  yet  as  a  group  they  usually  receive  too  little  atten- 
tion at  the  hands  of  the  physician.  The  list  is  very  long,  and  only  the 
most  important  ones  will  be  discussed. 

Sucking. — This  is  a  very  common  habit  in  infants,  and  during  the 
first  few  months  it  is  seen  to  some  degree  in  most  of  them.  If  they  are 
carefully  watched  the  habit  is  easily  stopped;  otherwise  it  may  continue 
indefinitely.  Young  infants  usually  suck  the  fingers  when  hungry,  and 
this  can  scarcely  be  considered  abnormal,  but  an  effort  should  always  be 
made  to  stop  it,  lest  the  habit  become  fixed.  Lindner  distinguishes  be- 
tween simple  sucking  and  sucking  with  combinations.  In  the  former, 
the  child  sucks  some  part  of  the  body,  such  as  the  thumb,  fingers,  toes, 
tongue,  lips,  back  of  the  hand  or  arm,  or  it  may  be  some  foreign  sub- 
stance, such  as  part  of  the  clothing,  the  blanket,  a  rubber  nipple,  or  the 
"  pacifier."  This  is  the  most  common  form  that  is  seen.  In  the  second 
variety  the  sucking  is  accompanied  by  the  rubbing  of  some  other  parts, 
which  seems  to  afford  a  pleasurable  excitement ;  this  may  be  the  ear,  the 
genitals,  or  any  other  portion  of  the  body.  Sometimes  sucking  is  accom- 
panied by  some  practice  which  produces  actual  pain,  such  as  pulling  of 
the  hair  or  scratching  the  body.  Habits  of  sucking  often  persist  through- 
out infancy,  and  not  infrequently  throughout  childhood ;  they  have  often 
been  known  to  continue  up  to  puberty.  The  longer  the  habit  has  lasted 
the  more  difficult  is  it  to  break. 

The  results  of  sucking  may  be  serious.  Deformities  of  the  thumb  or 
finger,  of  the  lips  and  teeth,  and  even  of  the  jaws,  are  sometimes  pro- 
duced. I  knew  a  woman  whose  thumbs  to  advanced  age  showed  a  de- 
formity resulting  from  the  habit  of  thumb-sucking  while  a  child.  In 
45 


690  DISEASES  OF  THE   NERVOUS  SYSTEM. 

her  case  the  habit  was  not  broken  until  she  was  eiglit  or  nine  years  old. 
I'robably  the  most  pernicious  result  of  sucking  is  its  tendency  to  develop 
the  habit  of  masturbation.  Habitual  sucking  of  one  hand  or  finger  may 
lead  to  spinal  curvature. 

Treatment. — In  the  management  of  these  cases  the  most  important 
thing  is  to  arrest  the  habit  early,  before  it  becomes  fixed.  Too  often  the 
habit  of  thumb-sucking,  or  of  sucking  a  rubber  nipple,  is  encouraged  by 
mothers,  nurses,  and  sometimes  even  by  physicians  because  of  the  tem- 
porary quiet  which  is  thereby  produced.  Under  no  circumstance  should 
it  be  resorted  to  as  a  means  of  putting  children  to  sleep  or  otherwise 
quieting  the  nervous  system.  With  infants,  the  only  treatment  which 
is  at  all  successful  is  mechanical  restraint.  It  is  of  no  use  to  cover  the 
part  which  is  sucked  with  bitter  solutions.  The  hands  of  young  infants 
may  be  covered  with  mittens,  or  with  the  long  sleeves  of  a  night-gown 
which  is  pinned  to  the  bed,  so  that  it  is  impossible  for  the  child  to  get 
the  part  to  the  mouth ;  or,  still  better,  cuffs  or  splints  of  pasteboard  may 
be  applied  at  the  elbow,  so  as  to  prevent  flexion  of  the  arms.  In  the 
milder  cases  the  habit  is  often  discontinued  spontaneously;  but  when 
it  has  been  indulged  in  until  a  child  is  four  or  five  years  old,  it  is  l>roken 
only  with  the  greatest  difficulty.  Punishments  are  of  little  avail,  but 
rewards  are  often  successful. 

Masturbation. — This  is  not  uncommon  even  in  infancy.  Many  cases 
have  been  observed  during  the  first  year,  and  some  as  early  as  the  sev- 
enth or  eighth  month.  It  is  seen  in  children  of  all  ages  and  in  both 
sexes;  but  in  infants  and  very  young  children  it  is,  in  my  experience, 
very  much  more  common  in  girls  than  in  boys. 

Etiology. — Local  causes  are  present  in  a  large  number  of  the  cases, 
and  they  are  usually  something  which  produces  undue  irritation.  The 
most  frequent  are,  long  or  adherent  prepuce,  phimosis,  balanitis,  vulvo- 
vaginitis, eczema  of  the  labia,  threadworms,  and  tight  clothing.  A  urine 
which  is  irritating  because  of  excessive  acidity  or  the  presence  of  crystals 
of  uric  acid  may  be  a  cause.  Any  irritation  may  lead  the  child  to  rub 
the  parts  in  some  way,  and  a  pleasurable  sensation  being  excited,  this 
action  is  repeated  until  a  habit  is  formed.  Other  causes  are  exercises 
in  which  the  legs  are  rubbed  together,  or  the  body  against  a  pole,  as  in 
climbing.  To  these  causes  must  be  added,  in  infants  at  least,  the  habit 
of  sucking.  After  infancy  the  habit  of  masturbation  is  usually  acquired 
from  other  children,  but  sometimes  taught  by  vicious  nurses. 

General  causes  are  also  important  as  predisposing  factors.  These 
are  the  same  as  underlie  most  of  the  neuroses  of  childhood — viz.,  marked 
anaemia,  general  malnutrition,  and  a  highly  neurotic  constitution,  which 
is  often  an  inheritance,  and  is  always  aggravated  by  surroundings  which 
tend  to  unnatural  stimulation  of  the  nervous  system.  When  masturba- 
tion develops  in  a  young  child  without  any  local  cause,  it  may  be  an 


INJURIOUS   HABITS  OF   INFANCY   AND   (CHILDHOOD.  691 

early  sign  of  either  mental  defieieiiey  or  inoml  (IcliiKiuciicy ;  if  looked 
for,  other  stigmata  of  degeneration  will  iisually  he  found,  and  in  most 
cases  other  vicious  traits  will  soon  appear. 

Symptoms. — In  infants  and  very  young  cliihlren  masturhation  is 
usually  accomplished  by  thigh  friction  or  by  rubbing  the  l)ody  against  a 
pillow,  a  chair,  or  some  other  object.  The  variety  of  ways  is  almost  end- 
less. Frequently  the  child  will  simply  lie  upon  the  floor  witli  the  thiglis 
crossed  and  rigidly  held,  and  sway  the  body  backward  and  forward.  This 
lasts  for  a  few  moments,  is  accompanied  by  flushing  of  the  face  and 
some  appearance  of  excitement,  followed  by  relaxation,  and  often  by 
perspiration.  It  frequently  happens  with  little  children  that  these 
"  queer  tricks,"  as  they  are  often  regarded,  have  been  continued  for 
months  before  their  true  nature  is  susj3ectcd. 

A  consciousness  that  they  are  doing  something  wrong  early  leads 
even  young  children  to  seek  seclusion  wlien  they  repeat  the  habit.  It 
is  especially  likely  to  be  practised  when  children  lie  long  awake  alone 
after  they  go  to  bed,  or  if  they  wake  early.  The  habit  is  always 
made  worse  by  any  deterioration  of  the  general  health.  I  have  known 
children,  who  were  thought  to  be  cured,  to  relapse  under  such  con- 
ditions. 

It  is  somewhat  difficult  to  separate  the  general  symptoms  with  which 
masturbation  is  associated,  and  upon  which  it  largely  depends,  from 
those  which  are  the  direct  result  of  the  habit.  There  are  some  children 
in  whom  the  condition  is  chiefly  or  entirely  de])endent  upon  a  local  cause, 
or  when  it  is  only  occasionally  practised,  in  whom  no  general  symptoms 
are  seen,  or  at  most  only  an  unnatural  shyness  and  a  disposition  to  seek 
seclusion.  Others  are  precocious  and  excitable,  with  an  excessive  amount 
of  nervous  sensibility.  There  are  others  in  whom  more  marked  nervous 
symptoms  are  present;  the  most  striking  are  absent-mindedness,  loss  of 
power  of  concentration,  loss  of  interest  in  all  amusements,  and  mental 
depression.  Some  girls  of  only  seven  or  eight  years  may  have  fairly 
regular  periods  in  which  masturbation  is  practised.  In  one  of  my  pa- 
tients such  periods  for  a  considerable  time  occurred  monthly.  During 
them  even  very  little  girls  may  lose  all  sense  of  modesty  or  decency. 
Every  particle  of  self-control  is  gone.  They  are  passionate,  excitable, 
apparently  possessed  by  the  one  uncontrollable  desire  to  practise  the 
habit.  In  the  intervals  such  children  may  be  quiet,  modest,  sweet-tem- 
pered, and  perfectly  normal.  In  some  older  subjects  nymphomania,  or 
even  insanity,  may  be  the  ultimate  result.  Epilepsy,  chorea,  or  hysteria 
may  develop,  particularly  where  a  strong  predisposition  to  them  already 
exists  in  the  family.  The  effect  of  masturbation  upon  the  physical  and 
mental  development  of  the  child  may  be  serious  when  it  is  begun  at  an 
early  age  or  is  frequently  practised.  But  even  more  striking  is  the 
change  sometimes  brought  about  in  a  child's  moral  nature.     Even  little 


692  DISEASES  OF  THE   NERVOUS  SYSTEM. 

children  of  eiglit  or  nine  years  may  become  centres  of  moral  infection, 
which  may  involve  a  group  of  playmates  or  even  a  whole  school. 

Local  symptoms  of  masturbation  are  not  always  present;  in  the  male 
there  may  be  redness  and  slight  swelling  of  the  prepuce;  the  orgaits  may 
be  abnormally  large  or  simply  much  relaxed.  The  frequent  occurrence 
of  erections  in  young  children  is  always  a  suspicious  symptom.  In  the 
female  there  is  often  seen  an  abnormal  development  of  the  genital  organs 
for  the  age,  with  an  early  appearance  of  pubic  hair.  No  importance  is 
to  be  attached  to  adhesions  of  the  clitoris.     Sometimes  there  is  vaginitis. 

Prognosis. — Masturbation  in  children  is  at  all  times  a  most  difficult 
condition  to  deal  with.  The  outlook  is  better  in  infants  and  young  chil- 
dren than  in  those  who  are  older,  because  the  latter  are  more  difficult  to 
watch  and  control;  besides,  in  them  the  habit  has  usually  become  more 
firmly  fixed.  In  young  children  local  causes  are  frequently  found  to  be 
at  the  root  of  the  trouble;  in  those  who  are  older  general  causes  are 
more  often  present,  and  these  it  may  be  impossible  to  remove.  In  almost 
any  case  in  which  the  habit  has  become  firmly  developed,  many  months 
and  usually  several  years  are  necessary  for  complete  cure.  Tlic  tendency 
to  relapse  is  very  -strong.  When  masturbation  is  a  symptom  of  degener- 
acy it  is  usually  hopeless. 

Treatment. — The  most  important  thing  is  an  early  recognition  of 
the  condition.  The  physician  should  put  parents  and  nurses  on  their 
guard,  and  the  first  suspicions  should  be  reported  and  the  child  care- 
fully watched  until  all  doubt  is  removed.  In  young  infants  much  may 
be  accomplished  by  mechanical  restraint.  The  kind  of  restraint  which 
is  necessary  will  depend  upon  the  manner  of  masturbating.  If  by  the 
hands,  they  should  be  tied  during  sleep,  so  that  the  child  can  not  reach 
the  genitals;  if  by  the  thigh-friction,  the  thighs  should  be  separated  by 
tying  one  to  either  side  of  the  crib.  In  inveterate  cases,  a  double  side- 
splint,  such  as  is  used  in  fracture  of  the  femur,  may  he  applied.  In 
children  that  are  over  three  years  old,  all  such  contrivances  are  almost 
invariably  unsuccessful.  It  is  of  the  utmost  importance  in  every  case  to 
have  the  child  under  the  close  surveillance  of  a  competent  and  trust- 
worthy person.  He  should  be  especially  watched  just  after  being  put 
to  bed  and  immediately  after  waking.  Corporal  punishment  is  often 
useful  in  very  young  children,  but  of  little  or  no  benefit  in  those  who  are 
over  three  years  old.  In  fact,  in  such  cases  it  may  do  positive  harm,  for 
deception  and  lying  are  soon  added  to  the  previous  vice.  The  mother 
should  secure  the  child's  confidence,  and  in  every  way  possible  seek  to 
strengthen  his  will  and  stimulate  his  self-control,  using  her  influence  to 
help  him  break  the  habit.  The  local  causes,  too,  must  be  examined  into 
and  removed  whenever  found.  Circumcision  should  be  done  if  phimosis 
exists,  and  even  when  it  does  not,  the  moral  effect  of  the  operation  is 
sometimes  of  very  great  benefit.     In  girls  improvement  sometimes  fol- 


INJURIOUS  HABITS  OF  INFANCY  AND   CHILDHOOD.         693 

lows  a  separation  under  anesthesia  of  the  preputial  hood  from  the 
clitoris.  But  unless  this  is  frequently  re})eated,  tlic  adhesions  soon  recur. 
Complete  circumcision  is  sometimes  done  with  advantage,  and  in  very 
obstinate  cases  the  clitoris  may  he  cauterised.  Blistering  the  inside  of 
the  thighs,  the  vulva,  or  the  prepuce  is  sometimes  useful.  But  as  a  rule 
none  of  these  measures  accomplishes  anything  permanent.  Care  sliould 
be  taken  that  the  clothing  does  not  irritate  the  parts.  The  child  should 
be  removed  from  all  vicious  companions;  Imt  it  is  quite  as  important 
that  the  greatest  vigilance  should  be  exercised  in  the  home  and  at  school, 
so  that  the  child  should  have  no  op])ortunity  to  teach  other  children  the 
habit.  In  the  most  serious  cases  the  child  should  he  sent  away  from 
home  and  kept  from  other  children.  The  co-operation  of  a  trustworthy 
nurse  or  companion  is  indispensable.  General  treatment  should  be  di- 
rected to  the  child's  condition;  it  is  required  in  most  of  the  cases.  A 
child  suffering  from  malnutrition  and  anemia  shotdd  be  sent  to  the 
country,  kept  out  of  doors  and  away  from  books,  studies,  and  from  every- 
thing which  stimulates  or  excites  the  nervous  system.  Almost  all  exer- 
cises except  horseback  may  be  recommended.  Every  means  should  be 
eniplo3'ed  to  build  up  the  general  health.  These  cases  are  most  difficult 
and  most  discouraging  ones  for  the  physician.  A  cure  results  only  by 
using  all  these  measures  and  for  a  long  time. 

Nail-biting  and  tongue-sucking  are  two  forms  of  habit  which  are  less 
frequent  and  less  important  than  those  already  mentioned.  The  former 
is  best  remedied  by  wearing  gloves  and  by  keeping  the  nails  cut  very 
short.  Tongue-sucking  seldom  becomes  a  fixed  habit,  and  the  child  usu- 
ally ceases  it  of  his  own  accord  as  he  grows  older. 

Pica  or  perverted  appetite  is  an  inordinate  desire  to  eat  various  sub- 
stances, such  as  dirt,  sand,  mortar  or  coal.  It  is  most  frequently  seen 
in  infants  but  may  occur  in  older  children.  This  habit  is  met  with  in 
those  who  are  mentally  defective,  but  not  rarely  in  other  children. 
These  patients  are  usually  highly  neurotic  and  exhibit  some  of  the  other 
habits  common  to  this  class.  In  some  children  gastric  derangements 
seem  to  play  the  part  of  an  exciting  cause.  Pica  is  a  common  symjitom 
of  infection  with  hook-worm.  Tiie  habit  may  continue  for  years  unless 
corrected.  The  general  health  often  becomes  seriously  undermined  as 
a  consequence  of  the  disturbed  digestion  resulting  from  the  presence 
of  abnormal  substances  in  the  stomach.  Children  in  whom  such  a 
habit  is  present  should  in  the  first  place  be  watched  and  prevented  from 
indulging  in  their  abnormal  craving.  Secondly,  the  digestion  and  gen- 
eral health  should  be  improved  according  to  indications  afforded  by  the 
individual  case. 

Head-banging  is  an  expression  of  extreme  nervous  irritability  most 
frequently  seen  in  infants  or  in  very  young  children.  It  is  not  indicative 
of  any  special  form  of  nervous  derangement,  but  is  caused  by  the  same 


694 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


morbid  impulse  which  leads  other  nervous  children  to  scratch  their  faces, 
pull  their  hair,  etc.  While  in  some  children  head-banging  occurs  only 
occasionally,  I  have  seen  patients  in  whom  it  existed  for  a  long  time. 
It  may  be  repeated  almost  every  night,  and  continue  at  intervals  for  two 
or  three  hours,  and  that  without  temper  or  excitement,  but  with  such 
force  as  to  produce  contusions  of  the  scalp  and  necessitate  padding  the 
sides  of  the  crib.  It  is  rarely  a  symptom  of  organic  brain  disease. 
Rickets  is  often  associated  and  the  nutrition  of  most  of  tlie  patients 
is  much  below  tlie  normal.     The  treatment  is  general. 


CHAPTER    III. 


DISEASES  OF   THE  BRAIN  AND  MENINGES. 
MALFORMATIONS. 

The  malformations  of  the  brain  are  of  great  variety,  and  many  of 
them  are  solely  of  anatomical  interest,  as  the  conditions  are  incompatible 
with  life.  Only  the  most  frequent  and  the  best-known  types  will  be  men- 
tioned, and  those  which  are  of  interest  from  a  clinical  point  of  view. 

Meningocele,  Encephalocele,  and  Hydrencephalocele. — These  three 
conditions  have  in  common  a  protrupion  of  some  part  of  the  cranial  con- 


FiG.  106. — Meningocele. 


Fig.  107. — Encephalocele.      Fig.  108. — Hydrenceph- 
alocele. 


tents  through  an  opening  in  the  skull.  In  meningocele  (Figs.  106,  109) 
there  is  protrusion  of  the  membranes  alone.  These  form  a  sac,  which 
is  usually,  but  not  invariably,  distended  by  fluid.    In  encephalocele  (Fig. 

107)  there  is  a  protrusion  of  a  portion  of  the  brain  substance;  this  is 
connected  with  the  rest  of  the  brain  by  a  constricted  neck  or  pedicle. 
The  tumour  may  or  may  not  contain  fluid.    In  hydrencephalocele  (Fig. 

108)  there  is  a  protrusion  of  a  portion  of  the  brain  substance  which 
contains  within  it  a  cavity  filled  with  fluid,  this  cavity  communicating 
with  the  distended  lateral  ventricles. 

In  all  these  conditions  there  is  a  tumour,  usually  pedunculated,  of 
a  round  or  pyriform  shape,  with  a  smooth  or  lobulated  surface.     The 


MALFORMATIONS  OF  BRAIN    AND   MENINGES. 


695 


ordinary  size  is  that  of  a  mandarin  orange ;  it  may  be  as  small  as  a 
walnut,  or  as  large  as  the  patient's  head.  It  is  generally  covered  hv  the 
scalp,  which  is  often  denuded  of  hair;  but  it  may  be  covered  only  by 

granulation-tissue,  or  it  may  show 
a  central  cicatrix,  like  tliat  of 
spina  bifida.  Other  deformities, 
sucii  as  spina  bifida,  club-foot. and 
hare-lip  are  freijuently  present. 


Fig.  109. 


-Meningocele.   From  a  patient  in 
the  Babies'  Hospital. 


Fig.  110. — Frontal  Meningocele.  From 
a  patient  in  the  Babies'  Hospital. 


All  these  conditions  are  rare,  but  the  most  frequent  and  most  serious 
one  is  hydrencephalocele,  this  being  usually  associated  with  hydrocephalus. 
The  next  in  frequency  is  encephalocele,  which  has  the  best  prognosis. 
This  is  frequently  termed  hernia  cerebri.  If  fluid  is  present,  it  is  exter- 
nal to  the  brain.  In  meningocele  (Fig.  109)  there  is  simply  an  accumu- 
lation of  fluid,  which  communicates  by  a  small  opening  with  the  general 
arachnoid  cavity  of  the  brain. 

Of  105  cases  collected  by  Schatz,  59  occupied  the  occipital  region 
and  46  were  frontal.     The  aperture  through  which  the  occipital  pro- 
trusion takes  place  is  usually  in  the  median  line.     It  may  communicate 
with  the  posterior  fontanel,  with  the  foramen 
magnum,  or  with  the  cleft  of  a   spina  bifida. 
The  occipital  bone  may  be  divided  in  the  me- 
dian line,  or  rarely  it  may  be  absent. 

In  the  naso-frontal  form  (Fig.  Ill)  the  tu- 
mour is  usually  at  the  root  of  the  nose,  a  little 
to  one  side  of  the  median  line.  The  aperture 
is  most  frequently  between  the  cribriform  plate 
of  the  ethmoid  and  the  frontal  bones.  It  may  be 
between  the  lateral  halves  of  the  frontal  bone, 
causing  a  median  tumour.  The  point  of  pro- 
trusion may  also  be  the  lateral  region  of  the  skull,  generally  about 
the  lateral  fontanel,  or  along  the  line  of  the  sutures;  it  may  project 
into  the  mouth  or  the  pharynx.     These  anterior  tumours  are  usually 


Fig.  111. — Naso-frontal 
Meningocele.  Infant 
one  week  old. 


696  DISEASES  OF  THE   NERVOUS  SYSTEM. 

small,  although  large  ones  containing  the  anterior  lobes  of  the  brain  have 
been  seen. 

The  theory  of  the  origin  of  these  malformations  which  is  most  widely 
accepted  is  that  they  are  primarily  cases  of  intra-uterine  hydrocephalus, 
and  as  the  cranial  cavity  is  gradually  closed  by  the  development  of  the 
bones,  a  certain  portion  of  the  brain  is  left  outside. 

Symptoms. — The  tumour  is  always  congenital,  although  after  ])irth 
it  frequently  increases  very  much  in  size.  A  typical  tumour  is  round 
and  elastic,  usually  giving  evidence  of  fluid;  it  pulsates  synchronously 
with  the  heart;  during  screaming  or  forced  inspiration,  it  increases  in 
size;  partial  and  in  some  cases  complete  reduction  is  possible,  but  this  is 
usually  followed  by  marked  cerebral  symptoms,  even  by  con^Tllsions. 
After  partial  reduction,  an  opening  in  the  skull  may  often  be  made  out. 
Microcephalus  may  be  present,  or  there  may  be  unequal  development  of 
the  two  sides  of  the  head. 

The  following  differential  points  indicate  the  most  characteristic 
features  of  the  three  varieties:  In  meningocele,  the  tumour  is  at  first 
small,  but  increases ;  it  has  a  smooth  surface ;  it  is  pedunculated ;  there 
is  distinct  fluctuation,  perfect  translucency,  rarely  pulsation;  often 
it  is  completely  reducible;  compression  of  the  tumour  causes  cerebral 
symptoms;  the  skull  is  normal.  In  encephalocele,  the  tumour  is  small 
and  smooth ;  it  is  rarely  pedunculated ;  fluctuation  is  absent ;  it  is  not 
translucent;  there  is  distinct  pulsation;  it  is  usually  reducible;  pressure 
causes  cerebral  symptoms;  the  skull  is  normal.  In  hydrencephalocele, 
there  is  a  large  pendulous  tumour  with  an  irregular  or  lobulated  sur- 
face ;  it  is  pedunculated ;  translucency  is  rarely  complete ;  fluctuation  is 
distinct ;  it  is  irreducible ;  pressure  rarely  causes  symptoms ;  microcepha- 
lus and  other  deformities  are  often  associated. 

The  occipital  tumours  are  usually  more  serious  than  the  frontal  ones. 
The  majority  of  cases  die  in  the  course  of  the  flrst  few  weeks  of  life, 
death  resulting  from  meningitis,  convulsions,  or  rupture.  In  menin- 
gocele the  tumour  usually  grows  slowly,  and  ultimately  may  be  shut  off 
from  the  cranial  cavit}' ;  but  gradual  thinning  of  the  membrane  may  take 
place,  and  spontaneous  or  accidental  rupture  occur.  In  encephalocele  the 
tumour  grows  slightly,  or  not  at  all.  Most  of  these  patients  exhibit  signs 
of  mental  impairment  or  other  evidences  of  organic  brain  disease. 

Treatment. — According  to  Treves,  operation  is  justifiable  only  in 
case  of  impending  rupture.  The  conditions  present  are  essentially  the 
same  as  in  spina  bifida.  Meningocele  may  be  aspirated  or  the  sac  may 
be  laid  open  and  a  plastic  operation  performed  for  the  closure  of  the 
communication  with  the  cranial  cavity;  or  the  skin  may  be  divided,  and 
a  ligature  or  clamp  applied  to  shut  off  the  communication  with  the 
brain.  All  these  methods  have  been  at  times  successful,  but  recovery 
has  in  many  instances  been  followed  by  the  development  of  chronic 


MALFORMATIONS  OF   BRAIN   AND   MENINGES.  697 

hydrocephalus.  Encephalocele  is  to  bo  treated  by  protection  and  com- 
pression. Aspiration  may  be  resorted  to  if  fluid  is  present.  In  hydren- 
cephalocele  the  prognosis  is  absolutely  bad  under  all  circumstances. 
Schatz  gives  the  following  statistics,  sliowing  the  results  with  and  with- 
out operation,  all  varieties  being  included:  Of  twenty-four  occipital 
tumours  not  operated  on,  tliree  recovered  ;  of  thirty-five  operated  on  by 
excision,  ligation,  or  injection,  six  recovered.  Of  forty-six  frontal  tu- 
mours, there  were  six  recoveries  in  tliirty-two  cases  without  operation, 
and  two  recoveries  in  fourteen  cases  with  operation. 

Microcephalus. — This  is  often  regarded  as  due  to  premature  ossi- 
fication of  the  skull ;  but  the  hypothesis  is  certainly  inadequate  to  ex- 
plain all  or  even  most  of  the  cases.  In  many  children  suffering  from 
marasmus,  the  sutures  ossify  and  the  fontanels  close  much  earlier  than 
in  healthy  infants  of  the  same  age,  chiefly  because,  with  the  rest  of  the 
body,  the  brain  also  has  ceased  to  grow.  In  microcephalus,  I  l)elieve 
it  usually  to  be  the  case  that  the  early  ossification  of  the  skull  is  due 
to  arrested  growth  of  the  brain,  and  not  the  reverse.  The  reasons  for 
the  developmental  arrest  in  the  brain  are  for  the  most  part  unknown. 

It  is  well  known  that  there  is  not  an  invariable  relation  between  the 
size  of  the  head  and  the  size  of  the  brain,  although  generally  the  two 
correspond.  If  the  circumference  of  the  head  is  much  below  the  average 
for  the  age  (see  introductory  chapters),  and  relatively  much  less  than 
the  measurements  of  the  rest  of  the  body,  microcephalus  may  be  assunied 
to  exist.  Sachs  calls  attention  to  the  fact  that  the  circumference  of  the 
head  may  be  nearly  normal  and  yet  the  essential  conditions  of  micro- 
cephalus exist,  owing  to  imperfect  development  of  the  anterior  part  of 
the  brain. 

The  symptoms  of  microcephalus  are  those  of  mental  deficiency  and 
cerebral  paralysis,  existing  in  all  possible  combinations  and  with  variable 
degrees  of  severity. 

The  essential  condition  in  microcephalus  being  an  arrest  in  the  devel- 
opment of  the  brain,  it  is  not  difficult  to  understand  why  the  operation 
of  craniectomy  once  thought  so  promising  has  been  generally  abandoned. 
The  results  do  not  justify  any  other  operative  measures  yet  proposed 
for  the  relief  of  these  cases. 

Congenital  Hydrocephalus. — These  cases  may  fairly  be  considered  as 
belonging  in  this  group,  although  they  are  discussed  elsewhere. 

Porencephalus  (literally,  a  hole  in  the  brain)  is  a  condition  in  which 
there  is  a  large  depression  in  some  part  of  the  brain,  but  with  surround- 
ing parts  well  developed.  Such  depressions  may  involve  a  whole  lobe, 
and  they  may  be  deep  enough  to  reach  the  lateral  ventricles. 

Porencephalus  is  described  as  congenital  or  acquired.  In  the  con- 
genital form,  the  defect  is  usually  found  in  the  anterior  or  middle  part 
of  the  brain.    The  origin  of  these  conditions  is  still  a  disputed  question. 


698  DISEASES  OF  THE   NERVOUS  SYSTEM. 

They  are  probably  due  to  early  vascular  changes.  Children  sometimes 
live  several  years  with  very  large  defects,  the  symptoms  depending  upon 
the  seat  of  the  lesion.  The  acquired  form  of  porencephalus  is  usually 
one  of  the  late  results  of  meningeal  haemorrhage.  It  may  affect  one  or 
both  sides.  Such  cases  present  the  symptoms  of  spastic  paralysis — 
usually  diplegia.  In  all  cases  with  large  brain  defects,  the  space  is  filled 
with  fluid. 

PACHYMENINGITIS. 

Pachymeningitis,  or  inflammation  of  the  dura  mater,  occurs  both  as 
an  acute  and  a  chronic  disease. 

Acute  Pachymeningitis. — This  is  very  rare  in  children.  Only  pachy- 
meningitis externa  is  generally  included  under  this  term,  as  acute  pachy- 
meningitis interna  does  not  occur  alone,  but  usually  with  inflammation 
of  the  pia  mater  (leptomeningitis).  It  may  be  associated  with  disease 
or  injury  of  the  bones  of  the  skull,  but  is  most  frequently  seen  in  con- 
nection with  middle-ear  disease.  It  generally  begins  as  a  localised  proc- 
ess, but  the  inflammation  may  extend  to  the  inner  layer  of  the  dura, 
and  to  the  pia  mater;  or  it  may  remain  circumscribed,  and  terminate 
in  the  formation  of  an  abscess  between  the  dura  mater  and  the  bone. 

The  symptoms  of  acute  pacMTneningitis  are  distinctive  only  when 
the  process  is  localised.  They  are  then  usually  associated  with  middle- 
ear  disease,  and  are  indistinguishable  from  those  of  cerebral  abscess. 
The  treatment  is  surgical. 

Chronic  Pachymeningitis. — This,  in  children,  almost  invariably  af- 
fects the  inner  layer  of  the  dura  mater  (pachymeningitis  interna) ;  it  is 
also  known  as  pseudo-rnemhranous  and  as  hcemorrhagic  pachymeningitis 
or  hcBmatoma  of  the  dura  mater.  Its  causes  are  for  the  most  part  un- 
known. It  is  a  rather  rare  condition,  being  usually  discovered  at  autopsy 
in  children,  chiefly  cachectic  infants,  who  have  died  of  other  diseases. 

Two  classes  of  cases  are  to  be  distinguished — those  with,  and  those 
without  extensive  haemorrhages.  In  the  latter  group  there  is  found  a 
thin,  translucent,  vascular  membrane  lining  the  inner  surface  of  the 
dura.  It  may  be  only  a  delicate  film  which  can  be  scraped  off;  it  may  be 
as  thick  as  ordinary  blotting-paper,  or  even  twice  that  thickness.  The 
membrane  is  often  oedematous ;  it  is  exceedingly  vascular,  and  the  vessels 
have  very  thin  walls.  There  are  usually  scattered  punctate  haemor- 
rhages, and  there  may  be  a  few  of  larger  size.  This  membrane  may  cover 
the  whole  inner  surface  of  the  dura,  but  in  most  cases  it  is  principally 
over  the  convexity  and  may  be  found  only  here;  it  is  apt  to  be  more 
upon  one  side  than  upon  the  other.  In  cases  of  long  standing  there  may 
be  adhesions  between  the  dura  and  the  pia.  When  large  haemorrhages 
have  taken  place,  quite  a  different  pathological  appearance  is  presented. 
The  lesions  found  in  a  case  upon  which  I  made  an  autopsy  in  the  New 


PACHYMENINGITIS.  699 

York  Infant  Asylum  are  fairly  typical :  The  infant  was  six  months  old, 
and  the  symptoms  had  existed  for  six  days.  Tlie  fontanel  was  hulging 
to  a  marked  degree,  and  the  sagittal  and  coronal  sutures  were  separated. 
A  thin  recent  clot  from  one-eighth  to  one-fourth  of  an  inch  in  thickness 
covered  nearly  the  whole  of  the  right  hemisphere  and  part  of  the  con- 
vexity of  the  left.  The  entire  dura  was  lined  both  at  its  convexity  and 
base  by  a  pseudo-membrane  of  grayish  color,  about  one-sixteenth  of  an 
inch  in  thickness.    The  brain  was  aujemic. 

In  cases  of  longer  standing  partial  organisation  of  the  clot  may  be 
seen;  in  more  recent  ones  the  blood  is  partly  or  entirely  fluid.  I  once 
found  acute  leptomeningitis  with  a  purulent  exudation,  associated  with 
haemorrhagic  pachymeningitis.  In  cases  where  life  is  prolonged  for 
years,  there  may. be  partial  or  even  complete  absorption  of  the  clot, 
followed  by  the  formation  of  cysts,  considerable  inflammatory  thicken- 
ing of  the  pia  with  deposits  of  blood  pigment,  and  finally  atrophy  and 
sclerosis  of  the  cortex.  The  source  of  the  hgemorrliage  may  be  the  rup- 
ture of  a  single  large  vessel,  but  more  frequently  the  blood  comes  from 
many  small  vessels. 

Symptoms. — These  are  due  to  the  haemorrhage,  and  not  to  the  inflam- 
matory process.  Until  haemorrhage  occurs  there  are  no  symptoms  by 
which  the  disease  can  be  recognised.  Thus  in  many  of  the  cases  in  which 
pachymeningitis  is  found  at  autopsy,  its  existence  is  not  suspected  dur- 
ing life.  The  occurrence  of  haemorrhage  is  sometimes  marked  by  vomit- 
ing or  convulsions,  and  usually  there  is  loss  of  consciousness.  It  may 
be  a  question  whether  the  convulsions  are  the  cause  or  the  result  of 
the  haemorrhage.  In  most  cases  they  seem  to  be  the  result.  They  are 
usually  general  and  repeated.  If  the  haemorrhage  occurs  slowly,  there 
may  be  stupor  without  convulsions  until  nearly  the  close  of  the  disease. 
In  the  fatal  eases  the  symptoms  generally  continue  from  two  days  to  a 
week.  There  are  dulness,  stupor,  and  finally  coma,  death  occurring  in 
coma  or  convulsions.  If  the  haemorrhage  is  diffuse — and  this  is  apt  to 
be  the  case — there  is  rigidity  of  all  the  extremities;  if  it  is  of  one  side 
only,  the  rigidity  affects  only  one  arm  and  leg.  The  pupils  are  more 
frequently  contracted,  but  may  be  dilated  or  unequal.  There  is  diplegia, 
hemiplegia,  or  monoplegia,  according  to  the  seat  and  extent  of  the 
haemorrhage.  The  respiration  is  slow  and  irregular  and  may  be  of  the 
Cheyne-Stokes  variety.  The  pulse  is  slow,  irregular,  and  sometimes 
intermittent.  The  temperature  is  at  first  normal,  but  rises  slowly  until 
death  occurs,  when  it  is  from  100°  to  103°  F.  Generally  the  cranial 
nerves  are  not  affected,  and  opisthotonus  is  absent.  The  knee-jerk  is 
often  exaggerated.  In  cases  which  do  not  prove  fatal — these  being  chiefly 
in  older  children — we  have  a  similar  onset,  but  after  a  few  days  con- 
sciousness is  regained,  and  only  hemiplegia  or  monoplegia  remains. 
The  course  of  the  paralysis  is  that  seen  after  meningeal  hasmorrhage 


700  DISEASES  OF  THE  NERVOUS  SYSTEM. 

due  to  other  causes.  Wagner  has  reported  a  case  in  which  recurring 
hsemorrhages  took  place  at  intervals  of  several  months,  the  autopsy 
showing  distinct  evidences  of  both  old  and  recent  lesions. 

Paciiynieniugitis,  1  am  inclined  to  believe,  plays  a  much  more  im- 
portant role  in  the  production  of  meningeal  hemorrhages  in  children 
than  has  generally  been  accorded  to  it.  From  the  frequency  with  which 
this  lesion  is  found  as  a  cause  of  sudden  meningeal  hsemorrhages  which 
are  fatal,  it  is  not  unlikely  that  some  of  the  cases  which  recover  with  hemi- 
plegia or  monoplegia,  may  be  due  to  the  same  cause. 

The  prognosis  depends  upon  the  age  of  the  patient  and  the  extent  of 
the  haemorrliage.  Extensive  haemorrhages  are  usually  fatal  in  infancy, 
but  small  ones  are  seldom  so,  for  they  are  rarely  at  the  base. ,  The  prog- 
nosis of  the  paralysis  in  cases  not  terminating  fatally  is  the  same  as 
after  meningeal  hemorrhage  due  to  other  causes,  with  perhaps  an  added 
liability  to  recurrent  attacks. 

Without  large  hemorrhages,  pachymeningitis  interna  can  not  be 
diagnosticated;  and  it  is  impossible  to  differentiate  the  haemorrhagic 
cases  from  other  varieties  of  meningeal  hemorrhage.  It  is  important  to 
make  a  diagnosis  between  pachymeningitis  with  hemorrhage,  and  acute 
simple  meningitis.  In  the  former  there  is  a  sudden  onset;  stupor  oc- 
curring early,  usually  on  the  first  day,  gradually  diminishing  in  cases  of 
recovery,  or  deepening  into  coma  in  fatal  cases;  localised  or  general 
paralysis,  also  occurring  early;  there  is  no  fever  in  the  beginning,  and 
only  moderate  fever  at  the  close.  In  acute  meningitis  there  is  usually 
a  higher  temperature,  especially  early  in  the  disease;  coma  develops 
later,  and  rigidity  of  the  extremities  is  less  pronounced.  In  certain 
cases,  however,  when  the  hemorrhage  occurs  in  the  course  of  some  other 
disease,  a  differential  diagnosis  may  be  impossible. 

Treatment. — The  treatment  of  pachymeningitis  hemorrhagica  is 
symptomatic.  The  indications  are,  to  relieve  cerebral  congestion  by 
applying  ice  to  the  head,  to  allay  irritative  symptoms  by  the  use  of 
bromides,  and  to  keep  the  patient  perfectly  quiet. 

ACUTE  MENINGITIS. 

Several  different  varieties  of  acute  meningitis  are  met  with  in  chil- 
dren. Cerebro-spinal  meningitis  is  the  only  form  which  occurs  epidem- 
ically ;  but  this  is  also  seen  as  a  sporadic  disease.  It  is  due  to  a  specific 
organism,  the  meningococcus.  There  are  several  other  forms  of  acute 
meningitis  which  more  or  less  closely  resemble  cerebro-spinal  meningitis 
clinically,  and  which  were  for  a  long  time  confounded  with  it.  Pneu- 
mococcus  and  influenza  meningitis  are  usually  secondary  inflammations, 
but  sometimes  are  apparently  primary.  The  typhoid  bacillus  and  the 
gonococcus  may  cause  acute  meningitis,  but  very  rarely  in   children. 


CEREBRO-SPINAL   MENINGITIS.  701 

Acute  meningitis  may  be  due  to  any  of  tlie  pyo-renic  organisms.  This 
is  sometimes  spoken  of  as  "  septic  "  meningitis,  and  is  almost  invariably 
secondary.  Finally,  tliere  is  tuberculous  meningitis,  altogether  the  most 
common  variety  in  young  children  except  during  epidemics  of  cerebro- 
spinal meningitis. 

Some  idea  of  the  relative  frequency  of  the  different  forms  of  acute 
meningitis  as  seen  apart  from  epidemics,  may  be  gained  from  the  fol- 
lowing figures  which  give  the  number  of  cases  occurring  in  the  Babies' 
Hospital  for  a  series  of  years,  the  diagnosis  in  every  case  being  made  by 
lumbar  puncture  or  by  autopsy.  The  patients  were  nearly  all  under 
three  years  of  age.     The  organism  found  was  as  follows: 

Tubercle  bacillus 157  cases. 

Pneumocoecus 23      " 

Meningococcus  (sporadic) 24      " 

Staphylococcus  or  streptococcus 11      " 

Influenza  bacillus 5      " 

Colon  bacillus 1      " 

CEREBRO-SPINAL   MENINGITIS. 
(Epidemic  Meningitis;  Cerebrospinal  Fever.) 

Epidemics  of  cerebro-spinal  meningitis  are  separated  by  quite  long 
intervals  and  occur  without  any  assignable  cause.  The  following  chart 
(Fig.  112)  represents  the  prevalence  of  the  disease  in  New  York  City 
during  forty  years.  But  little  was  seen  of  cerebro-spinal  meningitis  until 
the  epidemic  of  1872.     Since  that  time  a  certain  number  of  deaths  from 


cs 

^ 

CO 

K 

;:: 

s 

oo 

oo 

oo 

oo 

at 

o> 

en 

o> 

s    \ 

S 

g 

s 

s 

5 

g 

I0( 

10( 

90 

90 

80 

80 

70 

\ 

70 

60 

j 

\ 

60 

SO 

50 

40 

\ 

40 

30 

\ 

/ 

\ 

30 

20 

\ 

A 

n 

\ 

V 

20 

10 

^ 

/ 

V 

J 

>\ 

\^ 

>. 

7 

\ 

10 

_o 

- 

J 

■- 

"*" 

-V 

-*• 

-^ 

^ 

-»-■' 

~^ 

V 

0 

Fig.  112. — Chart  showing  Deaths  from  Cerebro-spinal  Meningitis  in  New  York 
City,  for  Forty  Years,  per  100,000  of  Population. 

this  cause  have  occurred  each  year ;  but  there  have  been  seen  about  onee 
in  ten  years  epidemics  of  greater  or  less  severity.  The  most  important 
one  was  that  of  1904-5.  After  each  epidemic,  for  two  or  three  years, 
the  disease  is  prevalent,  but  it  occurs  with  gradually  lessening  frequency 
until  the  average  incidence  is  reached.     What  has  been  said  of  New 


702  DISEASES  OF  THE  NERVOUS  SYSTEM. 

York  is  true  of  almost  every  large  city.  In  remote  country  towns, 
epidemics  are  occasionally  witnessed,  and  after  prevailing  a  few  months 
the  disease  disappears  as  mysteriously  as  it  came.  Epidemics  are  usually 
seen  in  the  winter  and  early  spring,  lasting  for  several  inontlis,  gen- 
erally reaching  their  height  in  March  or  April  and  slowly  subsiding  as 
warm  weather  approaches. 

With  reference  to  the  cause  of  epidemics  very  little  is  known.  When 
the  disease  prevails  in  cities  it  occurs  especially  in  crowded  tenements, 
being  relatively  infrequent  in  private  houses. 

Cerebro-spinal  meningitis  has  only  recently  been  included  among 
the  communicable  diseases.  In  a  series  of  observations  made  by  the 
New  York  Health  Department  the  meningococcus  was  found  in  the 
nasal  secretion  of  fifty  per  cent  of  the  cases  of  meningitis  examined 
during  the  first  two  weeks  of  the  disease.  It  was  found  in  the  nasal 
mucus  in  ten  per  cent  of  the  persons  in  close  contact  with  cases.  In 
Flexner's  experiments  upon  monkeys  he  found  tlie  organism  in  tlie  nasal 
mucus  after  animals  had  been  inoculated  by  way  of  the  spinal  canal. 
These  observations  indicate  that  the  nasal  mucosa  is  a  common  avenue  of 
infection  and  probably  also  a  channel  of  elimination.  The  degree  of 
communicability  when  compared  with  the  common  contagious  diseases 
seems  very  slight.  In  fully  seventy  per  cent  of  the  cases  investigated 
in  the  New  York  epidemic  of  1904-5,  but  one  person  in  a  household  was 
affected,  although  no  effort  at  isolation  was  made.  I  have  never  known 
the  disease  to  originate  in  a  hospital  patient,  although  in  New  York 
cases  of  cerebro-spinal  meningitis  have  been  until  very  recently  received 
into  the  general  wards  with  other  patients.  Sporadic  cases  of  menin- 
gitis occur  after  epidemics,  and  quite  apart  from  them  without  apparent 
cause,  and  it  is  very  exceptional  that  any  connection  with  a  previous 
case  can  be  established.  About  fifty  per  cent  of  the  cases  of  cerebro- 
spinal meningitis  occur  in  children  under  five  years,  and  about  twelve 
per  cent  in  those  under  one  year.  The  youngest  case  I  have  seen  was 
in  an  infant  six  weeks  old. 

The  specific  organism  of  cerebro-spinal  meningitis  is  the  diplococcus 
intracellularis  of  Weichselbaum  or,  as  it  is  now  generally  designated, 
the  meningococcus.  It  is  present  in  the  meningeal  exudate,  in  the 
cerebro-spinal  fluid  obtained  by  lumbar  puncture,  and  in  some  cases  can 
be  demonstrated  in  the  blood,  the  lungs,  and  other  organs,  sometimes 
in  the  large  joints.  It  is  almost  invariably  found  in  pairs  or  tetrads 
within  the  leucocytes.  It  is  decolourised  when  stained  by  Gram's  method. 
Outside  the  body  the  organism  is  unknown. 

Lesions. — In  epidemic  meningitis  death  may  take  place  so  early  that 
the  changes  found  at  autopsy  are  slight.  There  may  be  only  a  serous 
exudation  and  intense  hyperaemia,  which  is  doubtless  much  less  marked 
after  death  than  during  life.     The  cerebro-spinal  fluid  is  turbid  and 


CEREBROSPINAL   MENINGITIS.  703 

much  increased  in  amount.  The  microscope,  liowever,  may  show,  even 
in  these  early  cases,  an  abundant  exudation  of  leucocytes  in  the  pia 
mater.  After  the  third  day  the  lesions  are  ((uite  uniform.  The  con- 
volutions appear  somewhat  flattened  from  pressure  due  to  distention  of 
the  ventricles.  The  inner  surface  of  the  (hira  is  usually  normal  or  only 
congested.  There  may  be  thrombi  in  any  of  the  cerebral  sinuses,  or  in 
the  meningeal  veins  of  the  convexity.  There  is  an  exudation  of  greenish- 
yellow  fibrin,  which  is  sometimes  very  abundant.  It  is  generally  widely 
distributed,  but  is  most  marked  over  the  anterior  half  of  the  brain  and 
at  the  base.  In  some  cases  it  is  limited  to  the  base,  but  very  rarely 
limited  to  the  convexity.  There  is  an  increase  in  the  quantity  of  cerebro- 
spinal fluid.  The  ventricles  are  moderately  distended  with  serum  or 
sero-pus,  and  their  walls  may  be  slightly  softened.  The  brain  substance 
of  the  cortex  may  be  reddened  or  may  appear  normal.  In  the  meninges 
of  the  cord,  lesions  similar  to  those  of  the  brain  are  usually  seen.  The 
exudation  is  principally  upon  the  posterior  surface,  and  may  extend 
throughout  the  entire  length  of  the  cord,  or  be  limited  to  its  upper  or 
to  its  lower  portion. 

Microscopical  examination  shows  the  exudation  to  consist  of  fibrin 
and  pus  cells,  which  infiltrate  the  pia  mater.  The  superficial  layers  of 
the  cortex  in  the  inflamed  areas  often  show  minute  haemorrhages  and 
very  marked  cell-infiltration.  Minute  abscesses  may  be  present.  Very 
marked  degenerative  changes  can  usually  be  demonstrated  in  the  nerve 
cells  themselves.  The  cells  of  the  neuroglia  are  also  affected;  they  are 
swollen  and  increased  in  number;  and  there  may  be  proliferation  of  the 
connective  tissue  about  the  blood  vessels.  Changes  similar  to  those  just 
described  may  be  found  in  the  cord,  but  these  are  less  frequent  and  as 
a  rule  much  less  severe  than  those  in  the  brain.  Inflammatory  products 
are  sometimes  present  in  the  central  canal  of  tfte  cord  and  in  the  walls 
of  the  lateral  ventricles  of  the  brain.  The  inflammatory  process  fre- 
quently extends  along  the  cranial  nerves,  especially  the  auditory  and 
optic,  and  this  may  result  in  otitis  or  choroiditis ;  from  the  cord,  it  may 
extend  along  either  the  anterior  or  posterior  nerve  roots.  Descending 
degeneration  is  found  in  the  nerves  both  of  the  brain  and  cord. 

In  patients  that  die  after  the  disease  has  lasted  two  or  three  months, 
the  later  results  of  these  lesions  may  be  seen.  There  is  usually  present  a 
chronic  meningo-encepiialitis,  sometimes  difihise,  sometimes  localised. 
The  pia  mater  is  cloudy,  thickened,  and  frequently  adherent  to  the 
brain.  Here  and  there  are  seen  small,  yellow,  opaque  patches  which  are 
the  result  of  fatty  changes  in  the  cells  and  fibrin  of  the  exudate,  with 
some  proliferation  of  connective  tissue.  The  lesions  are  usually  most 
marked  at  the  base,  where  the  thickening  of  the  meninges  and  the  ad- 
hesions may  lead  to  the  development  of  a  secondary  hydrocephalus. 

In  cases  which  have  lasted  a  much  longer  time  the  most  marked 


704  DISEASES  OF  THE   NERVOUS  SYSTEM. 

changes  are  in  the  brain  substance.  Tliere  may  be  generalised  menin- 
geal adhesions/  with  a  diffuse  cortical  atrophy,  but  more  frequently  there 
are  areas  of  sclerosis,  especially  over  the  frontal  and  temporo-sphenoidal 
lobes,  with  which  there  are  almost  always  associated  marked  descending 
degenerative  changes  in  the  cord.  Such  lesions  are,  of  course,  perma- 
nent, and  seriously  interfere  not  only  with  the  functions,  but  also  with 
the  growth  and  development  of  the  brain. 

The  visceral  lesions  most  frequently  found  in  epidemic  meningitis 
are  pulmonary.  There  may  be  lobar  or  broncho-pneumonia,  and  in  the 
lungs  may  be  found  the  same  organism  as  in  the  brain.  Acute  de- 
generation of  the  liver  and  kidneys  is  also  frequent.  The  other  viscera 
are  seldom  affected.  Occasionally  suppurative  inflammation  of  the  joints 
occurs. 

Symptoms. — The  symptoms  of  cerebro-spinal  meningitis  do  not  differ 
essentially  in  the  sporadic  and  epidemic  cases,  except  that  the  most 
severe  forms  of  the  disease  are  seen  in  the  latter.  Tlie}'  may  be  divided 
into  several  quite  distinct  groups: 

1.  Hyper-acute  Form. — Cases  of  this  kind  are  rarely  seen  except  in 
an  epidemic,  and  usually  occur  at  its  height.  The  onset  is  very  abrupt, 
the  course  short  and  intense,  and  death  may  take  place  in  from  twelve 
to  thirty-six  hours.  The  following  case  illustrates  this  type:  A  little 
girl  of  ten  years  was  well  enough  at  2  p.m.  to  carry  a  bundle  of  clothes 
a  dozen  city  blocks.  Eeturning  home,  she  complained  of  intense  liead- 
ache,  vomited  frequently,  and  was  so  weak  that  she  was  obliged  to  go  to 
bed.  In  a  few  hours  she  passed  into  deep  coma,  with  very  high  fever, 
and  died  at  11  p.m. 

The  earliest  symptoms  are  usually  intense  headache,  repeated  attacks 
of  vomiting,  and  very  high  fever.  There  is  great  prostration  and  the 
nervous  symptoms  increase  so  rapidly  that  in  a  few  hours  the  patient 
may  become  comatose  and  death  occur  in  a  short  period.  The  tempera- 
ture rises  rapidly  to  103°  or  104°,  sometimes  to  106°  F.  A  few  petechial 
spots  may  be  discovered  over  the  face,  chest,  or  extremities.  There  is 
usually  no  rigidity,  but  rather  general  relaxation.  The  pulse  is  weak, 
in  most  cases  rapid,  but  sometimes  slow  and  irregular.  The  respiration 
is  usually  irregular  both  in  frequency  and  depth. 

*  This  lesion  and  its  effects  are  well  illustrated  by  one  of  my  own  patients  who 
died  six  months  after  an.  attack.  She  was  a  bright  little  girl  of  four  and  a  half  years, 
and  had  a  typical  attack  of  meningitis  of  moderate  severity.  Convalescence  was 
slow,  but  at  the  end  of  two  months  recovery  was  perfect  in  everything  but  her  mental 
condition.  She  remembered  nothing  which  she  had  previously  learned  in  the  kinder- 
garten, where  she  had  been  an  exceptionally  bright  pupil  Her  mind  was  a  blank. 
She  was  dull,  listless,  and  her  face  had  a  vacant,  idiotic  expression.  The  special 
senses  seemed  unaffected,  and  her  speech  was  retained.  She  died  during  an  attack 
of  convulsions.  At  the  autopsy  the  pia  was  everywhere  thickened  and  adherent, 
while  in  the  cortex  were  present  the  earlier  changes  of  a  general  encephalitis. 


CEREBRO-SPINAL   MENINGITIS. 


705 


The  symptoms  appear  to  be  due  to  two  factors :  First,  tlie  intensity 
of  the  infection;  second,  the  rapid  accumulation  of  cerebro-spinal  fluid, 
causing  coma  with  cardiac  and  respiratory  paralysis.  TIsually  both 
these  factors  are  present,  but  I  believe  that  the  second  one  is  the  more 
important.  In  support  of  this  view  is  tbe  striking  infrequency  of  cases 
of  this  type  in  infants  with  an  open  fontanel.  Should  the  patient  sur- 
vive the  violence  of  the  onset,  a  period  of  reaction  occurs,  and  after  a 
day  or  two  the  disease  follows  the  regular  course. 

2.  Usual  Form. — In  this  also  the  onset  is  generally  abrupt,  but  not 
so  violent  as  in  the  cases  just  described.  It  may  be  marked  by  intense 
headache,  vomiting,  convulsions,  delirium,  chills,  and  fever  with  general 
hyperaesthesia  and  rigidity.  The  initial  temperature  is  from  101°  to 
104°  F.  Opisthotonus,  with  severe  pains  in  the  back  of  the  neck  and 
along  the  spine,  and  general  muscular  rigidity  are  usually  present. 
There  is  often  active  delirium,  but  rarely  stupor  or  coma.  The  pulse 
is  generally  rapid,  120  to  150,  and  sometimes  irregular.  The  respira- 
tion is  often  slightly  irregular,  and  it  may  be  rapid  or  slow.  The  erup- 
tion is  not  so  frequently  seen  as  in  the  very  acute  cases. 

As  the  disease  progresses,  the  nervous  symptoms  often  change  but 
little  from  day  to  da}^  for  two  or  three  weeks.     They  are  mainly  of  the 


Fig.  II3.-.-P0STURE  IN  Cerebro-spinal  Meningitis.     (Smith.) 


irritative  type — moderate  delirium,  extreme  hyperaesthesia,  tremor  and 
muscular  rigidity.  The  posture  is  quite  characteristic  (Fig.  113). 
Owing  to  the  opisthotonus  the  child  can  not  lie  upon  the  back,  but  rests 
upon  the  side,  with  arched  spine  and  neck,  and  general  flexion  of  the 
extremities.  There  is  a  rather  rapid  loss  in  weight,  steadily  increasing 
prostration,  and  a  weak,  rapid  pulse.  The  bowels  are  usually  constipated. 
From  time  to  time  attacks  of  vomiting  occur.  In  most  cases  there  is 
considerable  difficulty  in  feeding.  The  duration  of  this  form  of  the  dis- 
ease is  from  three  to  six  weeks.  The  course  is  often  marked  by  periods 
of  remission  and  exacerbation.  If  recovery  is  to  take  place,  the  tem- 
46 


706  DISEASES  OF  THE  NERVOUS  SYSTEM. 

perature  gradually  falls  to  normal  and  often  at  times  it  is  subnormal. 
The  mind  becomes  clear,  and  one  by  one  the  nervous  symptoms  dis- 
appear, the  muscular  rigidity  being  usually  the  last  to  go.  Convalescence 
is  always  protracted. 

In  cases  ending  fatally,  the  patient  usually  passes  into  a  deep  stupor 
or  coma,  with  extreme  prostration,  a  slow,  weak,  irregular  pulse,  shallow 
respiration  of  the  Cheyne-Stokes  variety,  sunken  abdomen,  general  re- 
laxation, and  death  occurs  from  exhaustion  or  from  broncho-pneumonia. 

Occasionally  the  attack  is  much  prolonged,  the  fever  and  all  the 
active  symptoms  continuing  from  eight  to  twelve  weeks.  Emaciation 
sometimes  becomes  extreme,  and  with  a  few  nervous  symptoms  may  con- 
tinue long  after  the  fever  ceases.  In  infants,  death  is  often  due  to 
marasmus.  While  a  fatal  outcome  is  more  frequent  in  these  prolonged 
cases,  not  a  few  recover  completely,  even  when  symptoms  have  lasted 
for  eight  or  ten  weeks. 

3.  Mild  Form. — Especially  toward  the  end  of  an  epidemic,  and  some- 
times occurring  sporadically,  there  are  seen  cases  which  in  their  onset 
and  for  the  first  two  or  three  days  resemble  those  just  described;  but 
instead  of  running  the  usual  course,  the  fever  and  the  nervous  symptoms 
subside  rapidly  and  convalescence  is  established  early. 

4.  Chronic  Form. — Owing  sometimes  to  the  extent,  sometimes  to  the 
position  of  the  lesions,  the  disease  does  not  subside  at  the  usual  time, 
but  nervous  symptoms  continue  after  the  temperature  and  most  of  the 
other  constitutional  symptoms  have  passed  away.  These  cases  are  chiefly 
of  the  basilar  tyipe,  and  often  lead  to  the  development  of  chronic  basilar 
meningitis  with  secondary  hydrocephalus.  They  are  more  fully  con- 
sidered in  a  later  chapter. 

Onset. — One  of  the  most  striking  features  of  this  disease  is  the  ab- 
ruptness with  which  it  develops.  Occasionally  there  are  indefinite  sjmip- 
toms  for  a  day  or  two  before  active  symptoms  begin ;  but  in  the  great 
majority  not  only  the  day,  but  the  hour  of  the  onset  is  definitely  marked. 
The  most  frequent  initial  symptoms  are  the  simultaneous  occurrence  of 
severe  headache  and  vomiting,  followed  by  high  fever  and  marked  pros- 
tration. The  vomiting  is  usually  repeated,  projectile,  and  has  no  relation 
to  meals.  Convulsions  occurred  in  the  beginning  of  thirty  per  cent  of 
my  cases.  Occasionally  a  decided  chill  is  seen.  After  twenty-four  hours 
acute  general  pains  and  hyperesthesia  are  usually  present,  together  with 
rigidity  of  the  muscles  of  the  neck  and  extremities,  giving  rise  to  opis- 
thotonus and  muscular  contractions. 

Skin. — Eruptions  upon  the  skin  vary  much  in  frequency  in  different 
eases  and  in  different  epidemics.  The  most  characteristic  one  is  the 
appearance  of  small  punctate  haemorrhages,  resembling  flea  bites;  they 
are  not  numerous,  but  may  be  found  on  almost  any  part  of  the  body, 
most  frequently  upon  the  extremities,  the  upper  part  of  the  chest,  and 


CEREBRO-SPINAL   MENINGITIS.  707 

neck.  In  my  experience  they  have  heen  present  in  about  fourteen  per 
cent  of  the  cases.  Sometimes  larger  hemorrhages  are  present.  From 
this  symptom  the  name  "spotted  fever"  has  arisen.  This  petechial 
eruption  belongs  to  the  early  stage  of  the  disease,  fades  quickly,  and  is 
rarely  visible  after  the  third  or  fourth  day.  In  some  cases  a  general 
erythema  is  present;  in  others,  an  eruption  closely  resembling  measles. 
Herpes  upon  the  lips  and  face  is  common  in  older  children,  but  is  rare 
in  infants.  Bed-sores  have  been  seen  in  about  one-third  of  my  cases. 
They  are  found  over  pressure  points — the  trochanter,  the  malleoli,  and 
the  side  of  the  head;  in  several  instances  the  ear  has  been  the  part 
affected. 

Nervous  System. — Headache  is  a  frequent  initial  symptom  and  is 
usually  severe ;  it  is  more  often  frontal  than  elsewhere,  and  may  be  asso- 
ciated with  vertigo.  There  are  acute  pains  in  the  back  of  the  neck,  along 
the  spine,  and  marked  general  hypersesthesia,  which  is  often  so  intense 
that  any  movement  of  the  body  causes  agonising  cries.  This  is  one  of 
the  most  striking  symptoms  of  the  disease,  and  may  continue  throughout 
the  acute  stage.  The  mental  state  varies  much  in  different  cases.  De- 
lirium is  frequent  in  the  early  stage  of  the  severe  form;  it  is  usually 
wild  and  active.  After  delirium  a  stage  of  dulness  or  apathy  ensues, 
giving  place  to  great  irritability  when  the  patient  is  disturbed.  Con- 
vulsions are  sometimes  seen  early,  but  are  seldom  repeated  in  the  course 
of  the  disease  or  toward  its  close.  There  is  rarely  continuous  or  deep 
coma  except  toward  the  end  of  fatal  cases.  In  some  cases  with  high  tem- 
perature and  quite  severe  symptoms,  after  the  subsidence  of  a  short 
early  stage  of  excitement  or  delirium,  the  mind  remains  perfectly  clear 
throughout  the  attack.  Under  these  circumstances  an  erroneous  diag- 
nosis is  often  made,  particularly  if  the  physician  has  not  observed  the 
case  from  the  beginning. 

Tonic  spasm  of  the  various  muscular  groups  is  one  of  the  most  char- 
acteristic features  of  this  disease  and  is  seldom  absent.  Like  the  hyper- 
aesthesia  it  is  persistent.  The  rigidity  and  contraction  of  the  muscles 
of  the  neck  and  back  produce  cervical  or  general  opisthotonus;  cervical 
opisthotonus  is  most  marked  with  lesions  chiefly  at  the  base,  and  may 
be  wanting  in  the  rare  cases  when  the  lesion  is  almost  entirely  at  the 
convexity.  Tonic  spasm  of  the  extremities  usually  causes  general  flexion 
of  the  thighs,  legs,  and  arms.  Late  in  the  disease  this  may  be  replaced 
by  complete  extension  of  the  lower  extremities  with  dropping  of  the 
feet.  The  tonic  muscular  spasm  gives  rise  to  Kernig's  sign,  viz.,  inabil- 
ity to  extend  the  leg  when  the  thigh  is  flexed  upon  the  body.  In  young 
children  one  should  not  place  too  much  dependence  upon  this  sign. 
While  rarely  wanting  in  cerebro-spinal  meningitis,  it  is  often  present 
in  other  conditions.  Muscular  rigidity  is  one  of  the  most  common  symp- 
toms and  one  of  the  last  to  disappear.     It  may  be  absent  in  the  early 


708 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


stage  of  the  hyper-acute  cases,  and  very  late  in  fatal  cases,  when  there 
may  be  general  relaxation.  Other  nervous  symptoms  frequently  present 
are  ankle  clonus,  muscular  tremor,  especially  of  the  hands,  and  paralysis, 
which  may  be  facial,  monoplegic,  or  hemiplegic.  Early  in  tlie  disease 
the  knee-jerks  are  usually  increased;  in  the  later  stages  they  are  often 
lost. 

Eye  and  Ear. — The  pupils  in  the  early  stage  are  generally  contracted ; 
toward  the  close  they  are  usually  widely  dilated.  Ocular  paralyses  are 
not  so  frequent  nor  so  marked  as  in  tuberculous  meningitis.  The  same 
is  true  of  the  changes  in  the  optic  disc,  although  these  vary  much  in 
different  epidemics.  There  may  be  congestion  of  the  fundus,  retinitis, 
or  optic  neuritis.  In  some  epidemics  such  changes  have  been  observed 
in  fully  half  the  cases.  In  that  of  1904-5,  in  my  own  hospital  cases, 
they  were  rarely  seen,  and  then  were  but  slightly  marked.  Conjunctivitis 
is  frequently  present  and  may  be  severe.  There  may  be  choroiditis 
and  sometimes  complete  destruction  of  the  eye,  but  usually  this  is  uni- 
lateral. In  most  epidemics  the  ears  are  more  frequently  affected  than 
the  eyes.  Early  deafness  may  be  due  to  a  lesion  of  the  auditory  nerve, 
is  generally  bilateral,  and  often  permanent.  Acute  otitis  media  occurs 
as  a  complication,  and  the  meningococcus  is  occasionally  found  in  the 
discharge.  This  was  true  of  three  of  my  hospital  cases.  Permanent 
deafness  is  sometimes  due  to  changes  in  the  brain  itself. 


Fig.  114. — Cerebro-spinal  Meningitis.  Recovery.  Fairly  typical  chart  of  prolonged 
case,  showing  remissions  and  exacerbations.  Private  patient,  three  and  a  half  years 
old;  unconscious,  blind,  and  deaf  for  two  and  a  half  months;  complete  recovery. 


Fever. — This  disease  is  usually  attended  by  high  fever,  but  the  curve 
is  apt  to  be  an  irregular  one  and  show  wide  variations.  The  tempera- 
ture is  nearly  always  high  at  the  onset;  in  the  hyper-acute  cases  it  may 


CEREBRO-SPINAL   MENINGITIS.  709 

reach  106°  F,  or  higher.  The  usual  range  during  the  disease  is  from 
100°  to  105°  F.  (Fig.  114).  Sometimes  it  is  steadily  high;  not  in- 
frequently a  few  days  after  a  sharp  acute  onset  it  falls  nearly  or  quite 
to  normal  and  remains  there  for  several  days.  Cases  seen  in  this  afebrile 
period  are  most  difficult  of  diagnosis.  This  stage  may  be  followed  by 
another  sharp  rise,  and  afterward  continuous  fever.  Periods  of  remis- 
sion and  exacerbation  in  the  temperature  are  seen  in  a  large  proportion 
of  the  prolonged  cases.  Often  it  becomes  subnormal.  The  temperature 
may  bear  no  relation  to  the  severity  of  the  other  symptoms.  Its  course 
is  greatly  modified  by  the  serum  treatment. 

Respiration  is  disturbed  very  early  in  the  disease,  when  it  is  often 
irregular  and  may  be  slow  or  rapid.  Throughout  the  greater  part  of 
the  attack  it  may  be  nearly  normal.  Occasionally  it  is  of  the  typical 
Che3Tie- Stokes  variety. 

Pulse. — Throughout  the  greater  part  of  the  disease  the  pulse  is  rapid. 
In  the  early  stage  it  is  often  weak,  and  sometimes  irregular.  The  average 
frequency  in  young  children  is  from  130  to  150.  A  slow,  irregular  pulse 
is  occasionally  seen  late  in  the  disease  in  patients  who  are  in  deep  coma. 

Blood. — A  leucocytosis  is  present  in  nearly  all  cases.  The  average 
is  from  15,000  to  30,000.  The  increase  is  chiefly  in  the  polymorpho- 
nuclear cells.  Blood  cultures  made  early  in  the  disease  have  in  some 
cases  shown  the  presence  of  the  characteristic  organism. 

Digestive  System. — Vomiting  is  one  of  the  most  frequent  symptoms 
of  onset  but  rarely  persists  throughout  the  attack.  Late  in  the  disease, 
it  may  be  most  troublesome.  As  a  rule  constipation  is  present.  The 
tongue  is  coated,  dry,  glazed,  sometimes  covered  with  sordes.  In  a  small 
proportion  of  cases  jaundice  has  been  observed.  On  account  of  the  loss 
of  appetite,  great  irritability,  delirium,  and  stupor,  the  greatest  difficulty 
is  often  experienced  in  feeding  these  patients.  In  young  children  gavage 
is  much  more  satisfactory  than  rectal  feeding.  Early  in  the  disease 
the  abdomen  is  natural.  In  the  late  stage  it  is  often  very  much  re- 
tracted. 

General  Nutrition. — This  is  impaired  in  nearly  all  cases.  There  is  a 
progressive  wasting,  greater  than  would  be  explained  by  the  disturbance 
of  digestion.  In  the  protracted  cases  it  may  be  extreme.  Infants  and 
young  children  often  die  of  inanition  or  marasmus  long  after  the  active 
symptoms  of  the  disease  have  subsided. 

Other  symptoms  of  importance  are  the  tense,  bulging  fontanel,  in 
infants  rarely  absent  early  in  the  attack,  but  often  wanting  in  the  late 
wasting  stage;  incontinence  of  urine  and  fa;ces,  and  retention  of  urine, 
very  frequent  and  often  overlooked;  occasionally  swelling  of  some  one 
of  the  large  joints  is  seen. 

Course,  Duration,  and  Termination. — Excluding  the  fulminating  cases 
in  which  death  occurs  very  early,  the  usual  duration  of  active  symptoms 


710  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  cases  not  treated  with  serum  is  from  three  to  six  weeks.  Of  350  cases 
recovering  without  serum,  the  disease  lasted  less  than  one  week  in  three 
per  cent;  in  fifty  per  cent  it  was  five  weeks  or  longer.  Some  very  pro- 
tracted cases  terminate  favourably.  I  have  seen  one  child  recover  com-, 
pletely  after  84  days  of  fever,  and  another  after  102  days.  Most  of  the 
prolonged  cases  are  marked  by  periods  of  exacerbation  and  remission. 
Not  until  the  temperature  has  been  normal  for  several  days,  the  mind 
has  become  clear,  and  the  hyperaesthesia  and  rigidity  have  entirely  disap- 
peared, can  we  consider  convalescence  as  established.  Recovery  is  slow, 
and  it  may  be  many  months  before  the  child  is  quite  well.  In  220  cases 
receiving  serum  treatment  the  average  duration  of  active  symptoms  after 
the  first  injection  was  11  days. 

In  fatal  cases,  death  may  come  early  from  coma,  convulsions,  or 
heart  failure.  It  may  occur  in  the  middle  period  from  complications, 
most  frequently  pneumonia,  or  the  terminal  stage  of  the  disease  may  be 
seen  with  extreme  wasting,  and  finally  death  from  exhaustion. 

Complications  and  Sequelae. — The  chief  ones  are  pneumonia,  otitis, 
conjunctivitis  or  choroiditis,  and  bed-sores.  Rarely,  nephritis  and  arthri- 
tis are  seen.  Sequelae  are,  unfortunately,  very  common.  There  may 
be  perfect  recovery  so  far  as  physical  functions  are  concerned,  but  the 
child  be  left  mentally  deficient.  In  some  cases  the  defect  is  so  slight 
as  not  to  be  evident  for  several  months  or  even  years;  in  others  the 
mental  faculties  are  entirely  lost.  There  may  also  be  various  types  of 
paralysis — strabismus,  facial  paralysis,  monoplegia,  hemiplegia  or  diple- 
gia, and  often  contractures,  which  are  sometimes  temporary,  but  apt  to 
be  permanent.  The  acute  attack  may  be  followed  by  chronic  meningitis 
with  hydrocephalus.  Deafness  is  quite  common,  usually  of  both  ears, 
and  deaf-mutism  is  not  an  infrequent  result  in  young  children.  Blind- 
ness is  not  so  common  and  is  usually  unilateral.  As  a  late  result  epilepsy 
may  develop. 

Prognosis. — The  mortality  is  usually  higher  in  epidemics  than  when 
the  disease  occurs  sporadically.  It  is  usually  greater  at  the  height  of 
an  epidemic  and  lower  at  its  close.  The  average  mortality  before  the 
serum  treatment  was  about  70  per  cent.  I  know  of  no  epidemic  on 
record  in  which  the  mortality  was  less  than  50  per  cent.  In  the  last  year 
(1905)  of  the  New  York  epidemic,  of  1,780  cases  tabulated  by  the  De- 
partment of  Health  the  mortality  was  76  per  cent.  Of  59  cases  treated 
in  my  hospital  wards  in  the  same  epidemic  the  mortality  was  80  per 
cent,  nearly  all  these  patients  being  under  three  years  of  age.  Of  24 
cases  under  one  year  only  one  recovered.  Of  the  cases  I  saw  in  private 
practice,  largely  older  children,  the  mortality  was  50  per  cent.  Not  all 
of  those  who  do  not  die  are  to  be  classed  as  recoveries,  for  in  fully  25  per 
cent  serious  sequelae  remain.  The  results  with  Flexner's  serum  are  re- 
ferred to  under  Treatment. 


CEREBRO-SPINAL   MENINGITIS.  711 

Diagnosis. — Lumbar  puncture  is  the  only  accurate  means  of  diagnosis 
we  possess.  By  it  we  can  not  only  differentiate  meningitis  from  other 
diseases  with  nervous  symptoms,  but  can  distinguish  this  from  other 
varieties  of  meningitis.  Furthermore,  this  is  possible  very  early  in  the 
disease.  With  proper  precautions  I  believe  it  to  be  practically  free  from 
danger,  and  it  should  be  employed  whenever  meningitis  is  suspected. 
The  procedure  is  not  difficult,  but  the  technique  is  important.^  The 
quantity  of  fluid  which  may  be  removed  at  one  time  varies  from  a  few 
drops  to  three  or  four  ounces.  During  the  first  day  or  two  it  is  usually 
a  slightly  cloudy  or  turbid  serum;  sometimes  it  is  thick  and  purulent. 
As  the  disease  progresses  the  pus  cells  gradually  diminish,  and  in  favour- 
able cases  disappear,  but  may  reappear  witli  an  exacerbation  of  the  symp- 
toms.    These  changes  are  much  modified  by  serum  injections. 

The  presence  of  many  leucocytes  in  the  cerebro-spinal  fluid  indicates 
meningitis,  which  may  be  due  to  the  meningococcus,  but  also  to  the 
pneumococcus,  the  influenza  bacillus,  the  staphylococcus,  or  the  strepto- 
coccus. The  variety  can  be  determined  only  by  microscopical  examina- 
tion of  stained  smears  from  the  sediment  of  the  fluid  obtained  after 
standing  or  after  centrifuging,  and  by  cultures,  which  should  be  made 
immediately  after  the  fluid  is  withdrawn.  In  cerebro-spinal  meningitis 
diplococci  are  found  within  the  pus  cells  and  some  are  also  free  in  the 
fluid.     The  organisms  are  usually  numerous. 

The  diagnostic  value  of  lumbar  puncture,  when  properly  performed, 
is  very  great ;  not  only  are  positive  findings  conclusive,  but  early  negative 
findings  almost  certainly  exclude  meningitis.  I  have  met  with  two  ex- 
ceptional cases  in  which  early  punctures  gave  a  clear  fluid  and  no  organ- 

*  Puncture  may  be  made  with  an  ordinary  surgical  exploring  needle,  but  the  spe- 
cial lumbar  needle  devised  by  Quincke  is  preferable.  This  is  merely  a  fine  trocar  and 
cannula  and  is  made  somewhat  stronger  than  an  exploring  needle,  which  sometimes 
breaks.  The  child  is  placed  upon  the  right  side  with  the  thighs  tightly  flexed  against 
the  abdomen  to  separate  the  spines  and  lamina?  of  the  vertebrae  as  much  as  possible. 
The  point  chosen  for  puncture  is  in  the  median  line  between  the  third  and  fourth 
lumbar  vertebra;.  This  is  on  a  level  with  the  highest  part  of  the  iliac  crest.  The 
strictest  asepsis  is  required.  The  skin  should  be  carefully  cleansed  and  the  needle 
boiled.  The  pain  is  no  greater  than  from  exploratory  punctures  elsewhere.  No 
anaesthetic  is  necessary  for  infants,  but  sometimes  is  required  for  older  and  especially 
sensitive  or  nervous  children  unless  they  are  comatose.  Local  anaesthesia  may  be 
employed  or  a  few  whiffs  of  chloroform  given,  but  always  with  caution,  for  the  com- 
bined shock  of  the  puncture  and  the  chloroform  is  sometimes  considerable.  The 
child  should  be  closely  watched  for  at  least  fifteen  minutes  after  the  puncture  is  made. 
The  canal  is  reached  at  the  depth  of  about  one  inch.  The  trocar  is  now  withdrawn 
and  the  fluid  usually  flows  freely  through  the  cannula,  sometimes  spurting  forth  some 
distance,  owing  to  high  pressure.  A  dry  puncture  is  generally  due  to  the  fact  that 
the  canal  has  not  been  entered;  sometimes  that  the  exudate  is  too  thick  to  flow 
through  the  small  needle,  or  that  the  needle  has  been  plugged.  Raising  the  patient 
to  a  sitting  posture  usually  causes  a  freer  flow,  as  does  also  flexing  the  head  upon  the 
chest  if  opisthotonus  is  extreme. 


712  DISEASES  OF  THE  NERVOUS  SYSTEM. 

isms  were  found;  a  few  days  later  the  fluid  was  turbid  and  organisms 
were  abundant.  The  meningococcus  may  persist  for  a  long  time.  In 
one  of  my  cases  not  treated  by  serum  it  was  present  on  the  ninetieth  day. 

The  diagnosis  of  cerebro-spinal  meningitis  by  symptoms  alone  presents 
peculiar  difficulties  at  the  beginning  of  the  attack.  The  most  valuable 
early  symptoms  for  diagnosis  are,  a  sudden  onset  with  intense  headache, 
vomiting,  high  temperature,  prostration,  the  petechial  eruption,  marked 
rigidity  of  the  neck  and  extremities,  with  hyperaesthesia,  great  irritability 
or  early  stupor,  even  coma.  Later,  three  symptoms  are  rarely  wanting — 
persistent  hyperassthesia,  muscular  rigidity  of  the  neck  and  extremities, 
and  fever.  Kernig's  sign  is  seen  in  other  conditions  and  is  not  diagnosj:ic. 
The  spinal  symptoms  are  more  to  be  relied  upon  for  diagnosis  than  are 
the  cerebral  symptoms.  The  mind  in  some  cases  remains  perfectly  clear; 
in  others  there  is  delirium,  but  seldom  continuous,  deep  coma. 

At  its  beginning,  cerebro-spinal  meningitis  may  be  confounded  with 
pneumonia  or  other  diseases  with  cerebral  symptoms.  It  is  differentiated 
with  certainty  only  by  lumbar  puncture.  It  is  sometimes  difficult  to 
distinguish  between  cerebro-spinal  and  tuberculous  meningitis.  The 
former  is  relatively  infrequent  except  in  epidemics.  The  fluid  in  cere- 
bro-spinal meningitis  is  usually  turbid  and  contains  many  cells  of  the 
polymorphonuclear  variety;  in  tuberculous  meningitis  the  fluid  is  gen- 
erally clear  and  the  few  cells  found  are  lymphocytes.  Tuberculous 
meningitis  may  occur  anywhere  or  at  any  time.  Its  chcracteristics  are 
a  gradual  onset  with  indefinite  symptoms,  low  temperature,  drowsiness, 
irregularity  of  pulse  and  respiration,  absence  of  active  delirium,  late 
coma,  less  marked  hyperassthesia  and  rigidity,  duration  seldom  over  three 
weeks  from  the  beginning  of  definite  cerebral  symptoms,  termination  in- 
variably fatal.  Cerebro-spinal  meningitis,  however,  frequently  ends  in 
recovery,  and  it  is  the  only  form  of  acute  meningitis  which  does  so. 

Treatment. — Flexner  of  the  Eockefeller  Institute  has  developed  a 
serum  for  the  treatment  of  cerebro-spinal  meningitis  which  has  been 
shown  to  be  more  effective  in  controlling  the  disease  than  any  other 
measure  thus  far  proposed.  The  serum  is  obtained  by  immunising  horses 
with  toxins  and  cultures  obtained  from  many  strains  of  the  meningo- 
coccus. It  acts  chiefly  on  the  bacteria  themselves,  and  only  to  a  slight 
degree  on  their  products ;  i.  e.,  it  is  a  bacteriolytic  serum.  It  is  used  as 
follows :  After  withdrawing  by  lumbar  pimcture  all  the  fluid  that  will 
flow  readily,  under  the  strictest  aseptic  precautions,  the  serum,  warmed 
to  the  body  temperature,  is  injected  without  removing  the  needle.  In 
some  exceedingly  sensitive  patients  the  administration  of  a  few  whiffs 
of  chloroform  may  be  necessary.  The  injection  sliould  be  made  very 
slowly,  occupying  several  minutes.  Raising  the  hips  facilitates  the  inflow 
of  the  serum.  To  be  effective,  it  must  be  brought  into  contact  with  the 
organisms  in  the  spinal  canal  in  a  considerable  degree  of  concentration. 


CEREBRO-SPINAL   MENINGITIS.  713 

The  initial  dose  is  30  to  40  c.cm.,  which  should  be  repeated  in  twelve 
hours  if  there  is  no  improvement  in  the  symptoms.  Usually  the  second 
dose  is  not  given  until  the  end  of  twenty-four  hours,  and  after  that  a 
daily  dose  of  the  same  size  for  four  or  five  days  should  be  given,  unless 
there  is  a  prompt  disappearance  of  all  symptoms.  Injections  should  be 
continued  so  long  as  organisms  are  found  in  the  fluid  or  nervous  symp- 
toms, fever,  and  leucocytosis  persist.  If  done  cautiously,  it  is  safe  to  in- 
troduce more  serum  than  the  amount  of  fluid  withdrawn.  In  the  milder 
cases  it  sometimes  happens  that  a  single  dose  may  suffice  for  a  cure ;  but 
even  under  such  circumstances  it  is  safer  to  give  at  least  three  doses. 
The  serum  arrests  the  inflammatory  process  by  destroying  the  organisms 
which  produce  it.  To  accomplish  this  a  sufficient  dose  must  be  given, 
and  given  early,  before  important  inflammatory  changes  have  taken  place. 

An  immediate  effect  of  the  injection  is  seen  in  tlie  cerebro-spinal 
fluid.  There  is  a  marked  reduction  in  the  percentage  of  polymorpho- 
nuclear cells.  The  number  of  meningococci  is  greatly  reduced  and  their 
vitality  lessened.  After  the  first  injection  they  stain  with  difficulty,  and 
after  a  second  injection  it  is  generally  impossible  to  grow  them,  although 
they  are  usually  present  in  small  numbers  (Fig.  115).  The  effect  on  the 
symptoms  is  striking.  There  is  a  marked  reduction  in  the  temperature, 
which  may  amount  to  three  or  four  degrees  in  twenty-four  hours,  and  it 
may  not  rise  again  (Fig.  116).  The  stupor  and  delirium  often  diminish 
rapidly,  and  soon  disappear.  Improvement  is  also  seen  in  the  patient's 
general  condition,  pulse,  and  respiration.  The  last  symptoms  to  be 
affected  are  usually  the  rigidity  of  the  neck  and  extremities. 

The  results  of  this  treatment  show  a  much  larger  percentage  of  re- 
coveries than  has  been  obtained  by  any  other  method.^  Of  1,500  cases 
of  all  types,  in  patients  of  all  ages,  thus  far  treated  by  this  serum,  the 
general  mortality  was  about  25  per  cent.  The  figures  represent  results 
obtained  in  many  epidemics  in  all  parts  of  the  world.  The  statistics  from 
this  country  are  not  so  favourable  as  those  from  abroad  with  the  same 
serum,  for  the  reason  that  in  the  results  here  are  included  reports  from 
many  physicians  who,  without  experience  in  the  use  of  the  serum,  treated 
but  one  or  two  cases.  The  foreign  statistics,  however,  are  in  larger 
groups,  and  the  cases  for  the  most  part  were  under  the  care  of  men  who 
had  had  experience  with  the  serum.  In  the  recent  epidemic  in  France 
the  mortality  of  the  cases  not  treated  by  serum  was  about  70  per  cent, 
while  in  those  receiving  serum  it  was  but  15  per  cent.  This  indicates 
what  may  be  expected  with  serum  treatment  under  favourable  conditions. 
One  of  the  most  striking  evidences  of  the  value  of  this  treatment  is  the 
results  obtained  in  infants  under  one  year.     Without  serum  these  cases 

'  For  details,  see  articles  by  Flexner  and  his  associates  in  the  Journal  of  Experi- 
mental Medicine,  from  September,  1908,  to  1911.  The  sermn  can  be  obtained  from 
the  New  York  Health  Department. 


714 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


Day 
104° 

103° 

102° 

101  ° 
100° 
99° 

98  ° 

2 

3 

4 

5 

6 

7 

8 

9 

10 

I 

1 

^ 

1 

j 

\ 

1 

/ 

\ 

\ 

/ 

i 

\ 

/ 

\ 

\ 

1 

/ 

\ 

\ 

I 

1 

V 

i 

1 

V 

1 

J 

1 

/ 

/ 

S 

' 

1 

f 

/ 

1 

N 

i 

i 

^ 

' 

1 

/ 

' 

/ 

\ 

1 

1 

/, 

J 

I 

/ 

\ 

\ 

V 

\ 

^s 

y 

\  y 

\ 

3 

/ 

V 

1 

T 

1 

J 

f 

y 

1 

1 

^ 

J 

/ 

\ 

/ 

\ 

s 

Ju 

J 

T 

1^ 

^ 

^ 

^ 

^ 

^ 

^ 

^ 

^m 

^ 

■■1 

Ml 

■" 

"" 

"" 

"' 

' 

1 

Day 

2 

3 

4 

5 

6 

7 

8 

9 

10 

Leucocytes 

20,400 

25,600 

15,000 

16,400 

16,000 

12,500 

21,000 

20,000 

Serum 
Injected 

40c.c. 

30 

35 

30 

Fluid 
Removed 

80C.C. 

40 

40 

40 

55 

20 

Nature 
of  Fluid 

Purulent 

Slightly 
Turbid 

Slightly 
Turbid 

Almost 
Clear 

Clear 

Clear 

Organisms 

Many 

Few 

None 

None 

None 

None 

Fig.  115. — Cerebro-spinal  Meningitis  Treated  by  Serum.  Infant,  7  months  old, 
Babies'  Hospital:  24  hours  ill;  intense  prostration;  respiration,  80;  signs  of  pul- 
monary cEdema;  general  relaxation;  stupor;  profuse  haemorrhagic  eruption.  First 
fluid,  purulent;  amount  removed,  amount  of  serum  injected,  and  the  changes  in 
the  fluid  shown  in  the  chart.  Immediate  improvement  in  symptoms  after  first  in- 
jection. Subsequent  symptoms  typical.  A  rise  in  temperature  on  the  8th  day 
and  the  increase  in  leucocytes  on  the  9th  and  10th  days  suggested  relapse;  but 
as  fluid  was  clear  and  no  organisms  could  be  found  in  smears  or  by  culture  no  more 
serum  was  given;  complete  recovery. 


Fio.  116. — Cerebro-spinal  Meningitis.  Late  injection  of  the  serum,  prompt  effect; 
complete  recovery.  Boy,  11  years,  St.  Vincent's  Hospital,  New  York.  Early  symp- 
toms obscure,  and  on  account  of  swelling  and  pain  in  joints  diagnosis  of  rheu- 
matism made;  cerebral  symptoms  not  marked.  First  lumbar  puncture  made  on 
31st  day  and  meningococcus  found.  Serum  injected  on  the  34th  and  35th  days.  Rapid 
fall  in  the  temperature  followed  by  cessation  of  all  symptoms  and  complete  recovery. 


CEREBRO-SPINAL   MENINGITIS. 


715 


have  almost  invariably  terminated  fatall}^;  witli  serum  over  50  ])er  cent 
of  them  have  recovered. 

The  results  are  much  modified  hy  the  time  of  injection  as  shown  by 
the  following  table: 

Mortality  of  serum-treated  cases  according  to  time  of  injection. 


Time  of  Injection. 

Flexner. 
(All  sources, 
chiefly  U .  S.) 

Netter. 
(France.) 

Dopter. 
(France.) 

1st  to  3d  day 

4th  to  7th  day 

After  the  7th  day 

14.9% 
22.0% 
36.4% 

7.14% 

11.1  % 
23.5  % 

8.20% 
14.4  % 
24.1   % 

In  Netter's  series  Flexnor's  serum  was  used;  Dopter  used  the  serum  prepared 
at  the  Pasteur  Institute. 


The  effect  on  t^ie 
course  and  duration  of 
the  disease  is  no  less 
marked  than  that  upon 
the  mortality.  The  du- 
ration of  acute  symp- 
toms is  very  much  short- 
ened, and  in  about  one- 
fourth  of  the  cases  the 
disease  terminated  by 
crisis  (Figs.  116,  117). 
This  was  more  often 
seen  in  cases  injected 
earl}^,  although  it  was 
observed  in  some  in- 
jected as  late  as  the 
fourth  week.  The  in- 
frequency  of  complica- 
tions and  sequelae  is  also 
notew^orthy.  Not  only 
do  patients  recover,  but 
they  recover  quickly,  and 
in  most  instances  com- 
pletely. The  absence  of 
complications  and  se- 
quelae is,  no  doubt,  to  be 
explained  partly  by  the 
effect  of  the  serum  in 
shortening  the  disease. 


Day 

1 

2 

3 

4 

S 

•    1 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97°,, 

^  , 

^ 

, 

^ 

1 

t 

t 

t 

— 

r 

r 

t 

t 

T 

T 

T 

j 

II 

IT 

j 

T 

T 

± 

t 

r 

, 

r 

r 

t 

t 

t 

7 

t 

ti 

T 

± 

/ 

/ 

T 

/ 

f 

i 

/ 

' 

zj 

T 

I 

r 

I 

/ 

I 

/ 

I 

\^ 

' 

\ 

\ 

,/ 

\ 

" 

ta 

\ 

/ 

^ 

S 

J 

^ 

/ 

- 

-^ 



- 

- 

- 

- 

— 

- 

Fig.  117. — Cerebro-spinal  Meningitis.  Termina- 
tion by  crisis ;  recovery  after  two  injections.  Boy  of* 
6  years,  patient  of  Dr.  C.  H.  Dunn.  The  first  day, 
rather  indefinite  symptoms — headache,  vague  pains, 
slight  fever.  Second  day,  alarming  symptoms  rap- 
idly developed  and  patient  became  comatose;  30 
c.cm.  of  serum  given  and  repeated  the  following  day. 
The  temperature  rapidly  fell  and  did  not  again  go 
above  101°  F.  In  twelve  hours  the  coma  was  gone 
and  the  mind  clear;  by  the  fourth  day  the  child  was 
convalescent.     No  subsequent  symptoms. 


716  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Relapses  occur  in  a  small  proportion  of  the  cases.  They  are  due  to 
the  fact  that  the  organisms  have  not  heen  entirely  destroyed  by  the 
serum.  They  are  usually  indicated  by  a  rise  in  temperature,  an  increase 
in  the  leucocytosis,  and  an  aggravation  of  the  nervous  symptoms.  They 
are  to  be  treated  like  a  primary  attack,  daily  injections  being  repeated 
so  long  as  organisms  and  symptoms  persist. 

Very  little  improvement  is  to  be  expected  in  patients  who  have 
passed  the  febrile  stage  and  who  are  suffering  chiefly  from  the  effects 
of  distention  of  the  ventricles  due  to  a  chronic  basilar  lesion.  The  most 
unpromising  early  cases  are  those  of  the  fulminating  type  which  have 
usually  advanced  so  far  before  the  serum  is  given  that  recovery  is  im- 
possible. Unpromising  also  are  cases  in  which  a  very  thick  purulent 
fluid  is  present  which  can  hardly  be  withdrawn  through  the  needle.  The 
amount  which  can  be  removed  is  usually  very  small.  The  diffusion  of 
the  serum  in  the  canal  is  difficult.  In  such  cases  Robb  (Belfast),  before 
injecting  the  serum,  has  used  with  success  irrigation  of  the  spinal  canal 
with  a  warm  sterile  salt  solution.  In  some  cases,  particularly  in  infants, 
where  the  withdrawal  of  fluid  by  lumbar  puncture  has  been  impossible 
owing  to  adhesions  or  other  causes,  fluid  may  be  removed  by  puncturing 
the  ventricles  of  the  brain  through  the  fontanel.  The  serum  is  then  in- 
jected into  the  same  cavity.  The  procedure  is  not  very  difficult,  and,  if 
carefully  done,  attended  by  little  risk.  I  have  used  it  in  two  cases.  The 
effect  of  the  serum  seemed  quite  as  marked  as  when  it  was  introduced  in 
the  usual  manner. 

In  any  case  suspected  to  be  cerebro-spinal  meningitis  lumbar  punc- 
ture should  be  made  as  early  as  possible.  If  the  fluid  obtained  is  puru- 
lent or  only  slightly  turbid,  the  serum  should  be  injected  at  once.  If 
the  fluid  is  clear,  the  disease  is  probably  not  cerebro-spinal  meningitis, 
and  one  may  wait  for  a  bacteriological  report.  Meningitis  due  to  the 
pneumococcus,  the  bacillus  of  influenza,  or  pyogenic  organisms,  may  also 
give  a  purulent  fluid,  but  no  harm  would  result  from  using  the  serum 
in  such  a  case,  although  no  benefit  should  be  expected. 

Lumbar  puncture  per  se  has  some  slight  therapeutic  value.  It  re- 
lieves pressure  and  by  reducing  the  number  of  micro-organisms  may  have 
a  slight  effect  upon  the  inflammatory  process,  especially  when  used  early ; 
but  in  most  cases  this  is  only  temporary.  An  ice-cap  should  be  applied 
to  the  head,  and  at  times  an  ice-bag  along  the  spine.  The  bowels  should 
be  kept  freely  open.  Treatment  otherwise  is  directed  toward  the  symp- 
toms of  the  disease.  Severe  pain  requires  morphine  or  codeine  some- 
times in  quite  large  doses.  For  other  nervous  symptoms — delirium, 
sleeplessness,  etc. — the  bromides  and  chloral,  sulfonal,  or  trional  may  be 
given,  or  warm  sponge  or  tub  baths.  Stimulants  are  indicated  by  a 
weak,  rapid,  and  irregular  pulse.  Caffeine  and  digitalis  or  strophanthus 
should  be  used,  but  not  strychnine. 


ACUTE   MENINGITIS   DUE  TO  OTHER  CAUSES.  717 

The  nutrition  of  the  patient  is  important.  Feeding  is  often  difficult, 
and  gavage  may  be  advantageously  employed.  Bed-sores  should  be  pre- 
vented by  cleanliness,  frequently  changing  the  patient's  position,  etc. 
Eetention  of  urine  may  require  the  use  of  the  catheter. 

For  the  residual  paralysis,  massage,  warm  baths,  and  friction  should 
be  employed,  but  electricity  only  when  all  symptoms  of  central  irritation 
have  subsided.  The  prolonged  use  of  iodide  of  potassium,  especially  in 
combination  with  mercury,  seems  to  have  some  value. 


ACUTE   MENINGITIS  DUE  TO  OTHER  CAUSES. 

Besides  the  main  varieties  of  acute  meningitis,  viz.,  that  due  to  the 
meningococcus  and  that  due  to  the  tubercle  bacillus,  there  are  other 
forms  differing  in  etiology,  but  closely  related  clinically,  and  therefore 
tliey  may  be  advantageously  considered  together.  It  is  only  since  the 
general  adoption  of  lumbar  puncture  as  a  means  of  diagnosis  that  these 
forms  of  meningitis  have  been  clinically  differentiated.  Formerly  they 
were  grouped  under  the  somewhat  indefinite  heading  of  "  simple  menin- 
gitis." Three  of  these  varieties,  those  due  to  the  pneumococcus,  the  in- 
fluenza bacillus,  and  pyogenic  organisms,  are  sufficiently  important  to 
require  separate  description.  Cases  of  meningitis  due  to  the  typhoid 
bacillus,  the  gonococcus,  and  the  colon  bacillus,  have  all  been  reported 
in  children,  but  are  so  rare  as  only  to  deserve  mention. 

Pneumococcus  Meningitis. — Tbis  is  the  most  important  variety  in- 
cluded in  this  gj'oiip  and  the  one  most  frequently  met  with  in  young 
children.  In  my  hospital  patients  eleven  per  cent  of  the  cases  of  acute 
meningitis  were  of  this  form.  All  had  pulmonary  symptoms  of  greater 
or  less  severity,  and  two-thirds  of  the  patients  had  definite  pneumonia 
with  consolidation;  several  had  also  empyema.  Less  frequently,  pneu- 
mococcus pericarditis  and  peritonitis  have  been  present.  Occasionally 
pneumococcus  meningitis  is  seen  when  there  are  no  definite  pulmonary 
symptoms  or  signs  and  when  it  is  apparently  a  primary  inflammation. 
However,  in  most  cases  pneumococcus  meningitis  is  one  of  the  results 
of  a  generalised  pneumococcus  infection.  In  every  one  of  seven  cases  of 
pneumococcus  meningitis  of  my  own  in  which  cultures  of  the  heart's 
blood  were  made  at  autopsy,  this  organism  was  present.  This  form 
of  meningitis  occurs  in  infants  more  frequently  than  in  older  children, 
and,  in  my  experience,  usually  in  very  young  infants;  over  half  of  the, 
cases  seen  were  in  patients  under  six  months  old.  While  the  disease 
usually  develops  at  the  height  of  an  attack  of  pneumonia,  it  may  pre- 
cede the  pulmonary  symptoms  and  it  may  develop  during  convalescence. 
I  once  saw  it  as  late  as  the  fourth  week. 

Lesions. — In  a  general  way  the  anatomical  changes  resemble  those 
described    in    cerebro-spinal    meningitis,    with    the    exception    that    the 


718  DISEASES  OF  THE  NERVOUS  SYSTEM. 

marked  changes  in  the  brain  substance  wJiich  are  usually  dependent  upon 
the  long  course  of  that  disease  are  wanting.  As  a  .rule,  also,  the  lesions 
are  limited  to  the  brain.  If  the  cord  is  involved,  it  is  only  to  a  slight 
degree. 

Acute  meningitis  due  to  the  pneumococcus  is  characterised  by  a  more 
abundant  exudation  of  fibrin  and  pus  than  is  seen  in  any  other  variety 
of  meningitis.  The  lesion  may  affect  the  entire  brain,  but  it  is  espe- 
cially marked  at  the  convexity  and  over  the  anterior  lobes.  Sometimes 
it  is  limited  to  these  regions,  the  meninges  of  the  base  escaping.  The 
exudate  may  be  so  abundant  as  almost  to  conceal  the  convolutions.  (See 
Plate  XIV.)  There  is  usually  less  distention  of  the  ventricles  than  in 
cerebro-spinal  meningitis. 

In  cases  apparently  primary,  or  when  meningitis  occurs  very  early  in 
the  course  of  a  general  pneumococcus  infection,  the  symptoms  are  usually 
indistinguishable  from  ordinary  cases  of  cerebro-spinal  meningitis.  It 
is  generally  not  until  lumbar  puncture  is  made  that  the  variety  of  menin- 
gitis is  suspected.  When  meningitis  occurs  as  a  secondary  inflammation 
it  is  often  latent,  and  not  infrequently  is  found  at  autopsy  when  not 
suspected  during  life.  Usually,  however,  the  meningeal  complication 
is  indicated  by  the  abrupt  development,  in  the  course  of  an  attack  of 
pneumonia,  of  vomiting  or  convulsions,  followed  by  active  delirium  or 
stupor.  Because  the  lesion  is  principally,  sometimes  only,  at  the  con- 
vexity, many  of  the  symptoms  belonging  to  meningitis  with  basal  lesions 
are  absent.  There  is  rarely  cervical  opisthotonus;  the  fontanel  may  not 
be  bulging;  pulse  and  respiration  may  not  be  disturbed;  in  fact,  there 
are  no  cranial  nerve  symptoms  and  the  symptoms  due  to  spinal  in- 
volvement— hyperaesthesia,  rigidity,  Kernig's  sign,  etc.,  are  usually 
wanting. 

The  course  of  pneumococcus  meningitis  is  generally  short  and  acute, 
death  taking  place  within  three  or  four  days  from  the  first  symptoms. 
I  have  twice  seen  a  prolonged  type  of  the  disease  lasting  many  weeks; 
one  case  ended  fatally  near  the  end  of  the  third  month ;  the  other  patient 
recovered  from  the  acute  symptoms,  but  remained  partially  paralysed 
and  mentally  defective. 

The  diagnosis  of  pneumococcus  meningitis  can  positively  be  made 
only  by  lumbar  puncture.  The  cerebyo-spinal  fluid  in  gross  appearance 
does  not  differ  from  that  seen  in  cases  due  to  the  meningococcus.  The 
cells  present  are  chiefly  polymorphonuclear.  Pneumococci  are  very  abun- 
dant and  are  easily  found  in  smears  and  grown  readily  in  cultures.  The 
existence  of  pneumococcus  meningitis  is  not  alwa3's  shown  by  lumbar 
puncture.  I  have  met  with  one  case  in  which  repeated  punctures  gave 
negartive  results,  and  yet  the  autopsy  showed  meningitis  to  be  present, 
but  only  the  convexity  was  affected.  The  organisms  were  readily  found 
in  the  meningeal  exudate. 


PLATE    XIV. 


Acute  Meningitis,  complicating  Pleuro-Pneumonia. 

Child  twenty  months  old ;  on  twenty-third  day  of  a  protracted  attack  of  pneumonia, 
vomited  six  times,  and  the  temperature,  which  had  been  nearly  normal  for  four  days, 
rose  to  103°  F.  On  the  following  day  general  convulsions,  which  were  repeated  fre- 
quently during  the  next  few  days ;  temperature,  101°  to  104°  F. ;  death  in  convulsions 
on  twenty-eighth  day. 

Autopsy. — Pleuro-pneumonia  of  left  side;  lung  resolving.  Anterior  portion  of 
brain  enveloped  in  lymph  and  pus,  more  marked  at  the  convexity,  but  present  also 
over  the  base. 


ACUTE   MENINGITIS  DUE  TO  OTHER  CAUSES.  719 

Influenza  Meningitis. — This  form  of  meningitis  is  rare,  but  in  many 
respects  resembles  tlie  form  just  described.  According  to  Wollstein/ 
there  had  been  recorded,  up  to  1911,  49  cases  of  pure,  and  9  cases  of 
mixed,  influenza  meningitis.  Of  these,  28  were  in  infants  under  one  year 
old.  Of  the  reported  cases,  5  recovered,  2  of  these  being  in  infants.  Of 
the  5  cases  which  have  come  under  my  own  observation,  one  was  in  a  boy 
of  four  years;  the  others  were  in  infants.  All  ended  fatally.  In  my 
experience,  influenza  meningitis  has  been  secondary  to  other  influenza 
infections,  usually  those  of  the  naso-pharynx  or  bronchi.  Tlie  organisms 
were  found  by  culture  from  the  secretions  of  these  parts  during  life.  One 
patient,  an  infant  of  eight  months,  was  admitted  to  the  hospital  with  an 
acute  abscess  of  the  elbow.  Two  days  later  symptoms  of  meningitis 
developed,  and  death  occurred  in  three  days.  The  autopsy  showed  an 
extensive  purulent  meningitis.  Pure  cultures  of  the  influenza  bacillus 
were  obtained  from  the  pus  of  the  elbow,  the  fluid  drawn  by  lumbar 
puncture,  the  meningeal  exudate,  and  the  heart's  blood.  The  lungs 
showed  influenza  bacilli  and  streptococci. 

The  lesions  of  influenza  meningitis,  in  tlie  few  cases  in  which  autop- 
sies have  been  made,  have  differed  in  no  essential  particular  from  those 
described  in  the  pneumococcus  variety.  In  three  of  the  cases  coming 
under  my  observation  in  which  examinations  were  made,  the  influenza 
bacillus  was  obtained  from  the  heart's  blood  as  well  as  from  the  cerebro- 
spinal fluid. 

Clinically,  influenza  meningitis  runs  a  short,  very  acute  course. 
There  are  no  features  by  which  it  can  be  distinguished  from  the  pneu- 
mococcus or  meningococcus  form,  except  the  findings  of  lumbar  punc- 
ture. In  gross  appearance  the  fluid  does  not  differ  from  that  seen  in 
the  other  forms.  There  is  usually  marked  turbidity;  the  cells  are  abun- 
dant and  of  the  polymorphonuclear  variety.  The  organisms  are  gen- 
erally not  numerous  in  the  smears,  in  marked  contrast  to  the  other 
forms  of  meningitis.  They  are  readily  grown  upon  blood  agar,  but  not 
upon  ordinary  media.  If,  therefore,  from  a  turbid  cerebro-spinal  fluid 
no  growth  occurs,  influenza  meningitis  should  be  suspected. 

Meningitis  Due  to  Pyogenic  Organisms — Septic  Meningitis. — Menin- 
geal inflammations  set  up  by  the  streptococcus  and  staphylococcus  are 
not  very  common  in  young  children.  They  are  almost  always  secondary. 
In  the  newly  born  this  form  of  meningitis  is  seen  in  general  pyaemia, 
usually  from  umbilical  infection;  it  also  follows  infection  of  a  spina 
bifida.  In  older  children  it  follows  injuries  to  the  head,  erysipelas  of 
the  scalp,  operations  upon  the  brain,  and  otitis  media  with  mastoiditis 
or  sinus  thrombosis.  Such  a  complication  of  otitis  in  infancy  is,  how- 
ever, extremely  rare.     The  lesions  consist  in  a  widespread  general  in- 


1  American  Journal  of  Diseases  of  Children,  January,  1911. 


720  DISEASES  OF  THE   NERVOUS  SYSTEM. 

flammation  of  the  pia  with  an  abundant  exudate  of  pus,  but  with  less 
fibrin  than  in  the  two  varieties  previously  described. 

The  symptoms  of  septic  meningitis  are  not  distinctive.  The  course 
is  usually  a  rapidly  progressing  one,  and  the  termination  almost  invari- 
ably in  death.  The  fluid  drawn  by  lumbar  puncture  in  most  cases  is 
markedly  turbid,  and  shows  great  numbers  of  pus  cells.  The  organisms 
are  present  in  large  numbers  and  are  readily  recognised  both  in  smears 
and  by  cultures  upon  ordinary  media. 

Diagnosis. — The  differential  diagnosis  of  the  different  forms  of  menin- 
gitis from  each  other,  and  from  other  diseases  with  cerebral  symptoms, 
is  made  with  certainty  only  by  means  of  lumbar  puncture,  which  should 
be  done  in  all  cases  of  doubt.  The  appearance  of  the  cerebro-spinal  fluid 
is  essentially  the  same  whether  the  inflammation  is  due  to  the  meningo- 
coccus, the  pneumococcus,  the  influenza  bacillus,  or  to  the  staphylococcus 
or  streptococcus.  The  symptoms  of  meningitis  in  general,  fully  de- 
scribed in  the  chapter  on  Cerebro- Spinal  Meningitis,  are  present  in  most 
of  the  cases. 

Prognosis  and  Treatment. — The  prognosis  in  all  varieties  of  acute 
meningitis,  except  that  due  to  the  meningococcus,  is  very  bad;  almost 
every  case  of  meningitis  due  to  other  causes  is  fatal.  From  what  has 
been  said,  it  would  appear  that  treatment  is  as  yet  most  unsatisfactory, 
and  only  symptomatic.  Wollstein's  researches  at  the  Rockefeller  In- 
stitute, however,  indicate  that  influenza  meningitis  may  yet  be  controlled 
by  serum  treatment.  A  goat  serum  has  been  produced  which  regularly 
controls  the  experimental  disease  in  monkeys,  although  its  use  has  not 
yet  been  extended  to  man. 

TUBERCULOUS  MENINGITIS. 
{Acute  Hydrocephalus;  Basilar  Meningitis.) 

Tuberculous  meningitis  is  a  tuberculous  inflammation  of  the  pia 
mater  of  the  brain,  sometimes  involving  also  that  of  the  cord.  It  is  by 
far  the  most  frequent  form  of  acute  meningitis  seen  in  young  children. 
In  my  hospital  experience,  apart  from  epidemics  of  cerebro-spinal  menin- 
gitis, seventy  per  cent  of  the  cases  of  acute  meningitis  have  been  tuber- 
culous. It  is  more  uniformly  fatal  than  any  other  disease  of  early  life. 
It  is  doubtful  if  it  ever  occurs  as  the  only  tuberculous  lesion  of  the  body. 
In  infancy  it  is  usually  associated  with  general  or  pulmonary  tubercu- 
losis; in  older  children  with  tuberculosis  of  the  bones,  joints,  or  lymph 
nodes.  Of  my  own  cases,  forty  per  cent  of  all  deaths  from  tuberculosis 
in  children  have  been  due  to  meningitis. 

Lesions. — The  lesion  consists  in  the  production  of  miliary  tubercles, 
with  which  are  frequently  found  tuberculous  nodules  of  variable  size,  and 
in  almost  every  case  there  are  also  the  products  of  ordinary  inflammation 


TUBERCULOUS   MENINGITIS.  721 

of  the  pia  mater— fibrin  and  pus— together  with  an  accumulation  of 
fluid  in  the  lateral  ventricles  of  the  brain.  Frequently  there  are  tubercles 
in  the  pia  mater  of  the  upper  portion  of  the  cord.  When  few  in  number 
the  tubercles  are  usually  only  at  the  base.  When  numerous  they  are  seen 
scattered  over  the  convexity.  Tubercles  are  sometimes  found  in  the 
choroid  coat  of  the  eye.  The  amount  of  fibrin  and  pus  in  the  exudate 
is  usually  small,  and  is  much  less  than  is  seen  in  other  forms  of  acute 
meningitis.  The  inflammatory  products  are  most  abundant  at  the  base. 
In  addition  to  the  patches  of  greenish-yellow  fibrin,  there  are  adhesions 
between  the  lobes  of  the  brain  and  thickening  of  the  pia.  In  cases  which 
have  lasted  for  several  weeks,  this  thickening  may  l)e  marked,  owing 
to  cell  infiltration  and  the  production  of  new  connective  tissue.  The 
pia  is  studded  with  miliary  tubercles,  sometimes  witli  small  yellow 
tuberculous  nodules;  frequently  there  is  arteritis,  which  is  sometimes 
obliterating. 

In  the  most  acute  cases  the  brain  substance  immediately  beneath  the 
pia  is  intensely  congested,  slightly  softened,  and  shows  under  the  micro- 
scope a  superficial  encephalitis.  The  lateral  ventricles  are  usually  dis- 
tended with  clear  serum,  sometimes  wdth  serum  containing  flocculi  of 
fibrin  or  pus;  the  amount  present  varies  from  one  to  four  ounces  in  each 
ventricle,  being  always  greater  in  the  subacute  cases.  The  walls  of  the 
ventricles  may  be  softened.  The  distention  of  the  ventricles  leads  to 
flattening  of  the  convolutions  from  pressure  against  the  skull,  to  bulging 
of  the  fontanel,  and  sometimes  to  separation  of  the  sutures. 

Tuberculous  nodules  varying  in  size  from  a  small  pea  to  a  walnut  are 
frequently  seen  associated  with  meningitis  in  older  children,  but  not 
often  in  infants.  These  nodules  may  be  connected  with  the  meninges, 
or  they  may  be  situated  within  the  brain  substance,  usually  in  the  cere- 
bellum. The  larger  ones  are  classed  as  brain  tumours.  Inflammatory 
products  are  rarely  found  in  the  spinal  canal. 

Although  it  is  not  infrequent  to  see  meningitis  without  symptoms  of 
tuberculosis  elsewhere,  I  have  never  failed  at  autopsy  to  find  other  tuber- 
culous lesions  in  the  body.  In  my  own  experience  the  following  are 
those  most  often  met  with,  given  in  the  order  of  frequency:  (1)  In  in- 
fants, associated  with  general  or  pulmonary  tuberculosis;  (2)  in  chil- 
dren from  three  to  twelve  years  of  age,  with  tuberculosis  of  the  vertebrae, 
hip,  knee,  or  ankle;  (3)  at  any  age,  with  tuberculosis  involving  only 
the  tracheal,  bronchial,  or  mesenteric  lymph  nodes;  (4)  much  less 
frequently  wath  the  pulmonary  tuberculosis  of  older  children. 

Etiology.— Tuberculous  meningitis  is  produced  only  by  the  transpor- 
tation of  the  tubercle  bacilli  to  the  brain.  They  may  find  their  way  by 
the  blood-vessels  or  lymphatics. 

The  following  table  shows  the  age  at  which  the  disease  was  observed 
in  410  cases  of  which  I  have  notes: 
47 


722 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


Under  one  year 162 

One  to  two  years 149 

Two  to  five  years 76 

Five  to  nine  years 17 

Nine  to  sixteen  years 6 

Total 410 

In   this   series   three   cases   were   in   children   three   months   old   or 
younger.    Tuberculous  meningitis  occurs  much  more  often  in  the  winter 

and  spring  months  than 
at  other  seasons  (Fig. 
118).  The  most  plausi- 
ble explanation  of  this 
seems  to  be  that  these 
patients,  infected  some 
time  previously,  carry  a 
latent  focus  of  tubercu- 
losis somewhere  in  the 
respiratory  tract,  usually 
the  bronchial  glands. 
Under  the  influence  of 
acute  respiratory  infec- 
tions of  the  cold  season, 
the  latent  tuberculous 
disease  becomes  active, 
and  a  rapidly  spreading 
tuberculous  process  re- 
sults. In  infants  and 
young  children  it  rarely 
happens  that  pulmonary 
lesions  are  absent;  but  these  patients  are  especially  predisposed  to  early 
meningeal  infection,  and  this  often  occurs  before  symptoms  of  tubercu- 
losis elsewhere  have  manifested  themselves.  At  the  time  of  invasion, 
therefore,  most  of  these  children  are  apparently  in  the  best  of  health. 
In  older  children  there  may  have  been  previous  evidence  of  tuberculosis 
in  lungs,  bones,  or  lymph  nodes.  The  modes  of  acquiring  tuberculosis 
are  discussed  in  the  general  chapter  on  that  disease.  It  is  sufficient  to 
say  here  that  it  is  usually  from  some  member  of  the  family  or  household. 
This  may  be  not  only  a  person  who  is  in  the  active  stage  of  pulmonary 
tuberculosis,  but  one  who  is  supposed  to  be  cured  or  one  in  whom  the 
disease  has  not  yet  been  suspected.  Exposure  may  antedate  symptoms 
by  several  weeks  or  months.  Striking  evidence  in  favor  of  the  human 
origin  of  tuberculous  meningitis  is  obtained  from  a  study  of  the  type  of 
tubercle  bacillus  present  in  cases  of  meningitis.  In  thirty-two  cases  in 
my  series,  this  was  worked  out  by  Dr.  W.  H.  Park  in  the  Research 


Ju 

Feb 

Mel. 

A,. 

Ma; 

JUM 

Julj: 

Au?. 

S.H 

Otl. 

XoT. 

Dec. 

1400 
1200 
1000 
800 
600 
400 
200 

36 

1400 
1200 
1000 
800 
600 
400 
200 

33 

A 

30 

/ 

\ 

?^ 

\ 

24 

\ 

71 

\ 

18 

^ 

/ 

r 

•A 
\ 

\ 

15 

s/. 

' 

^ 

1 

V 

V 

12 

'V 

V^ 

V 

,0 

/ 

9 

\ 

**" 

v>/ 

/ 

6 

V. 

y 

9 

0 

Fig.  118. — Seasonal  Occurrence  of  Tuberculous 
Meningitis.  The  upper  curve  ( — )  represents  the 
seasonal  occurrence  of  218  cases  of  tuberculous 

meningitis.     The  lower  curve  ( )  represents  the 

deaths  from  pneumonia  in  New  York  City  for  one 
year. 


TUBERCULOUS   MENINGITIS.  723 

Laboratory  of  the  New  York  Healtli  Department.  In  tliirty  the  baeiUus 
was  of  the  human  type;  in  one  it  was  of  the  bovine  type,  and  in  one 
both  types  were  present. 

Symptoms. — In  about  two-thirds  of  tlie  cases  the  onset  is  gradual; 
but  in  a  considerable  number  of  those  classed  as  abrupt,  careful  inquiry 
will  elicit  a  history  of  previous  indisposition.  The  most  frequent  early 
nervous  symptoms  are:  disinclination  to  play,  drowsiness,  or  sometimes 
constant  fretfulness  or  irritability.  Often  there  is  a  complete  change  in 
disposition.  In  a  case  under  my  observation  this  was  most  striking; 
a  little  girl  previously  devoted  to  her  mother,  could  not  endure  her 
presence  in  the  room.  Sleep  is  restless  and  disturbed  ;  there  may  be 
grinding  of  the  teeth.  Older  children  often  complain  of  headache.  At 
all  ages,  but  particularly  in  infancy,  early  digestive  symptoms  are  prom- 
inent. There  are  seen  frequent  attacks  of  vomiting  without  apparent 
cause;  the  bowels  are  generally  constipated  and  tlie  appetite  is  almost 
entirely  lost.  Usually  there  is  also  a  slight  but  continuous  elevation  of 
temperature.  Indefinite  symptoms  may  last  for  four  or  five  days,  or 
they  may  be  spread  over  two  or  three  weeks  without  perhaps  being  suf- 
ficiently severe  to  attract  much  notice.  Finally,  unmistakable  evidence 
of  brain  disease  develops.  The  early  disturbances  are  often  ascribed  to 
dentition,  or  to  indigestion. 

In  most  cases  the  first  pronounced  cerebral  symptom  is  persistent  and 
increasing  drowsiness;  exceptionally  it  is  an  attack  of  general  convul- 
sions, followed  in  a  few  hours  by  stupor.  Often  a  period  of  irritative 
symptoms  is  present,  lasting  several  days.  There  is  headache,  usually 
located  in  the  frontal  region,  and  occasionally  photophobia;  sometimes 
pain  is  indicated  by  the  child's  suddenly  screaming  out  at  night,  which 
may  be  repeated  many  times  without  waking;  sometimes  during  the 
greater  part  of  the  time  for  two  or  three  days  these  frequent  screaming 
attacks  may  be  repeated.  The  skin  is  somewhat  hyperassthetic ;  the  re- 
flexes are  apt  to  be  exaggerated;  the  muscles  of  the  neck  may  be  rigid 
and  the  head  is  drawn  back,  or  there  may  be  rigidity  of  the  extremities. 
The  pupils  are  normal  or  contracted;  there  may  be  nystagmus.  The 
child  is  fretful,  wishes  to  be  left  alone,  and  cries  if  disturbed.  In  some 
cases  these  symptoms  are  so  marked  as  strongly  to  suggest  cerebro-spinal 
meningitis.  They  may  alternate  with  periods  of  marked  apathy  and 
dulness.  During  this  stage  there  is  occasional  vomiting,  and  the  bowels 
are  obstinately  constipated.  The  pulse  is  usually  somewhat  accelerated, 
but  may  be  slow  and  occasionally  it  is  irregular.  The  respiration  is  of 
normal  frequency,  but  a  careful  observation  during  sleep  or  perfect  quiet 
will  often  show  a  slight  irregularity  which  is  very  significant.  The 
temperature  is  usually  elevated,  ranging  from  99°  to  100.5°  F.  When 
a  high  temperature  is  seen,  it  is  usually  due  to  tuberculosis  elsewhere 
than  in  the  brain. 


724  DISEASES  OF  THE   NERVOUS  SYSTEM. 

As  the  disease  advances,  the  irritative  symptoms  siihside,  and  the  stu- 
por becomes  deeper  and  more  continuous.  If  undisturbed,  the  child  may 
sleep  a  great  part  of  the  time,  but  can  be  roused,  and  then  appears 
quite  rational.  Finally  the  stupor  becomes  so  profound  that  the  child  can 
not  be  roused  at  all.  Active  delirium  is  rare.  The  pupils  respond  slowly 
to  light  or  not  at  all;  they  may  be  unequal;  occasionally  there  is  seen 
strabismus,  ptosis,  or  paralysis  of  the  face.  More  often  there  is  hemi- 
plegia, or  paralysis  of  one  arm  or  leg.  Such  paralyses  are  often  transient, 
disappearing  after  a  day  or  two.  Automatic  movements  of  the  extremi- 
ties, particularly  of  the  arms,  are  frequent.  Muscular  twitchings  may 
be  noticed.  Opisthotonus  is  marked  and  well-nigh  constant.  In  infants 
the  fontanel  is  tense  and  bulging.  In  older  children  especially  the  ab- 
domen is  retracted,  giving  the  typical  "  boat-belly."  On  drawing  the 
finger-nail  along  the  skin  of  the  abdomen,  there  appears  a  distinct  red 
streak,  which  remains  for  several  minutes.  This  is  the  tdche  cerebrale, 
and  it  is  almost  always  present.  Other  vaso-motor  disturbances  may  be 
seen.  The  reflexes  are  variable;  in  the  early  part  of  the  disease  they  are 
usually  increased,  later  they  are  diminished  or  abolished.  The  pulse  now 
becomes  slow  and  irregular,  often  intermittent.  The  respiration  is  almost 
always  irregular;  a  very  characteristic  type  consists  in  the  movements 
becoming  deeper  and  deeper  until  there  is  a  sigh;  after  a  complete 
arrest  of  respiration  for  several  seconds  the  phenomenon  is  repeated. 

The    accompanying   tracing    il- 

An  examination  with  the  oph- 
FiG.  119.-TRACING  OP  Respiration  in  Tuber-    thalmoscope   usuallv   shows    the 
CULOU8  Meningitis.  »    i     ,     i  '  t 

presence  of  choked  discs. 

The  progress  of  the  disease  is  subject  to  great  variations,  especially 
in  children  over  two  years  old.  The  advance  of  symptoms  is  slower  and 
is  interrupted  by  periods  of  remission  which  may  continue  two  or  three 
days.  After  being  in  quite  deep  stupor,  a  child  may  recover  conscious- 
ness, and  even  sit  up  and  play  with  toys,  leading  to  the  view  that  an 
error  in  diagnosis  has  been  made.  But  this  respite  is  only  temporary; 
soon  the  child  passes  again  into  coma. 

From  this  time  the  duration  of  the  disease  is  from  three  to  ten  days. 
The  child  can  not  be  roused  at  all.  The  pupils  are  widely  dilated,  and 
do  not  respond  to  light.  There  is  general  muscular  relaxation.  There 
may  be  retention  of  the  urine.  Deglutition  is  difficult,  often  impossible. 
The  respiration  is  more  rapid,  but  still  irregular.  The  pulse  becomes 
very  rapid  and  feeble,  often  160  to  180  a  minute.  Toward  the  end  the 
temperature  rises  rapidly  to  104°  F.,  sometimes  to  106°  or  107°  F. 
(Fig.  120).  Death  usually  takes  place  from  exhaustion  in  deep  coma, 
or  convulsions  develop  and  continue  from  twelve  to  twenty-four  hours 
until  death.     Sometimes  a  patient  will  live  for  days  in  a  condition  of 


TUBERCULOUS   MENINGITIS. 


725 


prostration  so  extreme  that  death  is  lumrly  expected.  A  rapidly  rising 
temperature  or  the  occurrence  of  late  convulsions  usually  indicates  ap- 
proaching death.     Of  fifty-seven  cases,  fifty  died  in  coma,  seven  in  con- 


DAY 

1 

2 

3 

4 

6 

c 

7 

8 

9 

10 

11 

12 

13 

14 

IB 

IS 

17 

DATE 

OCT. 

10 

11 

12 

13 

14 

IB 

ie 

17 

18 

19 

20 

21 

22 

23 

24 

28 

28 

I 

1 

I 
< 
11. 

Ill 

B 

i 

o. 
z 

►- 

100° 

iu;° 

104° 

103° 
102° 
101° 
100° 
99° 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

/ 

( 

J 

/ 

h 

\, 

N 

,^ 

V 

A 

1 

\ 

fN 

P 

[^ 

\/ 

A 

\t 

\A 

A 

A 

y 

/ 

V 

J 

V 

^ 

V 

^ 

'V 

V 

^r 

[J 

V 

V 

V 

1        1 

Via.  120. — Fairly  Typical  Temperature  Curve  in  Tuberculous  Meningitis. 
Boy,  twenty  months  old ;  death  on  seventeenth  day. 

vulsions.  The  entire  duration  of  the  disease  from  the  hej^^iniiing  of 
definite  nervous  symptoms  is  rarely  over  three  weeks,  and  in  infants  it 
is  usually  shorter  than  this. 

Diagnosis. — Tuherculous  meningitis  is  often  overlooked  heeause  the 
patients  do  not  give  outward  evidences  of  tul)ereulosis.  Its  great  fre- 
quency should  always  lead  one  to  suspect  it  when  protracted  nervous 
symptoms  are  present  in  infants.  There  are  no  diagnostic  symptoms  in 
the  early  stage.  The  indefinite  symptoms  that  helong  to  tliis  stage  of 
the  disease  are  frequent  in  young  children  suffering  from  chronic  indi- 
gestion associated  with  constipation.  Cases  of  cyclic  vomiting  may 
present  many  of  the  symptoms  of  meningitis. 

The  most  diagnostic  symptoms  of  tuherculous  meningitis  enumerated 
in  the  order  of  tlieir  frequency  are  as  follows:  persistent  drowsiness, 
obstinate  constipation,  vomiting  without  apparent  cause,  irregular  respi- 
ration, irregular  pulse,  convulsions,  opisthotonus,  and  fever  which  is 
usually  slight.  A  positive  diagnosis  is  made  only  by  lumliar  puncture; 
by  this  means  this  form  is  distinguished  from  other  forms  of  acute 
meningitis. 

The  fluid  drawn  by  lumbar  puncture  is  usually  perfectly  clear,  but 
sometimes  after  standing  there  is  a  slight  deposit  present.  Exceptionally 
the  fluid  may  be  turbid.  Tlie  cells  are  usually  few  in  number,  and  of 
the  mononuclear  variety.  The  presence  or  absence  of  sugar  has  been 
in  my  experience  of  no  diagnostic  importance. 

Tubercle  bacilli  are,  I  believe,  invariably  present  in  the  fluid,  and 
by  careful  examination  can  be  found  microscopically  in  nearly  every 
case.     They  were  found  in  i;i5  of  137  consecutive  eases  of  tuberculous 


726  DISEASES  OF  THE   NERVOUS  SYSTEM. 

meningitis  at  the  Babies'  Hospital.^  They  are  more  numerous  late  in 
the  disease. 

Tlie  teelinique  is  important.  Fluid  should  be  drawn  into  several 
tubes  and  the  last  one  containing  15  or  20  com.  set  aside  for  examina- 
tion, as  the  bacilli  are  much  more  likely  to  be  found  in  this  than  in  the 
first  fluid.  Tiie  tube  should  not  be  shaken,  but  should  be  allowed  to 
stand  for  twelve  hours,  preferably  in  an  incubator.  A  central  coagulum 
or  film  generally  forms  in  the  fluid,  and  in  this  the  bacilli  are  usually 
entangled.  This  should  be  spread  out  entire  and  carefully  examined. 
In  other  cases  the  bacilli  may  be  found  after  centrifuging ;  in  still  others 
by  scraping  the  sides  of  the  tube  with  a  platinum  loop  or  by  examining 
superimposed  drops  which  have  been  allowed  to  dry  upon  a  slide.  In 
most  of  the  cases  the  number  of  bacilli  present  is  not  large  and  the  aver- 
age length  of  search  required  has  been  about  an  hour,  but  in  a  few  in- 
stances the  number  is  so  large  that  they  are  present  in  practically  every 
field. 

Xoguchi's  globulin  test  ^  is  useful  in  distinguishing  inflammatory 
from  normal  cerebro-spinal  fluids.  It  is,  however,  of  no  value  in  dis- 
tinguishing between  the  different  forms  of  meningitis.  A  positive  re- 
action is  obtained  with  great  uniformity  in  every  variety  of  acute  men- 
ingitis. This  test  is  of  special  assistance  in  the  tuberculous  cases,  for  in 
them  the  gross  appearance  of  the  fluid  does  not  usually  differ  from  the 
normal;  moreover,  it  gives  early  information. 

Bacilli  have  been  found  in  the  sputum,  in  my  experience,  in  nearly 
one-half  the  cases  in  infants  and  young  children,  although  in  most  of 
them  there  was  either  no  evidence  of  pulmonary  disease,  or  only  cough 
and  a  few  scattered  rales  in  the  chest. 

The  v.  Pirquet  cutaneous  test  gives  reliable  information  except 
in  moribund  cases,  in  those  excessively  prostrated  or  with  very  poor 
circulation.  A  positive  reaction  was  obtained  in  51  of  65  consecutive 
cases  tested,  the  negative  results  being  usually  for  the  reasons  men- 
tioned.    This  test  is  of  much  assistance  in  early  diagnosis.     If  then  a 

'  See  Hemenway,  American  Journal  of  Diseases  of  Children,  January,  1911. 
*  The  test  is  as  follows: 
To  0.5  c.cra.  of  a  10-per-cent  solution  of  butyric  acid  in  0.9-per-cent  salt  solution 
add  0.1-0.2  c.cm.  of  suspected  fluid  and  boil. 

Then  add  0.1  c.cm.  normal  sodium  hydrate  solution  and  boil  again. 
No  change  in  the  solution  or  only  a  faint  cloudiness  is  to  be  considered  a  negative 
reaction. 

A  flaky  precipitate  is  a  positive  reaction. 

Note. — The  test  should  be  controlled  by  boiling  the  two  solutions  without  the 
suspected  fluid.  The  reagents  should  be  freshly  made;  they  may  change  after  two 
or  three  weeks.  The  accidental  addition  to  the  fluid  of  even  a  ifew  drops  of  blood 
spoils  the  test,  for  this  is  sufiicient  to  give  the  globulin  reaction  although  no  menin- 
gitis is  present. 


CHRONIC   BASILAR   MENINGITIS   IN    INFANTS.  727 

child  with  symptoms  distinctly  meningeal  gives  a  positive  reaction  to 
the  tuherculin  test  the  probabilities  of  tnberculoiis  meningitis  are  greatly 
strengthened,  even  though  at  the  time  bacilli  may  not  have  l)een  found 
in  the  cerehro-spinal  fluid. 

The  cerebral  symptoms  of  intestinal  and  many  othei  acute  diseases 
sometimes  closely  resemble  those  of  tul)erculous  meningitis.  From  all 
such  the  diagnosis  is  made  hy  lumbar  puncture.  In  any  case  of  men- 
ingitis in  a  young  child  the  chances  are  greatly  in  favour  of  the  tuber- 
culous form,  since  it  is  much  more  frequent.  The  diagnosis  of  tuber- 
culous meningitis  from  the  cerebral  form  of  acute  poliomyelitis  is  at 
times  difficult.     It  is  discussed  under  the  latter  disease. 

Prognosis. — Although  there  have  been  recorded  a  few  instances  of 
recovery  after  the  tubercle  bacilli  have  been  found  in  the  fluid  obtained 
by  lumbar  puncture,  such  an  outcome  is  not  to  be  expecte(L  I  have 
never  seen  such  a  case  recover.  The  reported  recoveries  in  which  the 
diagnosis  has  rested  upon  clinical  symptoms  only  can  not  be  accepted. 

Treatment. — From  what  has  been  said  regarding  prognosis,  it  follows 
that  if  the  diagnosis  is  correct  the  case  is  practically  hopeless,  no  matter 
what  treatment  is  employed ;  but  as  a  positive  diagnosis  is  not  always 
possible,  all  cases  should  be  treated  like  other  forms  of  acute  meningitis. 

CHRONIC   BASILAR   MENINGITIS   IN   INFANTS. 

It  was  first  pointed  out  in  1898  by  Still  that  this  disease  is  usually 
due  to  the  diplococcus  intracellularis ;  in  other  words,  that  it  is  a  chronic 
form  of  cerebro-spinal  meningitis.  Chronic  basilar  meningitis  is  most 
frequently  seen  after  epidemics  of  cerebro-spinal  meningitis,  but  it  is 
occasionally  met  with  at  other  times  as  a  sequel  of  a  sporadic  case.  It 
occurs  after  an  acute  attack,  when  the  basilar  lesion  persists  and  be- 
comes chronic.  As  acute  cerebro-spinal  meningitis  in  infants  is  usually 
fatal  if  the  attack  is  severe,  it  follows  that  the  chronic  form  is  seen 
only  after  the  mild  attacks.  It  is  chiefly  for  this  reason  that  the  early 
symptoms  often  are  not  recognised  as  those  of  cerebro-spinal  meningitis. 
The  patient  frequently  does  not  come  under  observation  until  all  acute 
symptoms  have  passed  away,  the  persistent  opisthotonus  being  the  chief 
feature  of  the  case. 

There  is  also  seen  in  children,  though  very  rarely,  a  chronic  basilar 
meningitis  of  syphilitic  origin.  At  least  two  such  cases  have  come  under 
my  observation  in  the  Babies'  Hospital.  One  was  cured  by  anti-syphilitic 
treatment,  and  in  the  other  the  diagnosis  was  confirmed  by  autopsy. 

Lesions.— This  process  is  usually  limited  to  the  base  of  the  brain. 
The  pia  mater  is  thickened  about  the  interpeduncular  space,  also  over  the 
medulla,  pons,  and  cerebellum.  These  different  parts  may  be  adherent  to 
each  other,  or  to  the  inner  surface  of  the  dura.    The  cranial  nerves  may 


728  DISEASES  OF  THE   NERVOUS  SYSTEM. 

be  compressed.  The  openings  in  the  fourth  ventricle  are  usually  ob- 
literated, and  there  results  a  distention  of  the  lateral  ventricles  with 
clear  serum,  sometimes  in  sufficient  amount  to  be  regarded  as  hydro- 
cephalus.   Earely,  pus  may  be  found  in  the  ventricles. 

Symptoms. — The  onset  is  usually  gradual,  although  in  most  cases 
there  can  be  obtained  a  fairly  distinct  history  of  an  early  active  period. 
The  most  prominent  symptoms  are  cervical  opisthotonus,  moderate  hydro- 
cephalus, and  usually  general  muscular  rigidity.  The  opisthotonus  is 
often  extreme  (Fig.  121)  and  is  greater  than  is  seen  in  any  other  disease. 
If  placed  upon  its  back  the  body  of  the  child  often  touches  the  table  only 
at  the  occiput  and  the  sacrum  (Fig.  122).  The  head  is  usually  some- 
what enlarged,  but  never  to  the  degree  seen  in  primary  hydrocephalus; 
the  fontanel  bulges,  and  the  sutures  are  separated.  These  symptoms 
are  due  to  an  accumulation  of  fluid  in  the  lateral  ventricles;  they  are 
never  so  marked  as  in  primary  hydrocephalus.  The  rigidity  of  the  ex- 
tremities is  very  great  and  in  most  cases  constant ;  the  legs  and  feet 


Fig.  121. — Chronic  Basilar  Meningitis— Extreme  Deformity.  Ill  for  five  months; 
followed  cerebro-spinai  meningitis;  posture  shown  in  the  picture  maintained  for  the 
last  six  weeks;  death  at  ten  months.     Autopsy  showed  typical  lesions. 

are  usually  extended,  while  the  forearms  are  flexed  and  the  hands 
clenched.  All  the  reflexes  are  greatly  exaggerated.  There  is  rarely 
coma,  but  mental  dulness  alternating  with  periods  of  great  irritability 
in  which  general  convulsions  may  occur.  Vision  may  be  impaired  or 
wanting  entirely.  The  fact  that  in  most  cases  optic  neuritis  is  absent 
is  of  some  value  in  differentiating  this  disease  from  tumour.  Nystagmus 
is  often  present  and  attacks  of  vomiting  occur  without  evident  cause. 
There  is  no  fever  except  for  a  few  days  at  a  time  during  acute  exacerba- 
tions.    The  usual  duration  of  the  disease  is  from  two  to  five  months; 


THROMBOSIS   OF   THE   SINUSES   OF   THE    DURA   MATER.       729 

death  may  occur  from  convulsions,  or  from  some  intercurrent  disease, 
such  as  pneumonia,  but  most  frequently  from  marasmus.  IMie  prognosis 
is  very  bad  except  when  the  cause  is  syphilis,  when  recovery  may  take 
place. 

Diagnosis.— The  disease  is  to  be  distinguished  from  tuiierculous  men- 
ingitis, and  from  the  opisthotonus  of  reflex  origin  wliich  is  occasionally 
seen  in  infants  suffering  from  marasmus.     It  differs  from  tuberculous 


Fig.  122. — Chronic  Basilar  Meningitis. 
A  patient  in  the  Babies'  Hospital  (diagnosis  confirmed  by  autopsy). 

meningitis  in  its  more  protracted  course,  in  the  absence  of  fever  and 
paralysis,  and  also  in  the  greater  prominence  of  the  opisthotonus  and 
hydrocephalus. 

Treatment. — If  there  is  any  reason  to  suspect  syphilis,  salvarsan  and 
the  iodide  of  potassium  and  mercury  should  be  administered.  Lumbar 
puncture  is  useful  for  diagnosis  only.  The  establishment  of  auto-drainage 
of  the  ventricles,  as  practised  in  primary  hydrocephalus,  has  recently  been 
advocated  for  this  condition,  and  tried  with  some  measure  of  success. 


THROMBOSIS  OF  THE  SINUSES  OF  THE   DURA  MATER. 

This  is  not  very  frequent.  It  may  depend  upon  certain  general  con- 
ditions, when  it  is  usually  classed  as  cachectic  or  marantic  thrombosis; 
it  may  be  associated  with  local  pathological  processes,  when  it  is  known 
as  inflammatory  or  septic  thrombosis. 

Cachectic  Thrombosis. — This  is  seen  in  infants  and  young  children, 
but  is  very  rare  after  the  age  of  five  years.  It  occurs  in  the  course  of 
various  diseases,  the  most  frequent  being  pneumonia,  pertussis,  diph- 
theria, nephritis,  tuberculosis,  and  the   acute  intestinal   diseases.     In 


730  DISEASES  OF  THE   NERVOUS  SYSTEM. 

connection  with  the  last-mentioned  group,  altogether  too  much  has  been 
made  of  it,  as  it  is  really  rare,  and  in  only  a  very  few  cases  does  it  explain 
the  cerebral  symptoms  present.  The  actual  cause  of  the  thrombosis  is 
the  altered  condition  of  the  blood  and  the  feeble  circulation,  as  the  walls 
of  the  sinuses  are  normal. 

The  most  frequent  seat  of  cachectic  thrombosis  is  the  superior  longi- 
tudinal sinus.  At  autopsy  one  must  be  careful  not  to  confound  the  soft, 
partly  decolourised,  non-adherent  thrombi  of  post-mortem  origin,  with 
those  of  ante-mortem  formation.  The  latter  are  firm,  and  when  of  long 
standing  may  be  very  hard  and  even  show  a  laminated  structure.  They 
usually  fill  the  sinus  completely,  and  are  adherent.  The  thrombus  ex- 
tends from  the  sinuses  to  the  veins  emptying  into  it,  which  stand  out 
like  dark  worms  upon  the  surface  of  the  brain.  The  brain  itself  may  be 
deeply  congested,  or  it  may  be  covered  with  a  diffuse  haemorrliage,  but 
more  frequently  the  brain  and  the  membranes  are  simply  oedematous. 

The  symptoms  of  cachectic  thrombosis  are  few  and  uncertain,  and  in 
a  large  number  of  cases  the  disease  is  latent.  Very  rarely  is  a  positive 
diagnosis  possible  during  life.  When  the  thrombosis  occurs  just  before 
death,  its  symptoms  are  so  mingled  with  those  of  the  original  disease 
that  they  can  not  be  separated.  In  some  cases  there  may  be  localised 
or  general  convulsions,  or  paralysis,  loss  of  consciousness,  and  strabismus. 

The  prognosis  is  bad,  cases  generally  proving  fatal  in  the  course  of  a 
few  days.  The  diagnosis  is  so  uncertain  and  obscure  that  the  treatment 
must  be  symptomatic,  and  directed  toward  the  general  rather  than  the 
local  condition. 

Inflammatory  Thrombosis — Septic  Thrombosis — Sinus-Phlebitis. — This 
condition  is  most  frequently  seen  in  children  in  connection  with  acute 
meningitis.  It  may  exist  either  with  the  simple  or  the  tuberculous 
variety.  It  also  follows  otitis — especially  old  and  neglected  cases — usu- 
ally with  necrosis  of  the  petrous  bone,  but  sometimes  without  it.  It  is 
much  less  frequently  associated  with  disease  of  the  ear  in  children  than 
in  adults.  It  may  arise  from  traumatism,  necrosis  of  the  cranial  bones, 
or  from  septic  processes  involving  any  of  the  cavities  or  any  of  the 
structures  adjacent  to  the  brain,  such  as  the  scalp,  orbit,  nasal  fossa, 
mouth,  or  pharynx.  Infection  from  the  mouth  or  pharynx  is  most  fre- 
quent in  children  in  connection  with  scarlet  fever  or  diphtheria;  while 
usually  secondary  to  otitis  it  may  occur  without  it,  the  infection  being 
carried  by  the  blood-vessels.  Infection  from  the  nose  may  have  its 
origin  in  ulceration  from  syphilis  or  tuberculosis.  In  the  orbit,  the 
source  may  be  malignant  disease. 

The  seat  of  the  thrombosis  will  depend  upon  the  original  disease.  If 
this  affects  the  cranial  bones  or  the  scalp,  it  will  be  the  longitudinal 
sinus;  if  the  ear,  the  lateral  sinus;  if  the  base  of  the  skull,  the  orbit, 
the  mouth,  the  jaw,  or  the  nose  is  affected,  it  will  be  the  cavernous  sinus. 


CEREBRAL  ABSCESS.  731 

When  thrombosis  occurs  with  meningitis  the  lesions  are  much  the  same 
as  in  the  cachectic  form,  with  the  exception  that  tliere  are  sometimes 
slight  changes  in  the  walls  of  the  sinuses.  If  the  patient  has  suffered 
from  a  local  septic  process,  there  may  be  puriform  softening  of  the 
clot,  and  general  pyaemia,  with  the  development  of  secondary  abscesses 
in  the  brain,  in  the  lungs,  and  in  other  organs.  With  such  cases  there 
may  be  associated  a  general  or  localised  meningitis. 

Symptoms. — The  symptoms  of  septic  thrombosis  are  more  decided 
than  those  of  the  cachectic  form.  When  occurring  in  the  course  of  men- 
ingitis, it  usually  adds  no  new  symptoms  to  those  of  the  original  dis- 
ease. In  the  pyaemic  form  the  symptoms  are  more  characteristic,  par- 
ticularly when  associated  with  otitis.  There  are  recurring  chills  with 
very  high  and  widely  fluctuating  temperature.  There  is  headache,  and 
often  localised  tenderness  of  the  scalp;  the  other  symptoms  which  are 
present  are  usually  the  same  as  those  of  meningitis.  If  metastasis  oc- 
curs, there  may  be  evidences  of  abscesses  in  the  brain  or  in  other  organs, 
and  sometimes  there  are  signs  of  suppuration  in  the  jugular  vein.  A 
polymorphonuclear  leucocytosis  is  usually  present,  and  blood  cultures 
in  most  cases  show  the  presence  of  pyogenic  organisms. 

The  local  symptoms  of  the  thrombosis  differ  somewhat  according  to 
the  sinus  affected :  if  its  seat  is  the  superior  longitudinal  sinus,  there 
may  be  cyanosis  of  the  face,  dilatation  of  the  temporal  and  frontal  veins, 
and  sometimes  epistaxis ;  if  the  lateral  sinus  is  involved,  the  process  may 
extend  to  the  jugular  vein,  which  may  be  felt  in  the  neck  as  a  hard 
cord,  and  there  may  be  dilatation  of  the  veins  of  the  mastoid  region,  and 
even  localised  oedema ;  when  the  cavernous  sinus  is  affected,  there  may  be 
protrusion  of  the  eyeball  of  the  affected  side,  oedema  of  the  lid,  and  with 
the  ophthalmoscope  the  retinal  veins  appear  enlarged  and  tortuous,  some- 
times being  the  seat  of  thrombosis.  The  process  may  affect  either  one 
or  both  sides.  The  course  of  septic  thrombosis  is  rather  irregular,  vary- 
ing from  a  few  days  to  three  weeks.  In  fatal  cases  death  takes  place 
from  meningitis,  cerebral  abscess,  or  pyaemia.  The  prognosis  is  very 
grave,  unless  the  disease  is  so  situated  that  it  is  accessible  to  surgical 
operation. 

Treatment — The  only  successful  treatment  is  surgical.  Operation 
is  easiest  in  thrombosis  of  the  lateral  sinus,  being  much  more  difficult 
if  involving  the  superior  longitudinal  sinus.  So  many  cases  are  now  on 
record  of  successful  operation  upon  septic  thrombosis  of  the  lateral  sinus, 
that  it  should  always  be  urged  when  the  diagnosis  is  clear. 

CEREBRAL  ABSCESS. 

Cerebral  abscess  is  quite  rare  in  children,  decidedly  more  so  than  is 
cerebral  tumour.     In  Gowers'  collection  of  233  cases,  only  twenty-four 


732  DISEASES  OF  THE  NERVOUS  SYSTEM. 

were  under  ten  years  of  age.  In  infants,  abscess  is  one  of  the  least  fre- 
quent diseases  of  the  brain,  and  up  to  five  years  it  is  exceedingly  rare. 

Etiology. — By  far  the  most  frequent  cause  in  children  is  otitis.  This 
is  the  origin  of  the  great  majority  of  tlie  cases.  Abscess  rarely  compli- 
cates acute  otitis,  but  is  seen  with  the  chronic  form.  Exactly  how  otitis 
causes  cerebral  abscess  it  is  not  always  easy  to  determine.  Usually 
there  is  caries  of  tlie  petrous  bone,  but  there  may  be  none.  The  infection 
may  extend  through  the  small  veins  traversing  this  bone,  or  along  the 
lateral  sinuses  to  the  cerebellum.  Abscess  is  often  attributed  to  the  re- 
tention of  pus  in  the  ear,  but  it  may  occur  when  the  discharge  is  free. 

Traumatism  is  the  second  important  etiological  factor.  Abscess  may 
be  associated  with  fracture  of  the  skull,  or  follow  simple  concussion.  The 
abscess  is  generally  in  the  neighbourhood  of  the  injury,  but  occasionally 
is  produced  by  contre  coup.  In  one  instance,  reported  by  Wagner,  thrush 
was  believed  to  be  the  cause  of  cerebral  abscess,  the  same  fungus  that 
existed  in  the  mouth  being  found  in  the  brain,  which  in  this  case  was 
studded  with  small  abscesses.  Abscess  may  be  the  result  of  infectious 
emboli,  associated  with  general  pyaemia,  though  this  is  rare  in  early  life ; 
and  finally  it  may  occur  without  any  assignable  cause. 

Lesions. — The  most  frequent  seat  of  the  abscess  is,  first,  the  temporo- 
sphenoidal  lobe;  secondly,  the  cerebellum;  thirdly,  the  frontal  lobes. 
Other  locations  are  very  rare.  Abscesses  are  usually  single.  In  size  they 
vary  from  that  of  a  small  cherry  to  an  orange.  One  case  was  observed 
by  Meyer,  in  which  an  abscess  occupied  one  entire  hemisphere.  The 
contents  are  usually  thick  greenish-yellow  pus,  which  may  be  very  foetid. 
When  abscesses  have  lasted  for  some  time  they  are  usually  surrounded 
by  a  dense  pyogenic  membrane,  and  may  become  encysted.  The  patholog- 
ical process  may  be  slow,  and  often  is  apparently  stationary  for  a  long 
period.  Abscesses  may  rupture  into  the  ventricles,  less  frequently  upon 
the  surface  of  the  brain,  causing  meningitis,  or  the  pus  may  even  escape 
externally  through  the  auditory  meatus. 

Symptoms. — These  are  general  and  local.  The  general  symptoms  are 
much  the  more  important  for  diagnosis,  and  often  are  the  only  ones 
present.  The  local  symptoms  are  those  of  a  tumour.  The  clinical  history 
of  a  case  of  abscess  of  the  brain  may  be  divided  into  three  stages :  First, 
the  period  of  onset,  or  early  acute  inflammatory  symptoms,  fever,  etc., 
which  attend  the  formation  of  pus.  Secondly,  the  latent  period,  or  period 
of  remission,  in  which  very  few  symptoms  are  present.  In  many  acute 
cases  this  stage  is  wanting  altogether;  in  the  chronic  cases  it  may  last 
for  months,  or  even  years.  Thirdly,  the  final  period,  with  recurrence 
of  active  cerebral  symptoms,  followed  by  death  in  a  few  days. 

The  onset  may  be  accompanied  by  symptoms  so  slight  as  almost  to 
escape  notice.  In  most  cases,  however,  headache  and  fever  are  present. 
The  headache  is  usually  severe,  and  often  localised  upon  the  affected 


cerp:bral  ahsckss.  733 

side;  in  cerebellar  abscess  it  may  be  occipital.  'I'lie  fever  is  moderate  in 
intensity,  and  continuous.  In  addition  there  may  be  vertigo,  vomiting, 
general  convulsions,  and  cessation  of  the  aural  discharge,  if  one  has 
been  present.  The  duration  of  this  stag(;  is  variahkj;  it  may  he  only  a 
few  days,  or  several  weeks.  It  is  shorter  in  traumatic  cases,  and  in 
those  which  are  due  to  pya3mia. 

The  latent  stage,  or  period  of  remission  of  symptoms  may  be  quite 
short — only  a  few  days'  duration — and  it  is  often  absent.  During  this 
period  the  temperature  may  fall  quite  to  the  normal,  and  the  headache 
disappear,  or  be  only  occasional  and  slight.  Ilovvevor,  if  any  focal  symp- 
toms have  been  present  they  remain  unchanged. 

The  symptoms  of  the  terminal  stage  are  due  to  a  rapid  extension  of 
the  inflammatory  process,  with  o-dema  and  softening  about  the  abscess, 
sometimes  to  rupture  into  the  ventricle,  and  sometimes  to  meningitis. 
The  fever  now  returns,  and  may  be  high.  There  is  headache,  often 
very  intense  and  continuous;  there  may  be  delirium  and  convulsions,  and 
the  gradual  development  of  coma.  In  addition  there  may  be  vomiting, 
paralysis,  opisthotonus,  retracted  abdomen,  and  the  other  symptoms  of 
meningitis.  Occasionally  all  the  earlier  symptoms  may  be  latent,  and 
the  terminal  symptoms  may  be  the  only  ones  present.  In  infants,  the 
fontanel  is  usually  large  and  bulging;  convulsions  are  rather  more  fre- 
quent than  in  older  children. 

The  local  symptoms  of  abscess  are  rather  indefinite,  owing  to  its 
usual  situation.  Abscesses  of  considerable  size  may  exist  in  the  temporo- 
sphenoidal  lobe,  in  the  central  part  of  the  frontal  lobe,  or  in  the  cere- 
bellum, without  any  definite  local  symptoms.  If  the  abscess  is  near 
the  motor  area,  there  are  the  usual  symptoms  of  disease  in  this  location: 
spasm,  or  paralysis  of  the  face,  arm,  or  leg.  A  cortical  or  sub-cortical 
abscess  is  likely  to  cause  convulsions.  Cerebellar  abscess  may  give  rise 
to  occipital  headache,  frequent  vomiting,  and  when  the  abscess  is  large 
enough  to  press  upon  the  middle  lobe,  there  may  be  inco-ordination  of 
the  muscles  of  the  extremities.  Optic  neuritis  may  be  present,  but  other 
symptoms  relating  to  the  cranial  nerves  are  rare.  Localised  tenderness 
over  the  scalp,  when  persistent,  is  a  symptom  of  importance,  and  may 
serve  to  locate  the  abscess,  if  it  is  superficial. 

Diagnosis. — Of  the  general  symptoms,  the  most  important  for  diag- 
nosis are  fever,  headache,  delirium,  and  terminal  coma.  These  beQome 
particularly  significant  when  following  otitis  or  traumatism.  The  dif- 
ferential diagnosis  of  abscess  is  to  be  made  principally  from  tumour 
and  meningitis,  and  from  these  conditions  more  by  the  history  and  gen- 
eral course  of  the  disease  than  by  any  special  symptoms.  The  diagnosis 
of  abscess  from  tumour  is  considered  in  connection  with  the  latter  dis- 
ease. It  is  more  difficult  to  distinguish  between  meningitis  and  abscess, 
since  the  two  processes  are  often  associated.     With  meningitis  convul- 


734  DISEASES  OF  THE   NERVOUS  SYSTEM. 

sions  are  more  common,  but  they  are  rarely  localised ;  rigidity  and  the 
inflammatory  symptoms  are  more  intense;  the  course  is  usually  more 
rapid  and  more  regular,  being  rarely  interrupted,  as  is  the  course  of 
abscess.  Leucocytosis  is  more  constant  and  usually  more  marked  in 
meningitis.  Lumbar  puncture  gives  negative  results  in  uncomplicated 
abscess  while  it  gives  positive  definite  information  in  meningitis.  From 
the  cerebral  symptoms  occurring  with  otitis  it  is  extremely  difficult  to 
distinguish  abscess,  for  optic  neuritis  may  be  present  in  the  former  as. 
well  as  in  the  latter  condition.  The  more  intense  and  prolonged  the 
cerebral  symptoms  and  the  more  marked  the  neuritis,  the  greater  are 
the  probabilities  of  abscess. 

Prognosis. — The  prognosis  in  cerebral  abscess  is  always  grave,  unless 
accessible  to  surgical  operation.  The  progress  may  be  slow,  or  rapid,  but 
it  is  inevitably  from  bad  to  worse,  and  sooner  or  later  the  disease,  if  not 
interfered  with,  proves  fatal. 

Treatment. — The  medical  treatment  of  abscess  in  its  active  stage  is 
that  of  any  acute  intracranial  inflammation — ice  to  the  head,  absolute 
quiet,  free  catharsis,  and  full  doses  of  the  bromides  or  morphine,  if  pain 
is  intense.  The  absolutely  hopeless  condition  of  these  cases  when  left 
to  themselves,  and  the  recent  brilliant  results  from  surgical  operations, 
should  lead  the  physician  to  urge  operation  in  every  case. 

CEREBRAL  TUMOUR. 

Very  little  has  been  added  to  our  knowledge  of  cerebral  tumour  in 
children  since  the  exhaustive  monograph  of  Starr;  to  this  I  am  indebted 
for  many  of  the  facts  in  this  chapter. 

Varieties  and  Location. — Tumour  of  the  brain  is  not  very  infrequent, 
and  may  be  seen  even  in  infancy.  From  this  time  up  to  puberty  there 
is  no  period  of  special  susceptibility.  In  269  of  the  cases  in  Starr's 
collection,  in  which  the  nature  of  the  tumour  was  stated,  tiie  following 
were  the  varieties: 

Tubercle 152  cases. 

Glioma 37      " 

Sarcoma 34      " 

Glio-sarcoma 5      " 

Cyst 30      " 

Carcinoma 10     " 

Gumma 1  case. 

269  cases. 

Tuberculous  tumours  are  more  often  multiple  than  are  other  varieties. 
Their  most  frequent  seat  is  the  cerebellum;  next  to  this  the  pons  and 
crura  cerebri.  They  are  rarely  cortical  or  central.  Glioma  is  most  often 
found  in  the  cerebellum  or  in  the  pons,  and  next  in  the  cortex ;  but  it  is 


CEREBRAL  TUMOUR.  735 

rarely  central.  Sarcoma  is  most  frequently  in  the  cerel)ellum ;  next  to 
this,  in  the  order  of  frequency,  in  the  pons,  the  basal  ganglia,  and  the 
cortex.  Cystic  tumours  are  either  central  or  cerebellar.  Taking  the 
cases  as  a  whole,  the  most  frequent  seat  of  tumour  in  children  is,  first 
the  cerebellum,  second  the  pons,  third  the  centrum  ovale. 

Tuberculous  tumours  are  occasionally  seen  in  infancy,  but  they  oc- 
cur most  frequently  between  the  ages  of  five  and  twelve  years.  They 
are  usually  secondary  to  tuberculosis  elsewhere,  especially  in  the  lungs 
and  in  the  bronchial  lymph  nodes.  They  most  frequently  start  from  the 
membranes,  rarely  being  centrally  situated,  and  extend  inward,  infiltrat- 
ing the  superficial  portion  of  the  cerebellum  or  cerebrum.  There  is 
almost  invariably  localised  meningitis  at  the  site  of  the  tumour;  there 
may  be  adhesions  between  the  dura  and  pia  mater,  and  the  disease  may 
extend  to  the  cranial  bones.  In  size,  these  tumours  vary  from  a  small 
pea  to  a  child's  fist.  They  may  be  softened  and  broken  down  at  the 
centre,  or  cheesy  throughout.  They  are  the  result  of  a  localised  tuber- 
culous inflammation,  which  does  not  difl'er  essentially  from  that  seen 
in  other  parts  of  the  body. 

Glioma  is  not  infrequent  in  infancy.  It  is  probably  connected  in 
every  case  with  the  ependyma  of  the  ventricle.  It  repeats  the  structure 
of  the  neuroglia,  being  composed  of  connective  tissue  and  branching  cells. 

Sarcoma  may  be  of  the  spindle-celled  or  the  mixed  variety.  It  grows 
much  more  rapidly  than  glioma.  The  two  varieties  are  not  infrequently 
combined  in  the  same  tumour — glio-sarcoma. 

Cystic  tumours  are  sometimes  sarcomatous  in  origin,  the  wall  of  the 
eyst  containing  sarcoma  cells,  and  they  may  also  be  parasitic,  from  the 
growth  of  the  echinococcus.  They  may  be  found  in  any  ])art  of  the 
brain. 

The  other  varieties  of  sarcoma,  gummata,  and  vascular  tumours,  are 
exceedingly  rare  until  after  puberty. 

As  the  tumour  grows,  secondary  lesions  are  produced  in  most  of  the 
cases.  These  are  the  result  of  pressure  upon  arteries,  causing  localised 
ansemia,  or  even  cerebral  softening ;  or  upon  veins,  producing  congestion 
and  oedema.  When  affecting  the  middle  lobe  of  the  cerebellum,  pressure 
upon  the  vense  Galeni  may  lead  to  effusion  into  the  ventricles.  Localised 
meningitis  over  tumours  superficially  situated  is  the  rule,  and  this  may 
be  the  cause  of  some  of  the  symptoms.  Rarely,  cerebral  hemorrhage  may 
be  associated. 

Etiology.— The  causes  of  cerebral  tumours  are  for  the  most  part  un- 
known. In  a  few  instances  there  is  a  history  of  definite  traumatism. 
Sarcoma  or  carcinoma  may  be  secondary,  and  tuberculous  tumours  are 
probably  always  so. 

Symptoms.— These  may  be  divided  into  two  groups:  first,  the  gen- 
eral symptoms  which  are  commop  to  tumours  of  all  varieties,  and  are  in- 


736  DISEASES  OF  THE   NERVOUS  SYSTEM. 

dependent  of  location;  secondly,  the  local  symptoms  depending  upon  the 
situation  of  the  growth. 

General  Symptoms. — One  of  the  most  frequent  is  headache.  Tliough 
it  varies  much  in  its  severity,  cliaracter,  and  position,  it  is  rarely  absent. 
It  is  apt  to  be  severe,  and  may  continue  for  a  long  period,  or  it  may  be 
intermittent.  The  location  of  the  pain  has  no  definite  relation  to  the 
situation  of  the  tumour.  It  may  be  accompanied  by  sensations  of  tigiit- 
ness,  compression,  or  tension  in  the  head.  It  may  be  associated  with 
localised  tenderness  of  the  scalp;  when  tliis  is  constant  it  is  a  valuable 
symptom  for  diagnosis,  as  it  often  occurs  with  tumours  superficially 
located. 

General  C'on\'ulsions  are  frequent  in  the  early  stage,  but  separated 
by  quite  long  intervals;  they  become  more  frequent  and  more  severe 
as  the  disease  progresses.  All  degrees  of  severity  are  seen,  from  slight 
twitchings  and  temporary  loss  of  consciousness,  to  typical  epileptiform 
seizures.  They  are  most  common  when  the  growth  is  rapid  and  when 
complicating  meningitis  is  present.  Attacks  of  vomiting  or  of  localised 
spasm  may  for  a  considerable  time  precede  general  convulsions;  and  in 
a  single  attack  there  may  be  first  localised  and  then  general  convulsions. 

Mental  symptoms  are  generally  present  in  great  variety  and  complex- 
ity. There  may  be  only  fretfulness  and  irritability,  or  a  marked  change 
in  disposition.  These  s3'mptoms  are  so  frequent  from  other  causes  in 
children  that  they  excite  no  apprehension,  unless  to  them  are  added 
dulness,  apathy,  and  somnolence.  Later  in  the  disease  there  may  be 
attacks  of -hypochondriasis,  or  of  melancholia;  there  may  be  periods  of 
wild,  almost  maniacal  excitement;  and,  finally,  the  mental  impairment 
may  approach  a  condition  of  imbecility. 

Optic  neuritis  and  optic-nerve  atrophy  are  very  frequent,  occurring, 
according  to  Starr,  in  eighty  per  cent  of  the  eases.  This  is  only  recog- 
nised by  the  ophthalmoscope,  as  there  may  be  no  disturbance  of  vision. 
The  optic  neuritis  is  generally  double,  appears  earlier,  and  is  more  con- 
stant in  basal  tumours  than  in  those  at  the  convexity,  or  those  centrally 
located. 

Vomiting  is  very  frequent,  but  diagnostic  only  when  it  occurs  sud- 
denly without  assignable  cause,  and  without  nausea  or  other  symptoms 
of  indigestion.  It  is  especially  significant  when  frequently  repeated,  and 
of  more  importance  in  older  children  than  in  infants. 

Vertigo  is  often  associated  with  vomiting.  At  first  it  is  occasional 
and  seen  upon  changing  position,  but  later  it  may  be  quite  constant, 
especially  with  tumours  in  the  posterior  fossa. 

Disturbances  of  sleep  are  frequent.  There  is  usually  insomnia,  but 
sleep  may  be  broken  by  hallucinations,  accompanied  by  attacks  of  scream- 
ing; rarely  is  there  persistent  drowsiness  until  toward  the  end  of  the 
disease. 


CEREBRAL  TUMOUR.  737 

Local  Symptoms. — These  depend  upon  the  situation  of  the  tumour, 
hut  not  at  all  upon  its  character.  Local  synij)toHis  may  be  wanting 
entirely,  and  they  may  vary  much  in  different  cases  even  with  tumours 
in  the  same  situation.  They  are  modified  by  the  size  and  by  the  rapidity 
of  growth,  and  by  the  existence  of  localised  meningitis. 

In  tumours  of  the  cortex,  the  meninges  are  likely  to  be  involved, 
especially  with  tuberculous  and  gliomatous  growths.  The  pathological 
process  may  extend  from  within  outward  or  from  without  inward.  The 
most  frequent  general  symptoms  in  such  cases  are  headache,  circum- 
scribed tenderness  of  the  scalp,  convulsions,  and  mental  symptoms.  Op- 
tic neuritis,  vomiting,  and  vertigo  are  not  so  common.  Tumours  situ- 
ated in  the  frontal  lobe,  as  a  rule,  present  few  symptoms  and  may  be 
entirely  latent.  Irritation  of  the  frontal  lobe  may  extend  to  the  motor 
area  and  cause  convulsions  either  local  or  general ;  but  not  often  is  there 
paralysis.  Tumours  of  the  left  side  (of  the  rigiit  side  in  left-handed 
persons)  in  the  third  frontal  convolution  may  cause  motor  aphasia. 

Tumours  in  the  motor  convolutions  along  the  fissure  of  Rolando 
produce  the  most  definite  and  uniform  local  symptoms.  When  situated 
at  the  upper  portion  the  leg  is  affected,  at  the  middle  portion,  the  arm, 
and  at  the  lower,  the  face.  Irritative  symptoms,  such  as  rigidity  or 
clonic  spasm,  commonly  precede  for  some  time  the  paralysis  which  re- 
sults from  pressure  or  destruction.  These  attacks  of  localised  convulsions 
may  begin  in  the  face,  arm,  or  leg ;  but  they  usually  extend  more  or  less 
rapidly  until  all  three  are  involved.  There  is  no  loss  of  consciousness, 
but  there  may  follow  a  slight  transient  paralysis.  Such  attacks  are 
known  as  "  Jacksonian  epilepsy,"  and  form  one  of  the  most  diagnostic 
symptoms  of  cerebral  tumour.  Localised  spasm  may  be  associated  with 
anaesthesia  or  other  disturbances  of  sensation.  The  paralysis  generally 
first  affects  one  extremity — the  arm  or  leg,  according  to  the  location  of 
the  tumour — and  afterward  it  may  involve  the  entire  side,  including 
the  face. 

If  the  tumour  is  centrally  located,  or  at  the  base,  hemiplegia  may  be 
an  early  symptom  from  pressure  on  the  motor  tract.  With  cortical 
paralysis  there  may  be  associated  ataxia  and  anaesthesia. 

Tumours  of  the  parietal  lobe  may  give  no  local  symptoms.  At  times 
there  are  disturbances  of  muscular  sense,  tactile  sensibility,  or  sensations 
of  pain  and  temperature.  If  the  inferior  parietal  lobule  of  the  left  side 
is  affected,  there  may  be  word-blindness,  or  inability  to  understand 
written  language. 

Tumours  of  the  occipital  lobe  produce,  as  the  only  constant  local 
symptom,  hemianopsia.  This  is  usually  bilateral,  affecting  the  same 
side  of  both  eyes,  being  on  the  side  opposite  to  that  of  the  lesion,  i.  e.,  a 
.tumour  on  the  right  side  causes  blindness  in  the  left  half  of  both  eyes, 
so  that  the  patient  sees  nothing  to  the  left  of  a  line  directly  in  front 
48 


738  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  him.  Instead  of  hemianopsia,  there  may  be  only  irritation  and  various 
disturbances  of  sight. 

Tumours  of  the  temporo-sphenoidal  lobe  may  be  latent,  or,  if  on 
the  left  side,  may  cause  word-deafness,  i.  e.,  inability  to  understand  the 
significance  of  spoken  language. 

Tumours  in  the  island  of  Eeil  when  situated  upon  the  left  side  (right 
side  in  left-handed  persons)  may  cause  motor  aphasia  or  disturbances 
of  speech.  If  they  are  large  they  may  produce  symptoms  by  pressure 
upon  the  motor  tract — hemiplegia  or  monoplegia. 

Tumours  of  the  basal  ganglia  cause  marked  general  symptoms,  but 
none  of  a  definitely  local  character.  The  important  symptoms  relate  to 
the  various  tracts  or  bundles  of  fibres  which  pass  from  the  cortex  through 
the  internal  capsule.  These  include  the  motor  and  the  various  sensory 
tracts,  the  olfactory,  auditory,  visual,  and  speech  tracts.  Any  of  these 
may  be  pressed  upon,  and  the  nature  of  the  symptoms  will  depend  upon 
the  size  of  the  tumour  and  the  extent  of  the  pressure.  If  only  the 
anterior  part  of  the  capsule  is  affected  there  may  be  no  symptoms ;  if  the 
middle  fibres,  hemiplegia  and  disturbances  of  articulation ;  if  the  posterior 
fibres,  hemianagsthesia.  All  these  may  be  associated,  and  any  of  them 
may  be  complete  or  partial.  Tumours  in  this  situation  are  apt  to  im- 
plicate the  cranial  nerves.  Optic  neuritis  is  quite  constant,  and  appears 
early.     Localised  or  general  convulsions  are  rare. 

The  peculiar  symptoms  pointing  to  tumours  of  the  crura  cerebri  are 
nystagmus,  strabismus,  and  loss  of  pupillary  reflex,  sometimes  with  gen- 
eral muscular  inco-ordination,  and  a  staggering  gait.  There  is  usually 
third-nerve  paralysis  on  the  side  of  the  tumour,  and  on  the  side  opposite 
to  the  hemiplegia  with  which  it  is  often  associated.  This  variety  of 
crossed  paralysis  is  quite  diagnostic.  The  symptoms  of  third-nerve 
paralysis  are  external  strabismus,  dilatation  of  the  pupil,  and  ptosis. 
In  these  cases  optic  neuritis  appears  early.  There  may  be  a  complicat- 
ing hydrocephalus.  While  hemiplegia  is  commonly  present  with  large 
tumours,  it  may  be  absent  with  small  ones,  or  may  appear  later  than 
paralysis  of  the  third  nerve. 

Tumours  of  the  pons  are  quite  common.  The  diagnostic  symptoms 
consist  in  crossed  paralysis,  the  cranial-nerve  symptoms  being  on  the 
side  of  the  tumour,  and  the  general  motor  and  sensory  symptoms  on 
the  opposite  side.  When  the  seat  is  the  upper  half  of  the  pons,  the  third 
and  fifth  nerves  are  apt  to  be  implicated,  giving  rise  to  ptosis,  dilatation 
of  the  pupils,  external  strabismus,  trophic  disturbances  such  as  ulceration 
of  the  cornea,  and  neuralgic  pain  in  the  face.  Tumours  in  the  lower  half 
of  the  pons  involve  the  sixth,  seventh,  and  eighth  nerves,  causing  internal 
strabismus,  contracted  pupils,  facial  paralysis,  sometimes  deafness,  and 
auditory  vertigo.  Other  symptoms  associated  with  tumours  of  the  pons 
are  headache,  vomiting  and  optic  neuritis;  convulsions  being  rare. 


CEREBRAL  TUMOUR.  739 

Tumours  of  the  modulja  are  recognised  hy  llie  involveiiieut  of  the 
glossopharyngeal,  pneuniogastric,  spinal  accessory,  and  hyp()gh)ssal 
nerves.  There  are  difficulty  of  deglutition,  irregular  respiration,  irreg- 
ular pulse,  and  vaso-motor  disturhances,  such  as  flushing  of  the  face 
and  perspiration.  There  may  be  projectile  vomiting,  polyuria  or  gly- 
cosuria, opisthotonus,  difficulty  in  articulation  or  in  sucking,  and  in 
protrusion  of  the  tongue.  When  large,  these  tumours  may  produce 
symptoms  of  pressure  upon  the  motor  or  sensory  tracts — j)ai'alysis,  or 
partial  angesthesia,  with  rigidity  and  exaggerated  reflexes. 

Tumours  of  the  cerebellum  are  especially  important,  this  being  the 
most  frequent  location  in  childhood.  When  only  one  hemisphere  is 
affected  there  may  be  no  local  symptoms.  Tumours  involving  the  mid- 
dle lobe,  or  those  large  enough  to  produce  pressure  upon  the  middle  lobe, 
give  rise  to  vertigo  and  cerebellar  ataxia.  Vertigo  is  especially  frequent; 
it  may  occur  with  headache.  Cerebellar  ataxia  is  different  from  the 
ataxia  due  to  a  spinal-cord  lesion,  and  strikingly  resembles  that  of  intoxi- 
cation. It  may  increase  until  the  patient  is  unable  to  walk,  although 
there  is  no  loss  of  muscular  power.  Vomiting  is  a  frequent  symptom,  as 
are  also  optic  neuritis,  and  headache  which  is  usually  occipital.  When 
there  is  secondary  hydrocephalus,  as  is  not  uncommon,  mental  symptoms 
are  present,  and  there  may  be  enlargement  of  the  head.  Opisthotonus 
is  occasionally  seen,  but  general  convulsions  are  rare. 

Diagnosis. — The. size  of  the  tumour  is  to  be  determined  mainly  by  the 
general  symptoms,  special  attention  being  given  to  the  order  of  their 
development.  A  diagnosis  as  to  the  nature  of  the  tumour  is  really  not 
of  much  importance;  but  some  information  upon  this  point  may  be 
gained  from  the  consideration  of  its  etiology,  the  rapidity  of  its  growth, 
and  the  age  of  the  patient.  Cerebral  tumour  may  be  confounded  with 
abscess,  tuberculous  meningitis,  chronic  basilar  meningitis,  and  chronic 
hydrocephalus.  The  symptoms  distinguishing  tumour  from  abscess  are 
the  following :  Tumour  may  occur  at  any  age ;  without  definite  etiology, 
.excepting  when  tuberculous;  the  progress  is  steady,  but  generally  slow, 
new  symptoms  being  continually  added;  headache  is  more  constant  and 
more  severe;  optic  neuritis  more  frequent;  cranial  nerves  more  often 
involved;  mental  disturbances  more  marked;  focal  symptoms  are  often 
definite;  fever  and  leucocytosis  are  absent;  duration,  six  months  to  two 
years.  As  compared  with  the  above,  abscess  is  not  so  frequent,  being 
especially  rare  in  infancy ;  there  is  a  definite  history  of  traumatism  or  ear 
disease;  progress  more  irregular;  symptoms  often  intermittent;  head- 
ache less  severe;  mental  symptoms  less  marked;  optic  neuritis  and  in- 
volvement of  the  cranial  nerves  less  frequent;  focal  symptoms  usually 
indefinite;  localised  tenderness  over  the  scalp  more  constant;  fever  and 
leucocytosis  present  except  in  the  latent  period;  the  most  frequent 
complication  js  aeute  meningitis. 


740  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Cases  of  tuberculous  meningitis  which  may  be  confounded  with 
tumour  are  those  of  slow  course  sometimes  seen  in  older  children.  The 
difficulty  in  diagnosis  is  increased  by  the  frequent  association  of  tuber- 
culous tumours  with  tuberculous  meningitis.  The  main  points  of  dif- 
ference are  that  in  tumour  the  symptoms  are  more  localised  and  tlie 
course  generally  much  slower.  Almost  every  individual  symptom,  how- 
ever, may  be  present  in  the  two  conditions. 

Chronic  basilar  meningitis  may  produce  symptoms  almost  identical 
with  those  of  tumour  in  the  posterior  fossa.  It  is,  however,  confined  to 
infancy;  hydrocephalus  and  opisthotonus  are  much  more  marked  than 
are  usually  seen  with  tumour. 

Chronic  hydrocephalus  may  resemble  tumour;  this  occurs  so  fre- 
quently as  a  lesion  secondary  to  tumour  that  the  question  often  arises 
whether  there  is  only  hydrocephalus,  or  there  is  in  addition  a  tumour. 
Primary  hydrocephalus  is  usually  congenital,  and  commonly  attains  to 
a  greater  degree  than  is  seen  in  secondary  hydrocephalus. 

Prognosis. — The  prognosis  in  cerebral  tumour,  while  bad,  is  not  hope- 
less. Cases  are  occasionally  seen  which  exhibit  all  the  characteristic 
symptoms  of  tumour,  even  including  optic  neuritis,  which  recover  per- 
fectly. These  are  probably  syphilitic,  although  often  no  such  history 
can  be  obtained.  In  other  cases,  most  frequently  of  a  tuberculous  na- 
ture, an  arrest  of  the  growth  occurs  and  the  patient  recovers  with  some 
function  of  the  brain  impaired;  usually  there  is  loss  of  vision  or  some 
paralysis.  In  most  cases,  however,  the  progress  is  steadily  downward 
until  death. 

Treatment. — If  there  is  any  reason  to  suspect  syphilis,  the  iodide  of 
potassium  should  be  given  in  large  doses  and  continued  for  a  long  period ; 
the  effect  of  this  drug  even  in  tumours  not  syphilitic  is  sometimes 
beneficial.  Starr  refers  to  a  case  in  which  symptoms  of  six  months' 
duration,  including  optic  neuritis,  entirely  disappeared  under  the  use 
of  mercury  and  the  iodide.  The  tumour  was  supposed  to  be  gumma,  but 
an  autopsy  obtained  six  months  later  showed  it  to  be  a  sarcomatous  cyst. 
For  a  discussion  upon  the  surgical  aspect  of  the  treatment  of  brain 
tumours,  the  reader  is  referred  to  Starr's  work  on  Brain  Surgery. 

HYDROCEPHALUS. 

Hydrocephalus,  or  "  water  on  the  brain,"  consists  in  an  accumulation 
of  serum  in  the  cranial  cavity.  This  may  be  between  the  dura  mater 
and  the  pia  (external  hydrocephalus)  or  in  the  ventricles  of  the  brain 
(internal  hydrocephalus).  The  former  is  secondary  and  is  quite  rare, 
while  the  latter  is  not  uncommon.  Hydrocephalus  may  be  acute  or 
chronic. 

Acute  hydrocephalus  is  secondary  to  basilar  meningitis,  which  is  usu- 


HYDROCEPHALUS. 


741 


ally  of  tuberculous  origin.  The  terms  tuberculous  meningitis  and  acute 
hydrocephalus  are  sometimes  used  synonymously.  A  moderate  distention 
of  the  ventricles  is  frequent  in  all  varieties  of  acute  meningitis.  The 
amount  of  fluid  in  acute  hydrocephalus  is  not  great,  there  being  rarely 
more  than  three  or  four  ounces  present. 

Chronic  external  hydrocephalus  except  in  its  mild  form  is  extremely 
rare,  and  is  nearly  always  a  secondary  lesion.  It  may  follow  meningeal 
haemorrhage,  pachymeningitis,  or  any  lesion  causing  cerel)ral  atrophy.  It 
is  seen  in  its  most  marked  form  associated  with  congenital  malforma- 
tions of  the  brain,  particularly  imperfect  development  of  the  hemi- 
spheres.    (See  Fig.  123.)     On  incising  the  dura  mater  a  few  ounces,  or 


Fig.  123.— Brain  in  External  Hydrocephalus,  showing  Imperfect  Development 
OF  THE  Hemispheres.  Patient  three  and  a  half  months  old;  head  measured  20^ 
inches;  increase  in  size,  2  inches  in  the  six  weeks  before  death;  symptoms  were  typical 
of  ordinary  internal  hydrocephalus.  In  the  picture  the  small  size  of  the  cerebrum 
is  best  judged  by  comparison  with  the  cerebellum,  which  is  normal.  The  hemi- 
spheres were  rudimentary;  the  basal  ganglia  were  normal;  the  cranial  cavity  con- 
tained about  one  pint  of  fluid. 

sometimes  even  a  pint,  of  serum  may  escape.  The  convolutions  are 
somewhat  flattened,  and  may  be  greatly  atrophied.  Other  lesions  are 
found  either  in  the  brain  or  in  the  dura  mater.  External  hydrocephalus 
may  cause  enlargement  of  the  head  and  separation  of  the  sutures,  and 
in  fact  most  of  the  symptoms  of  the  internal  variety ;  but  usually  it  is 
not  severe  enough  to  give  rise  to  any  decided  symptoms. 


742  DISEASES  OF  THE  NERVOUS  SYSTEM. 

CHRONIC   INTERNAL  HYDROCEPHALUS. 

This  is  the  important  variety,  and  when  no  qualifying  term  is  men- 
tioned this  is  the  form  of  hydrocephalus  which  is  always  understood. 

Etiology. — Tliis  occurs  both  as  a  primary  and  a  secondary  condition. 
When  secondary  it  is  usually  associated  with  tumours  of  the  base  of  the 
brain  or  with  chronic  basilar  meningitis,  either  simple  or  tuberculous.  It 
is  in  these  cases  a  mechanical  condition  caused  by  pressure  which  oblit- 
erates the  openings  from  the  lateral  ventricles  into  the  fourth  ventricle, 
or  the  foramen  of  Magendie. 

The  causes  of  primary  hydrocephalus  are  as  yet  very  little  under- 
stood. In  a  large  proportion  of  the  cases  the  disease  is  congenital,  gen- 
erally beginning  in  the  latter  months  of  intra-uterine  life.  Some  of  these 
cases  are  clearly  syphilitic.  Rickets  and  hydrocephalus  are  occasionally 
associated,  but  so  infrequently  as  to  make  a  definite  etiological  connec- 
tion between  them  very  doubtful.  The  rachitic  head  has  been  so  often 
mistaken  for  hydrocephalus  that  an  erroneous  notion  has  arisen  as  to 
the  frequent  association  of  these  two  diseases.  Heredity  is  a  factor  of 
some  importance;  numerous  instances  are  on  record  where  two  children 
in  the  same  family  have  been  affected.  Hydrocephalus  not  infrequently 
develops  after  successful  operations  upon  spina  bifida  or  encephalocele. 

Lesions. — The  difference  between  the  primary  and  secondary  cases  is 
chiefly  one  of  degree.  The  amount  of  fluid  in  secondary  cases  is  rarely 
more  than  three  or  four  ounces.  In  primary  cases  it  is  usually  from 
half  a  pint  to  one  pint,  but  it  may  be  very  great.  In  one  of  my  own  cases 
there  was  removed  from  the  head  of  a  child,  who  died  at  four  months, 
five  pints  of  fluid.  Larger  quantities  than  this  have  been  reported,  but 
not  so  far  as  I  am  aware  at  so  early  an  age.  In  composition  this  re- 
sembles the  cerebro-spinal  fluid.  An  examination  in  one  of  my  cases 
showed  it  to  be  a  clear,  translucent  fluid,  slightly  alkaline  in  reaction, 
specific  gravity  1.005,  containing  sodium  and  potassium  chlorides,  alka- 
line phosphates,  and  a  trace  of  albumin.  In  some  specimens  sugar  is 
found.  In  cases  of  infiammatory  origin  the  amount  of  albumin  is  gen- 
erally larger,  and  the  fiuid  may  be  slightly  turbid.  The  effusion  may  be- 
come purulent  from  accidental  infection  resulting  from  operation,  from 
rupture,  or,  as  in  one  of  my  cases,  from  infection  through  the  sac  of  a 
spina  bifida  with  which  it  was  complicated,  the  process  extending  to  the 
brain  through  the  central  canal  of  the  cord. 

The  changes  in  the  brain  result  from  the  gradual  accumulation  of 
fluid  in  the  ventricles.  The  septum  lucidum  is  usually  broken  down, 
and  all  the  avenues  of  communication  between  the  ventricular  cavities 
are  greatly  enlarged.  The  continuous  distention  results  in  a  gradual 
thinning  of  the  brain  substance  which  forms  the  ventricular  walls;  often 
these  are  found  only  one-fourth  of  an  inch  in  thickness,  or  even  less 


CHRONIC   INTERNAL   HYDROCEPHALUS. 


743 


than  this,  the  cortex  being  a  mere  sliell  (Fig.  121).  In  one  of  my 
autopsies  the  ependyma  of  the  ventricle  and  the  pia  mater  were  in  places 
actually  in  contact,  all  of  the  brain  tissue  having  been  absorbed  •  the 
brain  resembled  a  large 
double  cyst.  In  a  case  of 
Peterson's,  with  the  ex- 
ception of  a  small  portion 
of  one  temporo-sphenoidal 
lobe,  all  of  both  hemi- 
spheres had  disappeared, 
the  cerebellum  and  basal 
ganglia  alone  being  in- 
tact. The  brain  is  always 
anasmic,  and  the  gray  and 
white  substance  may  be  in- 
distinguishable. The 
changes  are  largely  me- 
chanical, the  microscope 
showing,  in  my  case  just 
referred  to,  only  granular 
matter  and  round  nuclei 
evidently  from  broken- 
down  nerve  cells.  In  less 
severe  cases  the  changes  may  be  slight.  It  is,  however,  always  surprising 
to  see  the  amount  of  compression  which  the  cortex  will  tolerate  without 
interference  with  its  functions,  provided  the  pressure  comes  gradually. 
The  ependyma  may  be  normal,  but  it  is  usually  somewhat  thickened  and 
pale,  sometimes  granular,  and  may  be  infiltrated  with  new  cells.  When 
infection  takes  place  an  acute  ependymitis  may  be  set  up.  Chronic  in- 
flammation of  the  ependyma  is  thought  to  be  the  essential  lesion  in  many 
of  the  primary  cases,  whether  of  simple  or  syphilitic  origin. 

The  bones  of  the  skull  are  markedly  affected;  the  sutures  at  the 
vault  are  widely  separated,  and  sometimes  even  those  at  the  base.  After 
the  removal  of  the  fluid  the  head  collapses,  giving  an  appearance  which 
has  been  well  likened  to  a  "  bag  of  bones."  It  should  not  be  forgotten, 
however,  that  hydrocephalus  may  coexist  with  premature  ossification, 
in  which  case  the  head  may  be  small.  In  the  cases  which  recover,  the 
wide  gaps  in  the  skull  may  be  closed  by  the  development  of  Wormian 
bones ;  but  ossification  is  often  not  complete  until  the  fifth  or  sixth  year. 

The  most  frequent  lesion  associated  with  congenital  hydrocephalus 
is  spina  bifida,  in  which  case  there  may  also  be  a  patency  of  the  central 
canal  of  the  spinal  cord;  more  rarely  meningocele  or  encephalocele  are 
met  with.  Sometimes  there  are  deformities  in  other  parts  of  the  body, 
such  as  club-foot  or  hare-lip. 


Fig.  124. — Vertical  Transverse  Section  of  a  Brain 
IN  Congenital  Hydrocephalus.  From  a  child 
who  died  at  the  age  of  three  weeks.  A,  distended 
lateral  ventricle;  B,  its  descending  horn. 


744 


DISEASES  OF  THE   NERVOUS   SYSTEM. 


Symptoms. — Hydrocephalus  may  exist  with  a  small  head.  In  this 
condition  there  is  usually  premature  ossification  of  the  cranial  bones. 
Four  such  cases  have  come  under  my  notice,  one  child  having  lived  to 
be  fourteen  months  old.  These  children  are  usually  idiotic,  and  die  at 
an  early  age,  often  from  convulsions.  In  such  cases  other  malformations 
of  the  brain  are  frequently  associated. 

Hydrocephalus,  with  the  exceptions  mentioned,  is  recognised  by  the 
increased  size  of  the  head.  In  order  to  estimate  the  amount  of  enlarge- 
ment, it  must  be  remembered  that  at  birth  the  circumference  of  the 
normal  head  is  about  14  inches,  and  at  one  year  from  18  to  19  inches. 
The  degree  of  enlargement  in  hydrocephalus  may  be  very  great.  In  one 
of  my  cases,  the  head  at  four  months  measured  24-|  inches.  In  another 
at  ten  and  a  half  months,  26f  inches.     Steiner  has  reported  a  remark- 


FiG.  125. — Chronic  Hydrocephalus  of  Average  Severity. 
Head  of  pyramidal  shape ;  showing  characteristic  expression  of  the  eyes. 


able  ease  in  which  the  head  at  eight  months  measured  33^  inches. 
When  the  enlargement  of  the  head  is  not  great  the  diagnosis  is  not  so 
easy.  Hydrocephalic  enlargement  is  commonly  symmetrical  and  in  all 
directions.  The  head  is  sometimes  globular  in  outline  and  sometimes 
pyramidal  (Fig.  125).  The  forehead  is  exceedingly  high  and  project- 
ing, and  there  is  a  prominence  of  the  frontal  eminences  seen  in  no  other 


CHRONIC  INTERNAL  HYDROCEPHALUS.  745 

form  of  enlargement.  The  sutures  may  be  separated  from  half  an  inch 
to  two  or  three  inches;  the  fontanel  is  very  large,  tense,  and  bulging; 
the  veins  of  the  scalp  are  enlarged  and  prominent.  In  marked  cases 
fluctuation  may  be  readily  obtained,  and  the  head  may  even  be  distinctly 
translucent. 

In  the  acquired  form  all  these  symptoms  are  less  marked,  and  if  ossi- 
fication of  the  skull  has  taken  place  it  is  often  impossible  to  discover 
any  increase  in  size.  The  rate  of  growth  of  the  head  varies  much  in  dif- 
ferent cases,  and  it  is  the  surest  measure  of  the  progress  of  the  case.  The 
increase  in  circumference  is  usually  from  one  to  tliree  inches  a  month. 

The  primary  cases  are  for  the  most  part  of  congenital  origin,  and  the 
child  may  die  in  utero.  At  otJier  times  the  process  may  have  advanced 
so  far  before  birth  that  puncture  of  the  head  is  necessary  before  delivery 
is  possible.  In  perhaps  the  majority  of  cases  no  symptoms  are  observed 
at  birth,  or  the  head  is  only  slightly  larger  than  normal.  Usually  nothing 
is  noticed  until  the  child  is  two  or  three  months  old,  when  it  is  discov- 
ered that  the  head  is  increasing  in  size  at  an  abnormal  rate.  If  the 
progress  is  rapid,  other  symptoms  are  soon  evident:  the  infant  can  not 
hold  up  his  head;  he  is  lethargic,  and  all  his  perceptions  are  dulled,  sight 
and  hearing  included;  there  may  be  a  general  flaccid  condition  of  all 
the  muscles  of  the  extremities  due  to  a  slight  general  paresis,  but  more 
often  there  is  rigidity,  which  is  usually  most  marked  in  the  legs,  but 
sometimes  in  the  arms;  the  hands  are  often  clenched,  with  the  thumbs 
adducted;  the  reflexes  are  exaggerated;  the  pupils  are  generally  con- 
tracted and  equal,  though  they  may  be  dilated;  nystagmus  and  conver- 
gent strabismus  are  often  present.  Con^^llsions  may  occur  from  time  to 
time,  or  may  be  deferred  until  near  the  close  of  the  disease.  As  the  head 
enlarges  the  body  usually  wastes,  and  the  disproportion  between  the  two 
may  seem  greater  than  it  really  is. 

Such  congenital  cases  rarely  see  the  end  of  the  first  year,  and  are 
often  fatal  during  the  first  six  months.  The  causes  of  death  are 
marasmus,  convulsions,  and  intercurrent  disease,  rarely  rupture  of  the 
head. 

In  the  cases  which  develop  more  slowly,  the  symptoms  are  quite  dif- 
ferent. The  head  may  not  attain  at  eighteen  months  the  size  reached  in 
the  other  cases  at  the  third  or  fourth  month.  The  surprising  thing 
about  many  of  these  cases  is  that  the  distinctly  cerebral  symptoms  are 
so  few.  WHien  the  pressure  develops  gradually,  the  brain  seems  able  to 
tolerate  an  almost  indefinite  amount  of  it.  The  more  readily  the  bones 
of  the  skull  yield  to  pressure  the  fewer  are  the  nervous  symptoms; 
hence,  other  things  being  equal,  they  are  less  marked  when  the  disease 
begins  before  the  sutures  are  firmly  ossified  than  in  the  later  eases.  A 
comparatively  small  amount  of  effusion  may  cause  very  marked  symp- 
toms in  a  child  two  or  three  years  old,  while  a  much  larger  amount,  in 


746  DISEASES  OF  THE  NERVOUS  SYSTEM. 

an  infant  of  a  year,  may  produce  much  less  disturbance.  It  is  for  this 
reason  that  secondary  hydrocephalus  causes  such  striking  symptoms, 
although  the  accumulation  of  fluid  is  small. 

Whether  the  progress  of  these  cases  is  slow  or  rapid,  the  development 
of  the  children  is  greatly  retarded.  Many  are  not  able  to  support  the 
head  until  two  or  three  years  old ;  frequently  they  do  not  walk  until  five 
or  six  years  old.  The  special  senses  are  generally  not  noticeably  affected, 
but  intelligence  in  most  cases  is  interfered  with — in  some  only  slightly, 
in  others  very  markedly,  while  some  are  idiotic.  Contractions  of  the 
extremities  are  occasionally  seen,  but  usually  more  of  the  hands  than 
the  legs.  Sensation  is  not  often  affected.  The  course  is  a  very  chronic 
one.  From  time  to  time  there  are  exacerbations  of  the  symptoms,  and 
even  intercurrent  meningitis  may  be  excited. 

Prognosis. — Most  of  the  congenital  cases  are  fatal  before  the  end  of 
the  first  year.  It  is  very  rare  that  a  hydrocephalic  child  reaches  the  age 
of  seven  years.  The  process  may,  however,  go  on  up  to  a  certain  age, 
and  then  cease  spontaneously,  and  the  child  may  go  tlirough  life  with 
a  head  very  much  larger  than  normal  and  usually  with  a  mental  condi- 
tion somewhat  impaired.  Retrogression  of  the  symptoms  is,  however, 
never  to  be  looked  for. 

Diagnosis. — The  most  important  symptom  is  the  enlargement  of  the 
head,  and  this  can  only  be  arrived  at  by  careful  measurement  and  com- 
parison with  the  normal  size.  The  rapidity  of  growth  is  quite  as  impor- 
tant for  diagnosis  as  the  fact  of  enlargement.  If  the  head  grows  as 
much  as  an  inch  a  month  there  can  be  little  doubt.  The  enlargement 
most  frequently  confounded  with  hydrocephalus  is  that  which  occurs  in 
rickets.  In  the  latter  disease  it  is  almost  invariably  irregular;  there  are 
prominences  over  the  two  frontal  eminences  and  over  the  parietal  bones, 
often  with  furrows  between  them ;  the  size  of  the  head  is  chiefly  due  to 
thickening  of  the  bones  of  the  skull;  the  marked  prominence  of  the 
forehead  is  not  seen,  and  the  increase  in  the  bi-parietal  diameter  is  not 
present;  furthermore,  there  are  other  signs  of  rickets. 

Treatment. — If  there  is  any  suspicion  of  syphilis,  mercurial  inunc- 
tions should  be  employed,  and  potassium  iodide  given  internally  in  full 
doses.  Of  all  the  operative  measures  that  have  been  proposed  for  this 
condition,  and  their  name  is  legion,  the  only  one  at  the  present  time 
which  seems  to  hold  out  any  reasonable  prospect  of  permanent  improve- 
ment is  auto-drainage.  This  consists  in  establishing  a  communication 
between  one  of  the  lateral  ventricles  and  the  sub-arachnoid  space.  By 
this  means  the  fluid  is  conducted  to  a  place  from  which  it  can  be  ab- 
sorbed. A  considerable  number  of  cases  have  now  been  treated  in  this 
way.  The  dangers  of  the  operation  are  considerable,  nearly  half  the  pa- 
tients having  died  as  the  direct  result  of  it.  Of  those  who  have  survived, 
a  number  have  shown  improvement  and  a  few  very  striking  improve- 


INFANTILE  CEREBRAL   PARALYSIS.  747 

ment,  but  no  complete  cures-  have  been  reported.  Operation  is  not  to  be 
recommended  in  early  cases  witli  rapidly  increasing  enlarf,'eiiient.  The 
best  results  have  been  obtained  in  old  cases  wliicli  have  reached  a  nearly 
stationary  condition. 

INFANTILE   CEREBRAL  PARALYSIS. 

(Spastic  Diplegia,  Paraplegia,  or  Hemiplegia.) 
Fnder  the  term  cerebral  paralysis  are  included  several  groups  of  cases 
with  causes  quite  dissimilar,  but  having  certain  definite  clinical  features 
in  common.  While  the  symptomatology  is  quite  clear,  there  are  many 
questions  relating  to  the  pathology  that  are  not  yet  fully  settled,  al- 
though much  has  been  added  to  our  knowledge  within  the  last  few  years. 
Paralysis  depending  upon  cerebral  tumour,  abscess,  or  hydrocephalus  is 
not  included  in  this  chapter. 

The  cases  of  cerebral  paralysis  may  be  divided  into  three  groups, 
according  as  the  paralysis  depends  upon  conditions  existing  prior  to 
birth,  upon  those  connected  with  birth,  or  upon  those  of  subsequent 
development. 

I.  Paralysis  of  Intra-Uterine  Origin. — This  is  the  least  frequent  con- 
dition. In  such  cases  there  is  some  congenital  defect  in  the  brain,  due 
sometimes  to  arrest  of  development,  at  others  to  such  intra-uterine  lesions 
as  haemorrhage  or  thrombosis.  There  may  be  porencephalus,  or  cysts 
extending  deeply  into  the  substance  of  the  brain,  sometimes  communicat- 
ing with  the  ventricles.  The  origin  of  this  condition  is  for  the  most 
part  unknown.  In  rare  cases  the  paralysis  is  due  to  cortical  agenesis,^  a 
condition  in  which  the  brain  may  seem  normal  to  the  naked  eye,  but  the 
microscope  shows  a  complete  arrest  in  the  development  of  the  cells  of  the 
cortex,  usually  affecting  both  hemispheres.  In  still  other  cases  there  are 
found  gross  defects  in  development  in  the  motor  centres  of  the  cortex. 
Such  a  lesion  is  shown  in  Fig.  137.  Cases  in  which  there  is  conclusive 
evidence  of  intra-uterine  haemorrhage  are  very  rare. 

Symptoms. — In  most  of  the  paralyses  due  to  intra-uterine  lesions, 
loss  of  power  is  only  one  of  the  symptoms,  and  usually  not  the  most 
prominent.  It  is  rare  that  there  is  not  some  mental  impairment,  and 
usually  idiocy  is  present.  The  type  of  paralysis  is  nearly  always  diplegic 
or  paraplegic.  When  this  is  due  to  arrested  cortical  development,  a 
general  flaccidity  of  the  muscles  may  be  seen  instead  of  the  figidity  so 
characteristic  of  the  other  forms  of  cerebral  paralysis. 

II.  Birth-Paralysis.— Cerebral  birth-paralysis  is  due  in  nearly  all 
cases  to  meningeal  haemorrhage.  The  primary  lesions  and  the  early 
symptoms  have  already  been  described  in  connection  with  the  Diseases  of 
the  Newly  Born.     The  secondary  lesions  present  considerable  variety. 

»  For  fuller  description,  see  Sachs'  Nervous  Diseases  of  Children. 


748  DISEASES  OF  THE  NERVOUS  SYSTEM. 

There  may  be  found  (1)  meningo-encephalitis,  (2)  atrophy  and  sclerosis 
of  the  cortex,  (3)  cysts  upon  the  surface,  (4)  secondary  degenerations  in 
the  spinal  cord. 

1.  Meningo-encephalitis. — This  lesion  is  often  quite  diffuse.  There 
is  thickening  of  the  pia  mater,  and  it  is  usually  adherent  to  the  brain 
substance.    The  cortex  is  involved  to  a  variable  degree,  depending  some- 


Fio.  126. — Extensive  Atrophy  and  Sclerosis  of  the  Right  Hemisphere.  From  an 
infant  seven  and  a  half  months  old;  probably  the  result  of  a  meningeal  hiemorrhage 
at  birth  (lateral  view).  History. — Twelve  hours  after  birth  was  seized  with  general 
convulsions,  which  continued  for  three  days.  No  other  symptoms  noticed  till  one 
month  before  death,  when  weakness  of  the  left  arm  was  observed.  Never  held  head 
erect.  Was  plump  and  well  nourished;  died  from  erysipelas.  Autopsy. — Pia  not 
adherent;  a  large  cyst  occupied  the  region  of  the  occipital  and  posterior  part  of  the 
parietal  lobes,  showing  in  its  floor  discolouration  and  pigmentation,  evidently  from 
an  old  haemorrhage.     Right  optic  nerve,  tract,  and  crus  much  smaller  than  the  left. 

what  upon  the  time  which  elapses  between  the  initial  lesion  and  the 
autoi)sy.  Tiie  following  were  the  microscopical  clianges  found  by  Sachs  ^ 
in  the  brain  of  a  child  in  my  wards  at  the  Babies'  Hospital,  who  died 
at  the  age  of  one  year  of  measles :  The  lesions  were  found  everywhere  in 
the  cortex.  The  pia  was  universally  adherent,  and  showed  general  cel- 
lular infiltration;  its  blood-vessels  showed  marked  cell  proliferation, 
and  the  veins  in  the  sub-pial  space  were  dilated  and  filled  with  blood. 
In  the  pia  dipping  in  between  the  convolutions  similar  changes  were 
present.  •  In  the  cortex  few,  if  any,  normal  pyramidal  cells  were  found, 


^  The  clinical  features  of  this  case  are  quite  as  interesting  as  the  pathological  find- 
ings. The  child  was  a  first-bom,  delivered  after  a  dry  labour  of  forty-eight  hours. 
It  was  asphyxiated,  and  from  the  first  days  of  its  life  it  had  attacks  of  convulsions, 
usually  repeated  many  times  a  day.  During  one  of  these  convulsions  the  photograph 
from  which  Fig.  127  was  made,  was  taken  by  Dr.  Peterson.  The  child  had  the  symp- 
toms of  typical  spastic  paraplegia — the  arms  being,  however,  slightly  involved — 
retarded  mental  development,  and  convergent  strabismus. 


INFANTILE   CEREBRAL   PARALYSIS.  749 

but  in  the  outer  layers  were  an  enormous  niuiiljer  of  small  glia  cells. 
Many  of  the  blood-vessels  showed  a  cell-proliferation  of  their  walls. 
There  was  also  degeneration  in  the  pyramidal  tracts  of  the  lateral 
columns  of  the  cord. 

2.  Atrophy  and  Sclerosis. — These  changes  vary  much  in  extent  and 
degree.  There  may  be  only  a  circumscribed  area  in  which  the  convolu- 
tions are  small,  firmer  than  usual,  and  covered  witli  an  adherent  pia,  or 
there  may  be  an  atrophy  so  extensive  as  to  involve  a  large  part  of  one 
hemisphere  (Fig.  126),  or  sometimes  of  botli  hemispheres.  Usually  the 
lesion  is  somewhat  diffuse  over  the  convexity  of  both  sides,  and  much 
more  frequently  of  the  anterior  than  of  the  posterior  half  of  the  brain. 
Where  a  depression  of  the  brain  exists  the  space  is  filled  with  cerebro- 
spinal fluid,  and  in  many  cases  there  is  a  deformity  of  the  skull. 

3.  Cysts  upon  the  surface  may  occur  alone  or  in  connection  with  the 
lesions  Just  mentioned.  These  are  usually  small,  about  the  size  of  a 
walnut,  but  they  may  cover  a  large  part  of  a  hemisphere.  Such  large 
cysts  are  sometimes  classed  as  cases  of  external  hydrocephalus. 

4.  Secondary  degenerations  of  the  internal  capsule  and  the  lateral 
columns  of  the  cord  are  found  in  most  of  the  cases  associated  with  ex- 
tensive atrophy  and  sclerosis,  and  in  many  of  those  in  which  only  me- 
ningo-encephalitis  is  present. 

Symptoms. — The  type  of  paralysis  will,  of  course,  depend  upon  the 
extent  and  position  of  the  original  lesion.    A  diffuse  lesion  is  followed 


Fig.  127.— Convulsions  in  Spastic  Paraplegia. 
From  a  photograph  by  Dr.  Frederick  Peterson  during  an  attack. 

by  diplegia;  one  not  quite  so  extensive  by  paraplegia;  one  affecting  one 
side  only,  by  hemiplegia,  or  even  monoplegia,  though  this  is  very  rare. 
The  relative  frequency  of  the  different  forms  will  vary  according  to  the 
age  at  which  the  patients  come  under  observation.     According  to  my 


750 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


own  observations,  which  have  been  chiefly  upon  infants,  the  cases  of 
diplegia  and  paraplegia  have  outnumbered  those  of  hemiplegia  more 
than  four  to  one.  My  belief  is  that  the  great  majority  of  the  congenital 
cases,  or  those  due  to  haemorrhage  occurring  at  birth,  are  diplegias  or 
paraplegias,  and  that  very  many  of  them  succumb  during  the  first  two 
years;  however,  the  cases  of  hemiplegia,  because  of  the  less  serious 
lesion,  live  much  longer.  Diplegia  and  paraplegia  will  therefore  be  con- 
sidered as  the  characteristic  types  of  cerebral  birth-palsy,  as  the  cases  of 

hemiplegia  do  not  differ  from  those  due 
to  later  causes — i.  e.,  the  acquired  form. 

In  the  most  severe  cases  that  survive 
the  s}iuptoms  of  the  early  days  of  life 
there  remains  some  rigidity  of  the  ex- 
tremities, chiefly  of  the  legs,  which  is 
constant  or  intermittent,  slight  or  well 
marked.  There  is  often  spasm  of  the 
muscles  of  the  neck  and  trunk,  giving 
rise  to  opisthotonus.  In  many  cases 
there  are  frequent  attacks  of  convulsions 
(Fig.  127).  The  general  physical  de- 
velopment of  the  child  is  often  inter- 
fered with,  so  that  he  remains  small  and 
delicate,  and  perhaps  dies  of  some  acute 
disease  in  early  infancy,  never  having 
been  able  to  sit  erect,  or  even  support 
his  head.  In  other  cases  the  general  nu- 
trition is  not  affected,  and  life  may  be 
prolonged  indefinitely,  but  usually  with 
some  degree  of  mental  impairment. 
This  is  seen  in  all  degrees;  it  may  be 
to  slight  as  not  to  be  noticed  until  the 
child  is  two  or  three  years  old,  or  the 
child  may  be  idiotic.  Often  these  chil- 
dren are  not  able  to  stand  until  they  are 
over  three  years  old  and  do  not  walk  alone 
until  they  are  four  or  five  years  old,  and 
then  with  a  peculiar  cross-legged  gait, 
owing  to  spasm  of  the  adductors  of  the 
thighs.  This  may  be  so  great  as  entirely 
to  prevent  walking,  and  while  sitting  or 
lying  the  thighs  may  cross  each  other.  These  form  the  typical  cases  of 
spastic  paraplegia,  sometimes  called  Little's  disease  (Fig.  128).  All  the 
reflexes  are  greatly  exaggerated.  The  arms  are  much  less  affected  than 
the  legs,  and  in  about  half  the  number  they  are  not  involved  at  all. 


Fig.  128. — Spastic  Paraplegia. 
Child  two  and  one-half  years  old, 
New  York  Foundling  Hospital, 
unable  to  walk  or  even  to  stand 
without  assistance.  The  habitual 
position  of  the  limbs,  which  is  due 
to  strong  adductor  spasm,  is 
shown  in  the  picture. 


INFANTILE   CEREBRAL   PARALYSIS.  751 

In  the  milder  cases  the  early  syinptoiiis  may  l)o  ()verh)oke(l,  and  noth- 
ing excite  suspicion  until  the  infant  is  six  or  eight  months  old.  There 
is  then  discovered  unmistakable  muscular  weakness;  the  child  docs  not 
sit  up,  or  even  hold  up  the  head  when  the  trunk  is  supported.  Often 
there  is  observed  before  this  time  a  tendency  to  stiffen  the  body  and  to 
throw  the  head  backward,  owing  to  spasm  of  the  cervical  or  spinal  mus- 
cles. The  muscular  weakness  is  often  mistaken  for  rickets,  or  regarded 
simply  as  backwardness.  A  closer  examination  usually  discloses  the  pres- 
ence of  some  rigidity  of  the  extremities,  particularly  of  the  legs,  and 
exaggeration  of  the  knee-jerks.  As  the  cliild  grows  older  other  symp- 
toms of  imperfect  development'  become  more  and  more  evident. 

There  are  changes  in  the  shape  of  the  skull,  this  being  usually  smaller 
than  normal  in  all  its  diameters,  or  there  may  be  asymmetry.  There  is 
an  arrest  of  development  in  the  paralysed  limbs.  Those  are  both  smaller 
and  shorter  than  normal.  In  many  cases  abnormal  movements  are  seen, 
which  may  be  of  an  irregular  choreic  type,  or  they  may  be  athetoid. 
Epilepsy  develops  in  from  thirty-three  to  fifty  per  cent  of  all  these 
patients. 

III.  Acute  Acquired  Paralysis. — This  is  usually  of  the  hemiplegic 
type,  although  diplegia  and  paraplegia  may  in  rare  instances  be  met 
with.  This  group  includes  cases  developing  at  any  time  after  birth,  but 
the  great  majority  of  those  seen  in  childhood  begin  before  the  fifth 
year. 

Etiology. — The  etiology  is  often  obscure.  The  paralysis  sometimes 
follows  traumatism.  It  is  occasionally  seen  in  the  course  of  scarlet  fever, 
measles,  diphtheria,  variola,  or  pneumonia.  Much  more  frequently 
than  with  any  of  these  diseases  it  occurs  during  pertussis,  being  usually 
the  outcome  of  a  severe  paroxysm.  The  frequency  with  which  these 
cases  are  ushered  in  with  convulsions  has  led  many  to  assign  this  as 
the  cause  of  the  paralysis.  It  is  probable  that  the  convulsions  are  more 
often  the  result  than  the  cause  of  the  lesion.  In  some  of  the  acute 
inflammatory  cases  the  cause  is  possibly  the  same  as  in  acute  polio- 
myelitis. 

Lesions.— T\\e  lesions  of  acute  cerebral  palsy  may  be  grouped  under 
three  heads:  (1)  those  of  the  blood-vessels;  (3)  those  of  the  membranes; 
(3)  those  of  the  brain  substance. 

1.  Lesions  of  the  Blood-vessels.— There  may  be  haemorrhage,  em- 
bolism, or  thrombosis.  Haemorrhage  is  by  far  the  most  important.  It  is 
usually  meningeal,  rarely  cerebral.  It  occurs  more  frequently  at  the  con- 
vexity than  at  the  base,  and  is  often  diffuse.  Meningeal  haemorrhage 
may  result  from  pachymeningitis.  It  may  be  due  to  traumatism,  when 
it  is  also  from  the  dura  mater;  or  from  the  acute  hyperaemia  accompany- 
ing paroxysms  of  pertussis,  when  it  may  be  from  tlie  dura  or  the  pia ; 
or  it  may  be  secondary  to  thrombosis  of  the  superior  longitudinal  sinus. 


752 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


The  association  of  hasmorrhage  with  sinus-thrombosis  is  not  very  in- 
frequent. It  was  found  in  one  of  my  autopsies  upon  a  patient  who  died 
of  pneumonia.     Cerebral  haemorrhage  is  extremely  rare,  but  it  occurs 

even  in  infants;  I  once 
saw  it  in  one  only  two 
months  old. 

Embolism  is  rarely 
found  unless  associated 
with  acute  rheumatic  en- 
docarditis, and  then  usu- 
ally in  children  who  are 
over  seven  years  old.  As 
in  adults,  the  usual  seat 
of  the  embolus  is  a  branch 
of  the  middle  cerebral  ar- 
tery. Thrombosis  has 
been  met  with  in  a  small 
number  of  cases,  but  is 
extremely  rare. 

2.  Lesions  of  the 
Membranes. — These  are 
generally  the  result  of 
an  old  cerebro-spinal 
meningitis;  sometimes 
they  may  be  of  sypliilitic 
origin.  In  both,  how- 
ever, the  process  is  rarely  confined  to  the  membranes;  it  is  a  meningo- 
encephalitis. 

3.  Lesions  of  the  Brain  Substance. — Atrophy  and  sclerosis  are  found 
in  a  large  number  of  the  autopsies  made  upon  cases  when  the  paralysis 
has  been  of  long  standing.  They  represent  terminal  conditions,  however. 
They  vary  in  severity  and  extent,  and  are  followed  by  secondary  degen- 
eration in  the  cord,  as  in  cases  of  birth  paralysis.  There  may  be  the 
same  development  of  cysts  of  the  pia  mater,  or  an  accumulation  of  fluid 
in  the  arachnoid  cavity,  these  taking  the  place  of  the  atrophied  convolu- 
tions. The  nature  of  the  primary  lesion  in  these  cases  is  not  always 
clear.  In  a  certain  number  of  them  it  is  an  acute  poliencephalitis,  anal- 
ogous to  acute  poliomyelitis,  and  probably  due  to  the  same  cause.  The 
cerebral  lesion  may  be  associated  .with  cord  lesions  or  it  may  occur  alone. 
Their  nature  is  considered  in  the  chapter  on  Poliomyelitis.  In  other 
cases  a  chronic  diffuse  encephalitis  with  atrophy  is  found  at  autopsy, 
closely  resembling  the  conditions  which  follow  a  meningeal  haemorrhage 
occurring  at  birth,  yet  the  children  were  normal  up  to  the  second  or 
third  year,  and  there  was  no  acute  onset. 


FiQ.  129. — Recent  Meningeal  Haemorrhage.  Brain 
of  an  infant  seven  months  old  in  the  Babies'  Hos- 
pital. A,  punctate  haemorrhages;  B,  thrombosed 
vessels;  C,  diffuse  extravasation. 


INFANTILE   CEREBRAL   PARALYSIS.  753 

Acute  paralysis  sometimes  occurs  for  wiiich  no  explanation  can  be 
found  at  autopsy.  An  infant  with  pneumonia  was  admitted  to  the 
Babies'  Hospital,  who  had  developed,  a  few  days  before,  ty])ical  riglit 
hemiplegia.  It  came  on  suddenly,  with  convulsions,  and  involved  the 
face,  arm,  and  leg.  The  arm  and  leg  appeared  to  be  completely  para- 
lysed, but  in  the  face  the  paralysis  was  incomplete.  The  paralysis 
had  begun  to  improve  somewhat  at  the  time  of  the  child's  death, 
which  occurred  a  little  over  a  week  after  its  onset.  At  the  autopsy 
no  gross  lesion  could  be  discovered.  A  careful  microscopical  exam- 
ination was  made,  and  nothing  abnormal  was  found  except  a  slight 
increase  of  small  spheroidal  cells  about  some  of  the  meningeal  and 
cortical  vessels  of  the  motor  area.  The  frontal  and  occipital  lobes  were 
normal. 

Symptoms. — While  diplegia  and  paraplegia  are  occasionally  seen, 
the  great  majority  of  cases  of  acquired  cerebral  palsy  are  of  the  liemi- 
plegic  variety.  When  diplegia  and  paraplegia  occur,  it  is  usually  in 
early  infancy,  and  their  symptoms  and  course  differ  in  no  wise  from  the 
birth  palsies.  We  may  therefore  regard  hemiplegia  as  the  chief  mani- 
festation of  acquired  cerebral  palsy. 

The  onset  of  the  paralysis  is  almost  invariably  sudden,  with  convul- 
sions, which  are  usually  repeated,  and  in  severe  cases  followed  by  loss  of 
consciousness.  In  the  secondary  cases  these  are  generally  the  only  symp- 
toms. In  one  of  my  cases  the  patient  went  to  bed  apparently  well,  and 
awoke  in  the  morning  with  hemiplegia.  Sucli  an  onset,  liowever,  is  very 
exceptional. 

When  the  paralysis  is  due  to  acute  poliencephalitis,  the  onset  is  usu- 
ally with  high  fever,  vomiting,  often  convulsions,  followed  by  delirium 
or  stupor.  These  general  symptoms  continue  for  a  variable  time,  usually 
two  or  three  days,  before  paralysis  is  seen.  The  temperature  in  most 
cases  is  from  101°  to  103°  F.,  and  the  fever  sometimes  follows,  sometimes 
precedes,  the  convulsions.  The  loss  of  consciousness  may  last  for  several 
days,  and  the  paralysis  is  frequently  not  discovered  until  consciousness 
is  regained.  If  there  is  a  very  extensive  lesion  there  may  be  diplegia, 
deep  coma,  and  death,  but  this  is  very  infrequent.  Usually  the  lesion  is 
more  limited,  and  the  symptoms  are  those  of  typical  hemiplegia.  The 
face  sometimes  escapes,  and  if  involved  it  generally  soon  recovers.  The 
paralysis  of  the  arm  and  leg  is  at  first  complete,  but  may  improve  rap- 
idly in  the  course  of  a  few  weeks.  Disturbances  of  sensation  may  be 
present,  but  are  usually  of  a  transient  character.  After  a  variable 
period,  from  one  to  several  weeks,  the  patient  begins  to  use  the  paralysed 
extremities,  first  the  leg,  afterward  the  arm,  as  in  adult  hemiplegia. 
The  convulsions  may  be  repeated  for  the  first  day  or  two,  but  prolonged 
or  continuous  convulsions  are  rare.  They  may  be  general  or  unilateral. 
With  lesions  of  the  left  side  of  the  brain,  speech  may  be  affected,  and 
49 


754 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


not  infrequently  in  young  children  when  the  lesion  is  upon  the  right 
side.  The  reflexes  are  increased  upon  the  affected  side,  and  a  slight 
ankle-clonus  may  be  present. 

After  a  few  weeks  the  child  may  be  able  to  walk,  dragging  the  af- 
fected leg.  The  recovery  in  the  leg  is  sometimes  complete,  but  in  most 
cases  a  slight  halt  in  the  gait  remains.  The  arm  usually  recovers  more 
slowly  than  tiie  leg,  and  contractures  are  likely  to  develop  after  a  variable 

time,  generally  two  or  three  years.  In 
Fig.  130  is  shown  a  frequent  deformity 
of  the  upper  extremity.  Contractures 
of  the  leg  lead  to  various  forms  of 
talipes,  generally  equinus,  from  short- 
ening of  the  tendo-Achillis.  Sometimes 
the  arm  or  the  leg  recovers  so  perfectly 
that  the  case  may  be  regarded  as  one 
of  monoplegia.  In  old  cases  the  para- 
lysed limbs  are  atrophied ;  there  is  more 
or  less  rigidity,  and  the  spastic  condi- 
tion may  be  quite  marked.  I  have  seen 
this  limited  to  a  single  group  of  mus- 
cles in  the  leg.  Apliasia  is  common  in 
right  hemiplegias,  and  it  is  not  very  rare 
in  those  of  the  left  side,  because  infants 
appear  to  use  both  sides  of  the  brain 
with  nearly  equal  facility. 

The  mental  condition  of  these  chil- 
dren is  often  normal,  in  striking  con- 
trast with  the  cases  of  congenital  di- 
plegia. The  earlier  the  paralysis  occurs 
the  more  likely  are  mental  symptoms 
to  be  present,  since  we  have  here  not 
only  the  direct  effect  of  the  lesion,  but 
an  arrested  development  of  some  part 
of  the  brain.  Epilepsy  is  not  an  un- 
common sequel;  it  may  be  of  the  Jack- 
sopian  type,  or  there  may  be  attacks  of 
general  convulsions.  In  other  cases 
there  are  post-hemiplegic  movements  of  a  choreic  or  athetoid  character, 
or  irregular  inco-ordinate  movements. 

Prognosis  of  Infantile  Cerebral  Paralysis.— In  diplegia  and  para- 
plegia the  outlook  is  always  unfavourable.  A  very  large  number  of  these 
cases  which  are  due  either  to  intra-uterine  or  birth  lesions  never  reach 
the  third  year,  but  die  in  infancy  from  marasmus  or  acute  intercurrent 
disease.     Those  who  survive  usually  show  serious  mental  defects,  and 


Fio.  130.  —  Deformity  of  Left 
Hand  the  Result  of  Contract- 
ures FOLLOWING   AN  ATTACK   OF 

Hemiplegia    Four   Years   Be- 
fore.    Child  seven  years  old. 


INFANTILE   CEREBRAL   PARALYSIS.  755 

many  are  practically  helpless  on  account  of  the  extreme  spastic  condition 
of  the  muscles  of  the  extremities. 

In  hemiplegia  the  prognosis  is  much  more  favourable.  In  most  of 
these  cases  the  paralysis  is  of  the  acute  acfiuired  variety,  and  the  later 
the  period  of  onset,  the  less  likely  is  the  brain  to  be  seriouslv  damaged. 
In  some  of  these  patients  complete  recovery  takes  jjlace;  in  others  the 
residual  paralysis  is  so  slight  as  to  be  easily  overlooked  except  on  careful 
examination,  the  occurrence  of  epilepsy  being  peibaps  the  first  thing 
which  leads  one  to  suspect  that  a  previous  paraly.^is  has  existed.  The 
great  majority  of  children  who  have  suffered  from  infantile  cerebral 
palsy  have  some  degree  of  permanent  paralysis  and  usually  some  deformi- 
ties from  contractures,  the  extent  of  both  varying,  of  course,  with  the 
severity  of  the  primary  lesion.  In  all  cases  seen  in  young  infants  it  is 
exceedingly  difficult  to  give  a  prognosis  in  regard  to  future  mental  de- 
velopment. As  a  rule,  the  impairment  is  directly  proportionate  to  the 
extent  of  the  paralysis  and  its  intensity. 

Diagnosis. — The  diagnosis  between  the  congenital  and  acquired  forms 
of  cerebral  palsy  is  of  no  great  practical  im])ortance,  and  it  may  be  im- 
possible; for  the  symptoms  in  congenital  cases  are  often  not  sufficiently 
marked  to  attract  attention  until  children  are  old  enough  to  sit  alone  or 
to  walk. 

It  may  be  quite  difficult  to  distinguish  cerebral  paralysis  from  infan- 
tile spinal  paralysis.  The  history  of  an  acute  onset,  the  atrophied  limbs, 
the  deformities,  and  the  absence  of  sensory  disturl)ances,  may  be  found 
in  both  conditions.  Spinal  paralysis  is,  as  a  rule,  monoplegic,  and  often 
affects  but  a  single  group  of  muscles.  Cerebral  paralysis  is  either  di- 
plegic  or  hemiplegic  in  character,  and  even  though  only  a  leg  or  an  arm 
may  seem  to  be  affected,  a  critical  examination  will  usually  reveal  the 
fact  that  the  other  limb  of  the  same  side  has  also  suffered.  The  presence 
of  rigidity  and  exaggerated  reflexes  is  quite  as  important  evidence  of 
this  as  loss  of  power.  The  electrical  reactions,  however,  are  conclusive; 
the  reaction  of  degeneration  is  absent  in  cerebral  paralysis,  while  it  is 
present  in  spinal  paralysis. 

Simple  as  the  differentiation  may  seem  in  most  cases,  the  mistake  is 
frequently  made  of  confounding  cerebral  diplegia,  particularly  of  the 
flaccid  type,  with  rickets.  Cases  of  acute  acquired  paralysis  at  the  onset 
may  be  mistaken  for  acute  meningitis,  but  early  loss  of  consciousness, 
the  early  development  of  the  paralysis,  its  permanent  character,  and  the 
shorter  duration  of  the  acute  symptoms,  usually  distinguish  these  cases 
from  those  of  meningitis.  The  only  definite  means  of  differential  diag- 
nosis is  by  lumbar  puncture ;  this  gives  negative  results  in  cerebral  paral- 
ysis and  positive  results  in  meningitis. 

Treatment.— The  course  and  the  result  of  cerebral  paralysis  depend 
upon  the  extent  of  the  injury  to  the  brain,  its  nature,  and  the  age  at 


756  DISEASES  OF  THE   NERVOUS  SYSTEM. 

which  it  is  inflicted — all  these  being  conditions  which  are  beyond  the 
power  of  the  physician  to  modify  or  control.  The  treatment  of  cerebral 
palsy  is  therefore  extremely  unsatisfactory.  For  the  congenital  cases 
practically  nothing  can  be  done,  except  for  the  deformities  and  compli- 
cations. The  acquired  cases  during  the  acute  onset  are  to  be  managed 
like  all  other  cases  of  acute  cerebral  congestion  or  inflammation — abso- 
lute rest,  ice  to  the  head,  and  bromides.  Electricity  is  not  to  be  used 
in  early  cases,  and  little  or  nothing  is  to  be  expected  from  it  in  the  late 
ones.  Much  can  be  accomplished  in  an  educational  way  for  the  mental 
derangements  resulting  from  cerebral  palsy.  An  important  part  of  the 
treatment  relates  to  the  deformities.  Many  of  these  may  be  prevented 
by  the  early  use  of  orthopasdic  apparatus.  Serious  deformities  in  old 
cases  may  be  greatly  benefited  by  tenotomy  or  myotomy,  followed  by 
the  use  of  suitable  apparatus.  Division  of  the  posterior  nerve  roots  has 
been  performed  for  the  relief  of  extreme  spasticity  with,  in  some  cases, 
very  striking  benefit.  Epilepsy  is  to  be  treated  as  when  it  depends  on 
other  causes. 

MENTAL  DEFECTS. 

DEFICIENCY,    IDIOCY,    IMBECILITY. 

All  grades  of  mental  defects  are  seen  in  children.  While  the  terms 
above  used  characterise  the  chief  clinical  types,  it  should  be  remembered 
that  these  shade  into  each  other  by  almost  imperceptible  degrees.  They 
may  be  the  result  either  of  arrested  development  or  of  disease  or  injury 
of  the  brain. 

The  backward  child  does  not  belong  in  this  group,  although  often 
placed  here  by  parents  or  teachers.  Such  children  may  present  many 
mental  peculiarities,  but  differ  from  the  normal  standard  chiefly  in  the 
slowness  with  which  the  mental  functions  are  developed,  the  most  notice- 
able of  these  being  speech.  It  is  backward  children  and  those  who  pre- 
sent the  milder  grades  of  mental  defect  that  are  of  the  greatest  clinical 
interest  and  importance,  for  in  them  the  mental  condition  often  depends 
upon  some  physical  cause  which  time  and  proper  treatment  may  remove. 
Common  causes  are  defective  sight  or  hearing,  severe  early  rickets,  pro- 
longed malnutrition,  etc. 

Following  somewhat  the  classification  of  Ireland,  the  mental  defects 
of  children  may  be  divided  into  the  following  groups: 

1.  Those  depending  upon  such  congenital  conditions  as  porenceph- 
alus,  arrested  development  of  the  brain  as  a  whole,  or  of  some  portion, 
particularly  the  frontal  lobes.  An  excellent  illustration  of  this  class  of 
cases  is  seen  in  Fig.  137.  Another  variety  is  known  as  "  Agenesia  cor- 
ticalis,"  described  elsewhere. 

2.  Those  associated  with  external  or  internal  hydrocephalus. 


MENTAL  DEFECTS. 


757 


3.  Those  associated  with  microcephaius,  either  with  or  without  pre- 
mature ossification  of  the  cranial  bones  (l^'igs.  134-136). 

4.  The  paralytic  cases,  including  the  varieties  which  occur  in  the  dif- 
ferent forms  of  cerebral  paralysis,  the  greater  part  of  which  are  due  to 
meningeal  haemorrhage  at  birth,  and  which  are  clinically  associated  with 

Various  Types  of  Mental  Defects. 


Fig.   131. 


Fig.   132.  Fig.   133. 

Figs.  131-133.— Mongolian  type. 
Fig.  131. — Six  months  old;  died  at  twenty-two  months;  could  not  hold  up  the  head, 
or  understand  anything. 

Fig.  132.— Boy  six  and  a  half  years  old;  did  not  walk  or  talk  till  four  years  old;  now 
quite  intelligent,  but  not  normal. 

Fig.  133. — Girl  four  years  old;  mental  development  like  that  of  a  normal  child  of  two 
and  a  half  years;  walks  very  awkwardly. 


Fig.  134. 


Fig.  135. 


Fig.   136. 


Fig.  134.— Boy  twelve  years  old;  microcephalic;  walked  at  about  four  years;  can  read 
and  write;  development  like  that  of  a  normal  child  of  eight  years. 

Fig.  135.— Microcephalic,  seven  years  old;  understands  most  of  what  is  said;  can  not 
talk  intelligibly. 

Fig.  136.— Girl  of  eight  years;  imbecile;  can  not  walk  without  help. 

Note  that  the  expression  in  132,  133.  and  134  is  not  due  to  adenoids;  132  and  134 
have  had  them  removed. 

spastic  diplegia  or  paraplegia;  a  smaller  number  are  associated  with 
acquired  cerebral  paralysis,  most  frequently  following  meningeal  h*m- 

orrhage. 

5.  Those  of  inflammatory  origin.  They  follow  cerebro-spmal  menin- 
gitis and  acute  poliencephalitis.  _ 

6.  Those  associated  with  epilepsy,  in  which  the  condition  is  a  result 


758  DISEASES  OF  THE   NERVOUS  SYSTEM. 

of  chaiif^^os   in   the   l)rain   produced    by   the   repetition   of  the   epileptic 
seizures. 

7.  Mongolian  Idiocy. — This  is  a  form  characterised  by  a  peculiar 
Chinese  type  of  skull  and  face,  with  marked  backwardness  in  physical 
and  mental  development  (Figs.  131-133).  The  head  is  somewhat  flat- 
tened from  l)eforo  backward;  the  nose  rather  broad  and  fiat;  but  the 


Fig.  137. — Arrested  Development  of  the  Frontal  Lobes  of  the  Brain,  Particu- 
larly OF  the  Right  Side.    From  an  idiotic  child  twelve  months  old.' 

most  striking  thing  is  the  narrow  palpeliral  fissures  which  have  a  down- 
ward inclination  toward  the  nose.  These  patients  almost  always  have 
the  mouth  open ;  and  the  facial  expression  like  that  due  to  large  adenoids 
may  lead  to  the  suspicion  that  this  is  the  only  condition  present.  The 
mouth  breathing  is,  however,  due  rather  to  the  peculiar  conformation  of 

*  A  microscopical  examination  by  Dr.  Martha  Wollstein  showed  the  cortex  in  the 
affected  region  to  be  only  one-third  the  normal  thickness;  the  cortical  layers  were  ill- 
defined  ;  there  was  a  striking  absence  of  the  characteristic  nerve  cells,  both  the  large 
and  small  pyramidal  cells  being  few  in  number.  There  was  no  growth  of  connective 
tissue.     The  white  substance  was  normal,  as  were  also  the  dura  and  pia. 


MENTAL  DEFECTS.  759 

the  base  of  the  skull,  and  the  anterior  projection  of  tlie  bodies  of  the 
upper  cervical  vertebrae.  The  Mongolian  type  is  seen  in  all  degrees  of 
severity.  In  early  infancy  these  children  may  present  no  striking  pe- 
culiarities except  in  facial  expression,  and  a  general  backwardness  in 
physical  development.  Dentition  is  delayed;  they  may  not  sit  alone 
until  the  age  of  eighteen  months  or  two  years,  and  frequently  do  not  walk 
or  talk  intelligently  until  they  are  four  or  five  years  old.  In  tlie  milder 
forms  they  are  often  regarded  simply  as  very  backward  children.  In  the 
more  severe  forms  the  mental  defect  may  be  great.  Their  resistance  is 
feeble,  and  many  die  in  early  childhood.  Little  is  known  of  the  etiology 
of  this  condition.  Cases  occur  in  all  classes  of  society,  and  when  other 
children  in  the  family  are  quite  normal. 

8.  Amaurotic  Family  Idiocy. — This  name,  proposed  by  Sachs,  indi- 
cates the  prominent  features  of  the  malady,  whicli  is  not  a  very  rare  one. 
Nothing  is  known  of  its  etiology  except  that  nearly  all  the  recorded  cases 
have  been  in  the  Jewish  race.  Two,  and  sometimes  tbree  or  four  cbil- 
dren  in  succession  have  been  affected  in  the  same  family.  The  first 
symptoms  are  usually  noticed  between  the  sixth  and  tenth  month,  up  to 
which  time  the  infant  has  generally  appeared  normal.  At  first  it  is  only 
noticed  that  the  child  is  making  no  progress  in  his  development.  He 
does  not  gain  in  ability  to  sit  up  or  use  his  muscles  in  other  ways.  He 
lies  quietly,  does  not  respond  as  he  once  did,  and  takes  less  interest  in 
his  surroundings.  After  a  few  weeks  it  is  clear  that  the  child,  instead 
of  advancing,  is  actually  retrograding,  both  physically  and  mentally. 
His  muscles  become  so  weak  that  he  can  no  longer  sit  up  or  even  hold  up 
his  head.  Closer  observation  shows  that  vision  is  becoming  less  and 
less  distinct.  The  child  no  longer  recognises  the  faces  of  friends  or 
objects  shown  him.  Finally,  he  becomes  dull,  apathetic,  and  quite  in- 
different to  his  surroundings,  and  it  is  evident  that  he  can  not  see  at  all. 
In  the  early  stages  the  muscles  are  usually  weak  and  flaccid ;  later  there 
is  rigidity,  with  increased  knee-jerks  and  often  marked  spasticity.  There 
may  be  general  convulsions.  The  characteristic  features  of  the  disease 
are  revealed  by  the  ophthalmoscope.  There  is  a  milky-blue  or  white  area, 
with  a  bright,  cherry-red  centre,  occupying  the  ])lace  of  the  macula  lutea, 
and  with  this  there  is  also  atrophy  of  the  optic  disc.  Tbe  ocular  changes 
are  symmetrical.  The  disease  is  progressive,  accompanied  by  marked 
wasting,  and  usually  fatal  within  a  year  from  the  time  when  the  first 
symptoms  are  seen;  but  occasionally  the  blind,  helpless  child  may  live 
for  two  or  even  six  years.  The  essential  lesion  consists  in  degenerative 
changes  of  the  ganglion  cells  of  the  central  nervous  system.  The  changes 
are  most  marked  in  the  cerebral  cortex,  but  are  widespread,  and  hardly 
a  normal  ganglion  cell  may  be  found.  The  outlook  is  absolutely  bad,  all 
cases  terminating  fatally. 

9.  Both  sporadic  cretinism  and  chondro-dystrophy  have  many  symp- 


760  DISEASES  OF  THE   NERVOUS  SYSTEM. 

toms  suggesting  mental  defects,  but  they  do  not  strictly  belong  in  this 
category.     They  are  considered  separately  later. 

In  addition  to  the  etiological  factors  belonging  to  the  different  con- 
ditions above  described,  the  influence  of  heredity  is  to  be  considered; 
there  may  be  hereditary  nervous  diseases,  alcoholism,  syphilis,  or  some 
other  vice  of  constitution.  Intermarriage  among  l)lood  relations  is  one 
of  the  causes  most  frequently  assigned ;  but  after  an  exhaustive  study  of 
the  question,  Huth  reaches  the  conclusion  that  this  view  is  not  supported 
by  the  facts. 

Diagnosis. — Certain  types  of  mental  defect  may  easily  be  recognised 
after  the  age  of  three  or  four  years,  especially  the  more  marked  forms 
when  they  are  due  to  the  gtaver  cerebral  lesions — hydrocephalus,  micro- 
cephalus,  various  cerebral  palsies,  amaurotic  idiocy,  etc.  In  the  milder 
forms  and  in  infancy,  however,  this  is  not  so  easy  a  matter;  it  is  often 
impossible  without  a  considerable  period  of  observation  to  distinguish 
a  backward  or  peculiar  child  from  one  who  has  some  serious  mental 
defect. 

To  appreciate  the  abnormal,  one  must  be  familiar  with  the  mental 
and  physical  development  of  healthy  children.  A  normal  infant  of 
average  muscular  development  can  usually  support  the  head  steadily  be- 
fore five  months  old,  often  at  three  months;  he  can  usually  sit  erect  at 
eight  or  nine  months,  and  stand  with  assistance  at  twelve  or  thirteen 
months.  Toys  are  held  and  usually  handled  with  facility  at  five  or  six 
months.  The  recognition  of  the  nurse  or  mother  comes  at  about  the  same 
time.  Usually  the  first  distinct  words  are  pronounced  about  the  end  of 
the  first  year,  and  at  two  years  most  children  put  words  together  in 
short  sentences.  Variations  of  a  few  months  from  the  averages  above 
mentioned  can  not  be  considered  abnormal. 

To  determine  whether  an  abnormal  mental  state  is  simply  the  result 
of  poor  general  nutrition,  or  is  dependent  upon  actual  disease  or  imper- 
fect development  of  the  brain,  is  frequently  a  matter  of  the  greatest 
difficulty.  The  backward  infant  is  usually  distinguished  chiefly  by  the 
things  which  he  does  not  do;  while  with  those  who  are  deficient  not 
only  are  the  proper  signs  of  development  wanting,  but  many  new  and 
peculiar  symptoms  may  be  observed.  The  backward  child  may  not  sit 
alone  until  he  is  twelve  or  fifteen  months  old,  and  may  not  walk  until 
he  is  two  and  a  half  years  old,  but  the  cerebral  development  is  in  most 
cases  proportionate  to  the  physical  condition.  Speech  may  be  so  delayed 
that  the  first  words  do  not  come  until  two  years,  and  short  sentences  not 
until  three  years  old,  and  yet  in  understanding  what  is  said  to  and  done 
for  him,  the  child  may  seem  bright  and  his  development  steady  and  pro- 
gressive, although  slow. 

All  children  whose  development  is  delayed  should  be  examined  for 
local  signs  of  cerebral  disease;  the  symptoms  mentioned  under  the  vari- 


MENTAL  DEFECTS.  761 

ous  heads  of  early  hydroceplialus,  meningeal  luEinorrhage,  and  cretinism 
should  be  sought.  Sight  and  hearing  should  he  tested,  and  the  eyes, 
if  possible,  examined  with  an  ophthalmoscope;  the  co-ordination  of  the 
hands  should  be  tested  in  various  ways;  the  reflexes  examined,  and  gen- 
eral rigidity  or  slight  paralysis  noted,  also  the  nuiscular  ])o\ver  in  the 
trunk,  neck,  and  extremities.  Many  children  who  are  mentally  deficient 
do  not  show  any  disturbances  of  nutrition  during  the  first  year.  The 
growth  of  the  body  in  height  and  weight  may  be  (luite  normal;  although 
this  is  rarely  true  of  the  muscular  power.  Some  of  them  show  marked 
signs  of  backwardness  in  physical  development,  and  in  nearly  all  there 
are  some  other  striking  symptoms.  Among  the  most  frequently  noticed 
are:  drooling,  an  open  inouth,  a  ])rotruding  tongue,  a  (ixed,  aimless  stare, 
the  production  of  some  inarticulate  sounds,  which  are  usually  peculiar 
to  the  child  and  may  be  repeated  many  times  a  day.  Occasionally  there 
are  sharp  screams  without  any  evident  cause,  also  irregular,  aimless 
movements  of  the  hands.  Objects  are  not  properly  held,  and  if  grasped, 
they  are  soon 'dropped  by  an  infant  of  twelve  or  fourteen  months  as  by 
a  normal  one  of  three  or  four  months.  The  child  does  not  recognise  his 
bottle  or  liis  nurse.  Nystagnms  is  often  present;  and  there  may  be  ill- 
defined  attacks  of  a  convulsive  nature,  or  typical  convulsions.  The  in- 
fant is  not  attracted  by  bright  colours  or  toys,  and,  in  short,  seems  dull 
and  unresponsive  to  every  mental  impression. 

An  accurate  diagnosis  usually  carries  with  it  the  data  for  a  definite 
prognosis.  Few  misfortunes  which  can  befall  a  family  are  worse  than 
to  have  a  mentally  defective  child,  and  the  physician's  opinion  is  sought 
early  and  eagerly  as  to  the  probable  outlook  for  all  children  who  are 
suspected  of  being  in  any  way  abnormal.  The  possibilities  of  error  in  the 
early  years  are  great,  and  much  needless  suffering  is  often  caused  to 
parents  by  an  erroneous  opinion.  It  is  the  experience  of  all  who  see 
many  of  these  children,  that  some  who  were  regarded  at  the  age  of  three 
or  four  years  as  seriously  defective,  have  in  the  end  turned  out  to  be 
entirely  normal.  One  should  therefore  always  put  the  best  possible  in- 
terpretation upon  the  facts.  The  amount  of  improvement  which  takes 
place  in  many  of  these  cases  is  most  surprising.  The  above  statement 
applies,  of  course,  chiefly  to  children  in  whom  there  are  no  evidences 
of  gross  cerebral  lesions.  The  deviations  from  what  is  normal  are  many 
and  wide,  and  careful  observation  for  a  long  period  is  necessary  before  a 
child  is  pronounced  idiotic  or  even  feeble-minded. 

Most  cases  of  idiocy  exhibit  to  a  greater  or  less  degree  the  stigmata 
of  degeneration.  In  an  examination  of  517  idiots  by  Howe,  there  was 
found  blindness  in  21 ;  deafness  in  12;  some  defect  of  the  nose  or  mouth, 
such  as  hare-lip,  high  palatal  arch,  or  cleft  palate,  in  23  cases ;  and  some 
deformity  of  the  hands  or  feet  in  54  eases;  while  in  96  there  was  paral- 
ysis of  one  or  more  limbs. 


762 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


Treatment. — The  problem  is  essentially  an  educational  one,  and  for 
such  education  special  teachers  and  often  special  schools  are  indispensa- 
ble. With  such  advantages  it  is  surprising  to  see  what  can  be  accom- 
plished with  many  children  who  have  a  severe  grade  of  mental  defect. 
To  furnish  a  proper  means  for  educating  these  children  is  a  duty  of  the 
State,  and  up  to  the  present  time  very  inadequate  provision  has  been 
made  for  them.  Except  in  the  mild  forms,  defective  children  are  better 
trained  and  educated  in  institutions  than  in  the  home,  and  parents 
should  be  urged  to  place  them  in  institutions  whenever  practicable  as 
soon  as  they  have  passed  the  age  or  development  of  infancy. 

CHONDRO-DYSTROPHY. 
{Achondroplasia — Congenital  or  Foetal  Rickets.) 

This  rather  rare  condition  is  the  cause  of  some  of  the  most  marked 
examples  of  dwarfism  known.  It  was  recognised  as  an  abnormality  by 
the  early  Egyptians  and  has  figured  in  art  in  various  ways  since  that  date. 


Fio.  138. — Skull  in  Chondrodystrophy.  Showing  Frontal  Prominence  and  Prog- 
nathism.    Girl  six  years  old. 


Paintings  show  that  many  of  the  old  court  jesters  were  of  this  type. 
Because  of  their  striking  appearance,  these  dwarfs  have  always  excited 
much  curiosity  and  interest. 

The  causes  of  chondro-dystrophy  are  unknown;  only  in  rare  cases 
has  any  hereditary,  connection  been  traced.  The  pathological  process 
begins  in  fcetal  life  and  consists  in  a  disturbance  of  the  normal  ossifica- 


CHONDRO-DYSTROPHY. 


763 


tion  of  primary  cartilage.  It  affects  endochondral  ossification  only,  never 
intra-membranous  ossification.  The  flat  bones  and  tlie  vertebra  there- 
fore escape,  while  the  bones  of  the  extremities  suffer  most.  Tlie  dis- 
ease does  not  affect  bones  which  are  cartihiginous  or  almost  entirely  so 
through  the  greater  part  of  intra-uterine  life.  One  of  the  most  striking 
changes  in  the  skull  is  the  synostosis  or  early  ossification  of  the  tribasilar 
bone;  this  is  formed  of  two  parts  of  the  sphenoid  and  the  splienoidal 
process  of  the  occipital  bone.  Normally  this  ossification  does  not  take 
place  until  adult  life ;  in  children  with  chondro-dystrophy  it  often  begins 
in  utero.  This  prevents  a  normal  expansion  at  the  base  of  the  skull,  and 
the  brain,  as  it  grows,  is  thus  crowded  upward  and  forward,  causing  the 
great  prominence  of  the  forehead  (Fig.  138).  The  u])per  jaw  appears 
very  prominent  on  account  of  the  depression  at  the  root  of  the  nose. 

In  the  long  bones  there  is  a  marked  interference  with  the  normal 
row-formation  of  the  proliferating  cartilage  cells,  which  may  be  seen  in 
all  degrees.  In  some  cases  a  periosteal  lamella  pushes  its  way  between 
the  epiphysis  and  the  diaphysis,  still  further  restricting  the  growth  of 

the  long  bones.    As  bone  formation 
beneath    the    periosteum    goes    on 
normally,  the  bones  in  this  condi- 
'/■■  tion  are  thick  as  well  as  short. 


Fig. 


140. —  Chondro-dystrophy — Infan- 
tile Figure.     (Marie.) 


FiQ.  139. — Normally  Developed  Long 
Bones  of  a  Fcetus  Compared  with 
Those  of  Chondro-dystrophy.  (Spill- 
mann.) 

Symptoms.— The  majority  of  children  suffering  from  this  condition 
are  either  born  dead  or  die  shortly  after  birth.  Those  who  survive  are 
delicate  during  infancy,  but  afterward  may  become  strong  and  healthy. 
The  most  striking  thing  about  their  appearance  is  the  very  short  legs 
and  arms  as  compared  with  the  length  of  the  body.  At  birth  the  arms 
in  many  cases  do  not  reach  to  the  waist  line,  and  the  length  of  the  body 
may  be  less  than  the  circumference  of  the  head.    The  epiphyses  appear 


764 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


somewhat  enlarged,  the  abdomen  is  prominent,  the  skin  of  the  extremities 
is  in  deep  folds,  the  soft  parts  seeming  to  be  much  too  abundant  for  the 
shortened  bones  (Fig.  140).  In  infancy  these  children  are  often  quite 
fat.  The  facial  expression  is  characteristic.  There  is  usually  a  deep 
depression  and  flattening  at  the  base  of  the  nose,  with  a  very  marked 
prominence  of  the  forehead.  The  head  may  not  only  seem  large,  but  by 
measurement  may  be  one  or  even  two  inches  above  the  normal  average. 
An  erroneous  diagnosis  of  hydrocephalus  is  often  made  in  the  early 
stage.  Dentition  is  slightly  later  than  normal,  but  not  more  so  than  is 
seen  in  moderate  rickets.  Marked  relaxation  of  the  ligaments  and  rather 
feeble  muscular  power  often  delay  walking  until  the  third  or  fourth  year. 
If  the  head  is  large,  the  fontanel  may  not  close  till  the  fourth  or  fifth 
year.  The  appearance  of  the  fingers  is  quite  characteristic,  causing 
the  so-called  "  trident  hand."  The 
fingers  are  very  short  and  of  nearly 
equal  length,  and  an  angular  sepa- 
ration is  seen  at  the  second  joint 
(Fig.  141). 


Fig.  141. — Characteristic  Hand  of 
Chondro-dystrophy.     (Marie.) 


A  B 

Fig.  142. — A.  Normally  Developed  Boy, 
Age  Eight  Years.     B.  Typical  Cho\- 

DRO-DY8TROPHY,    AgE  EIGHTEEN  YeaRS. 

(Mariei) 


Although  not  normal  in  their  mental  development,  these  children  are 
far  from  being  feeble-minded.  They  are  often  several  years  behind  the 
normal  in  speech  and  in  most  intellectual  efforts.  The  average  patient 
is  able  to  read  and  do  many  ordinary  things,  but  throughout  life  always 
remains  somewhat  peculiar,  and  on  critical  examination  is  found  to  be 
subnormal  in  his  mental  growth.  These  dwarfs  are  good-natured,  often 
amusing,  easily  controlled,  and  frequently  live  to  a  great  age.  With 
advancing  years  the  figure  assumes  a  very  peculiar  and  cliaracteristic  ap- 
pearance.    The   prominent   hips,   with   the   marked    lordosis,   shortened 


SPORADIC  CRP:T1N1!SM.  765 

extremities,  and  late  bowing  of  the  legs,  present  a  striking  picture  (Fig. 
142).  The  maximum  height  attained  is  often  not  more  than  three  and 
a  half  or  four  feet.  Although  while  young  of  feeble  muscular  power, 
later  in  life  they  often  become  very  muscular.  When  adult  life  is  reached 
the  sexual  powers  are  normal;  if  the  women  become  pregnant,  Caesarian 
section  is  almost  always  required  on  account  of  deformity  of  the 
pelvis. 

In  infancy,  chondro-dystrophy  is  often  confounded  with  rickets,  hy- 
drocephalus, and  cretinism ;  but  its  features  are  so  characteristic  that  the 
mistake  can  hardly  be  made  if  the  child  is  carefully  examined.  No 
known  treatment  has  any  influence  upon  the  condition.  The  use  of  the 
thyroid  extract  is  entirely  without  effect. 

SPORADIC   CRETINISM. 

(Cretinoid  Idiocy;  Myxoedematous  Idiocy.) 

.  Since  the  early  description  of  this  disease  by  Fagge,  in  1871  and 
1874,  numerous-  cases  have  been  published  in  England,  on  the  continent 
of  Europe,  and  in  America,  showing  that  sporadic  cretinism  is  not  con- 
fined to  any  country.  While  the  condition  is  relatively  a  rare  one,  since 
it  has  been  generally  recognised  it  is  found  to  be  nmch  more  common 
than  was  formerly  supposed. 

Etiology.— It  is  now  well  established  that  this  condition  depends 
upon  the  absence  of  the  internal  secretion  of  the  thyroid  gland.  In  a 
series  of  sixteen  autopsies  collected  by  Fletcher  Beach,  the  thyroid  gland 
was  absent  in  fourteen  and  the  seat  of  bronchocele  in  two.  The  symp- 
toms closely  resemble  the  myxoedema  of  adults  which  follows  the  removal 
of  the  thyroid.  Regarding  the  causes  which  destroy  the  thyroid  gland 
or  abolish  its  functions  little  is  as  yet  known.  In  most  cases  it  is  prob- 
ably a  congenital  condition.  In  some  instances  it  has  followed  acute 
disease.  In  a  certain  number  of  cases  sporadic  cretinism  is  associated 
with  goitre.  As  a  rule,  only  one  case  occurs  in  a  family,  the  other  mem- 
bers of  which  present  nothing  abnormal  in  mental  or  physical  devel- 
opment. 

Symptoms.— The  symptoms  of  cretinism  in  most  cases  make  their 
appearance  during  the  first  year,  but  are  sometimes  so  slight  as  not  to 
be  noticed  until  children  are  two  or  three  years  old,  and  exceptionally 
not  until  the  seventh  or  eighth  year.  The  general  appearance  of  the 
cretin  is  striking,  and  so  characteristic  that  when  once  seen  the  disease 
can  hardly  fail  to  be  recognised  (Figs.  143,  144,  and  146).  The  body  is 
greatly  dwarfed,  and  children  of  fifteen  years  are  often  only  two  and  a 
half  or  three  feet  in  height.  All  the  extremities,  the  fingers  and  the  toes 
are  short  and  thick.  The  subcutaneous  tissue  seems  very  thick  and 
boggy,  but  does  not  pit  upon  pressure  like  ordinary  oedema.    The  facies 


766 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


is  extremel}'  characteristic :  The  liead  seems  large  for  the  body ;  the  fon- 
tanel is  open  until  the  eighth  or  tenth  year,  and  it  may  not  be  closed 
even  in  adults;  the  forehead  is  low  and  the  base  of  the  nose  is  broad,  so 
that  the  eyes  are  wide  apart ;  tlie  lips  are  thick,  the  mouth  half  open, 
and  th'e  tongue  usually  protrudes  slightly;  the  cheeks  are  baggy,  the 
hair  coarse,  straight,  and  generally  light-coloured.  The  teeth  appear  very 
late — in  one  of  my  cases  none  were  present  at  two  years — and  are  apt 
to  decay  early. 

Fatty  tumours  are  quite  constant  in  older  children,  although  they  are 
often  wanting  in  infantile  cases.  They  are  seen  in  the  supra-clavicular 
region,  just  behind  the  sterno-mastoid  muscle,  sometimes  in  the  axilla, 
or  between  the  scapulae,  and  sometimes  in  other  parts  of  the  body.  In 
distribution  they  are  apt  to  be  symmetrical,  and  are  usually  about  half 
the  size  of  a  hen's  egg.  The  neck  is  short  and  thick.  In  rare  cases  there 
may  be  a  slight  depression  corresponding  to  the  location  of  the  thyroid 

gland.  The  chest  is  not  deformed. 
The  abdomen  is  large,  j)endulous,  and 
resembles  that  of  rickets-.  An  umbilical 
hernia  is  almost  always  present.  The 
skin  is  dry,  perspiration  scanty,  and 
eczema  is  common.  Th^  voice  is  hoarse 
and  rough.  Patients  often  do  not  walk 
until  they  are  five  or  six  years  old,  and 
then  they  waddle  in  a  clumsy  way.  All 
the  movements  of  the  body  are  slow  and 
lethargic,  and  everything  indicates  men- 
tal and  physical  torpor.  The  rectal 
temperature  is  usually  subnormal.  I 
had  once  an  opportunity  to  observe  an 
attack  of  acute  broncho-pneumonia  in 
one  of  these  cretins  two  years  old.  The 
symptoms  and  physical  signs  were  typi- 
cal, but  during  the  greater  part  of  tlie 
disease  the  rectal  temperature  fluctu- 
ated between  95°  and  98.5°  F.  Only 
once  was  a  temperature  above  99°  F. 
recorded.  On  account  of  their  low  tem- 
])erature  and  torpid  condition  these  pa- 
tients are  very  sensitive  to  cold.  Tlie 
mental  condition  is  always  impaired, 
and  they  are  often  idiotic.  Speech  is 
acquired  late,  and  in  some  cases  not  at  all.  Cretins  are  dull,  placid,  and 
good-natured,  rarely  troul)lesome  or  excitable;  and  when  fifteen  or  eight- 
een years  old  they  a])pear  like  children  of  two  or  three  years.    There  is 


FiQ.  143. — A  Typical  Cretin;  Two 
AND  A  Half  Years  Old.  A  pa- 
tient in  the  Babies'  Hospital. 


SPORADIC  CRETINISM. 


767 


an  absence  of  development  of  the  sexual  <ji<(aiis,  and  almost  invariably 
they  suffer  from  chronic  constipation. 

Diagnosis.— The  diagnosis  is  usually  easy,  although  the  early  cases 
are  sometimes  miscalled  rickets.  The  low  temperature,  the  facial  ex- 
pression, the  torpor,  and  the  fatty 
tumours  are  enough  to  differentiate 
the  two  diseases. 


Fig.  144. — Dr.  J.  P.  West's  Case  of  Cre- 
tinism, Seventeen  Months  old,  Be- 
fore Treatment. 


Fig. 


145. — After    Six    Months'    Treat- 
ment WITH  Thyroid  Extract. 


Prognosis  and  Treatment. — There  is  little  tendency  to  spontaneous 
improvement.  Many  of  these  patients  die  in  childhood,  but  a  few  live 
to  adult  life.  Until  within  the  last  few  years  they  were  considered  hope- 
less. The  thyroid  extract  is  a  specific  remedy  for  this  disease.  In  many 
cases  the  improvement  is  truly  remarkable  (Figs.  144-147).  After  a 
few  months'  treatment  the  entire  appearance  of  the  child  is  changed. 
The  idiotic  expression  of  the  face  is  lost;  the  thickening  of  the  skin 
and  subcutaneous  tissues  disappears;  there  is  a  marked  increase  in 
height  and  in  the  circumference  of  the  head;  muscular  power  is  rapidly 
developed,  so  that  many  soon  become  able  to  walk ;  and  progress  is  seen 
in  dentition,  and  in  some  older  girls  in  the  establishment  of  menstrua- 
tion.    Intellectual  progress  is  much  slower  than  physical  changes;  how- 


768 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


ever,  nearly  all  the  children  become  brighter  and  more  intelligent  and 
learn  to  speak. 

The  ultimate  results  vary  with  the  grade  of  the  affection  and  the 
time  when  treatment  is  begun.    I  have  under  observation  several  cretins 
who  have  been  treated  from  eight 
to  twelve  years.    Although  many  of 


Fig.  146.  —  Dr.  J.  A\ .  Coyner's  Case, 
Twenty-three  Months  Old,  Before 
Treatment. 


Fig.  147. — -After  Iu.kven  Months'  Treat- 
ment with  Thyroid  Extract. 


these  children  seem  quite  intelligent  and  are  able  to  attend  school,  they 
are  without  exception  below  other  children  of  their  ages  in  mental  and 
physical  development.  Complete  recovery  I  have  not  soon ;  but  there 
seems  to  be  no  reason  why  it  might  not  occur  if  the  thyroid  were  begun 
in  early  infancy  and  faithfully  continued.  If  the  thyroid  is  omitted,  re- 
lapses occur  in  a  few  months,  even  in  cases  well  advanced  toward 
recovery. 

Most  of  the  thyroid  extracts  on  the  market  are  prepared  from  the 
glands  of  the  sheep.  There  is  little  doubt  that  the  fresh  glands  are  more 
active  than  the  extracts  prepared  from  them;  but  they  are  difficult  to 
obtain.  A  reliable  extract  should  be  given  if  results  are  to  be  expected. 
The  thyroid  extract  of  Burroughs  and  Wellcome  I  have  found  to  be  more 
satisfactory  than  many  of  those  on  the  market.     Of  this  half  a  grain 


INSANITY.  769 

may  be  given  once  or  twice  a  day  at  first :  after  the  child  liecomes  some- 
wliat  accustomed  to  it  the  daily  do>e  may  h.-  -riadually  iiicrcasod  to  five 
or  six  grains.  Some  disturhancos  an-  often  st-cn  at  tlie  beginning  of 
the  treatment — perspiration,  marked  irritability,  and  sometimes  a  rise 
in  temperature — but  these  soon  pass  off.  For  old  cases  at  least  five 
grains  daily  should  be  given  for  an  indefinite  period. 

INSANITY. 

Insanity  is  so  special  a  subject  that  all  that  will  be  attempted  here 
will  be  to  mention  the  most  frequent  varieties  seen  in  early  life,  with  the 
important  etiological  factors  which  operate  at  this  period.  For  a  full 
discussion  of  the  subject  the  reader  is  referred  to  works  upon  insanity. 

Insanity  is  distinguished  from  idiocy  in  that  it  affects  a  mind  previ- 
ously sound ;  however,  the  two  conditions  may  l)e  associated.  Undoubted 
cases  of  mental  disease  have  been  observed  before  the  seventh  year,  but 
they  are  extremely  rare.  From  this  time  up  to  puberty,  however,  nearly 
all  the  varieties  seen  in  adult  life  occasionally  occur,  but  they  are  very 
infrequent  even  at  this  period.  The  form  which  insanity  in  childhood 
most  frequently  assumes  is  mania. 

Etiology. — Insanity  is  sometimes  seen  as  a  sequel  of  one  of  the  infec- 
tious diseases,  more  often  typhoid  fever  than  any  other,  although  it  may 
follow  measles,  scarlet  fever,  diphtheria,  or  variola.  Another  cause  is 
masturbation,  although  its  effect  is  much  more  frequently  seen  after 
puberty  than  before.  Hereditary  syphilis  is  sometimes  the  cause  of  de- 
mentia, which  comes  on  about  the  fourth  or  fifth  year,  or  even  later. 
Alcoholism,  epilepsy,  insanity,  or  other  nervous  diseases  in  the  parents 
are  important  causes.  Prolonged  or  continuous  mental  strain,  the  result 
of  overwork  in  school,  is  a  cause  of  considerable  importance,  especially  in 
girls  about  the  time  of  puberty.  As  exciting  causes  may  also  be  men- 
tioned various  reflex  conditions,  such  as  intestinal  worms,  phimosis,  delay 
in  the  establishment  of  menstruation,  and  abnormal  conditions  of  the 
nose  and  throat;  these,  however,  can  not  have  much  influence  except 
where  the  predisposition  is  a  strong  one.  Insanity  may  be  associated 
with  or  may  follow  hysteria,  chorea,  or  epilepsy.  It  has  sometimes  fol- 
lowed injury  to  the  brain,  acute  meningitis,  and  occasionally  other  forms 
of  brain  disease. 

Symptoms.— Certain  forms  of  insanity  are  practically  never  seen  in 
children,  such  as  paranoia,  acute  dementia,  paretic  dementia,  periodic 
or  circular  insanity,  and  cataleptic  insanity. 

Mania  is  one  of  the  most  frequent  forms,  and  is  the  most  common 
variety  of  post-febrile  insanity.    Its  symptoms  may  be  quite  intense,  but 
are  usually  of  short  duration,  lasting  but  a  few  days  or  weeks.    In  rare 
cases  it  may  continue  for  montlis,  and  it  may  even  be  permanent. 
50 


770  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Melancholia  is  not  uncommon.  It  is  seen  as  a  result  of  prolonged 
mental  strain  in  school,  it  may  be  due  to  fear  of  punishment,  and  some- 
times may  follow  masturbation.  It  is  usually  associated  with  some  very 
marked  disturbance  of  the  general  health.  It  shows  itself,  as  in  the 
adult,  by  fits  of  depression,  self-mutilation,  and  even  by  suicidal  ten- 
dencies. 

Epileptic  insanity  may  follow  epilepsy  in  children  who  were  pre- 
viously mentally  sound,  in  whom  it  may  take  the  form  of  true  epileptic 
dementia,  or  there  may  be  attacks  of  mania  which  occur  in  the  place 
of  an  epileptic  seizure  or  follow  such  a  seizure.  Transitory  attacks  of 
fury  or  frenzy  coming  on  without  apparent  cause  should  always  suggest 
the  possibility  of  epilepsy. 

Other  forms  which  insanity  assumes  in  early  life  are :  transitory  psy- 
choses, such  as  delirium,  night-terrors,  attacks  of  sobbing  or  weeping, 
sometimes  from  fright;  moral  insanity,  as  shown  by  perversion  of  the 
moral  sense  and  by  various  vicious  tendencies;  morbid  impulses,  wiiich 
may  be  homicidal  or  sexual,  or  a  disposition  to  thieving,  lying,  pyro- 
mania,  etc. ;  morbid  fears,  of  which  there  may  be  an  almost  endless 
variety.  Tiiese  are  sometimes  associated  with  a  low  state  of  physical 
health;  this,  however,  is  usually  not  the  case. 

Prognosis. — On  the  whole,  insanity  in  childhood  has  a  better  prog- 
nosis than  in  the  adult.  In  most  of  the  cases  of  mania,  melancholia,  the 
various  transitory  psychoses,  or  the  choreic  and  hysterical  forms,  recovery 
occurs  with  proper  treatment.  The  outlook  for  the  other  varieties  is 
much  worse,  especially  in  those  in  which  there  is  a  strong  hereditary 
tendency  to  mental  disease. 

The  treatment  is  to  be  conducted  along  the  same  general  lines  as  in 
adults. 

THE  STIGMATA  OF  DEGENERATION. 

These  marks  are  of  much  importance  in  relation  to  the  different  forms 
of  nervous  disease  in  children,  especially  epilepsy,  idiocy,  and  insanity. 
They  are  of  great  value  in  determining  existing  nervous  disease,  or  as 
showing  latent  neuropathic  tendencies. 

The  physician  should  be  familiar  with  these  various  signs  in  order 
that  he  may  connect  them  with  each  other  and  refer  them  to  their 
proper  source,  and  at  the  same  time,  by  appreciating  their  significance, 
be  able  to  advise  parents  with  regard  to  the  care,  education,  mode  of 
life,  and  occupation  of  children,  in  whom  to  a  greater  or  less  degree  these 
signs  may  be  present.  These  stigmata  are  not  of  equal  importance  as 
marks  of  degeneration.  Some  of  them,  such  as  facial  asymmetry  and  most 
of  the  deformities  of  the  palate,  are  always  to  be  so  regarded ;  the  speech 
defects  are  often  so,  while  many  of  the  others  may  or  may  not  be,  ac- 
cording to  their  association.    The  stigmata  are  divided  into  anatomical. 


DEAF-MUriSM.  771 

physiological,  and  psychical.     The  followiiifr  is  the  elassifieation  given 
by  Peterson : 

Anatomical  Stigmata. — Cranial  anomalies:  Facial  asymmetry;  de- 
formities of  the  palate;  anomalies  of  the  teeth,  tongue,  lips,  or  nose. 

Anomalies  of  the  eye:  Flecks  on  the  iris;  strahisinus;  chromatic 
asjonmetry  of  the  iris;  narrow  palpebral  fissure;  albinism;  congenital 
cataract;  pigmentary  retinitis. 

Anomalies  of  the  ear. 

Anomalies  of  the  limbs :  Polydactyly ;  syndactyly ;  ectrodactyly ;  sym- 
elus;  phocomelus;  excessive  length  of  the  arms. 

Anomalies  of  the  trunk:  Hernije;  malformation  of  the  breasts  and 
thorax;  dwarfishness ;  giantism;  infantilism;  feminism;  inaseulinism ; 
spina  bifida. 

Anomalies  of  the  genital  organs. 

Anomalies  of  the  skin:  Polysarcia;  ]iy})ertrich()sis;  jihscnce  of  hair; 
premature  grayness. 

Physiological  Stigmata. — Anomalies  of  motor  function  :  Walking  late; 
tics;  tremors;  nystagmus;  epilepsy. 

Anomalies  of  sensory  function  :  Deaf-mutism ;  neuralgia ;  migraine ; 
hypersesthesia ;  anaesthesia;  blindness;  myopia;  hypermetropia;  astig- 
matism; Daltonism;  hemeralopia;  concentric  limitation  of  the  visual 
field. 

Anomalies  of  speech:  Mutism;  defective  speech;  stuttering;  stam- 
mering. 

Anomalies  of  genito-urinary  function:  Enuresis;  sexual  irritability; 
impotence;  sterility. 

Anomalies  of  the  instinct  or  appetite:  Merycism ;  uncontrollable  ap- 
petites for  food,  liquor,  drugs,  etc. 

Diminished  resistance  to  external  influences  and  diseases. 

Eetardation  of  puberty. 

Psychical  Stigmata.— Insanity ;  idiocy;  imbecility;  feeble-minded- 
ness;  eccentricity;   moral   delinquency;  sexual  perversion. 

DEAF-MUTISM. 

Excluding  the  cases  in  which  idiocy  is  present,  which  are  not  con- 
sidered in  this  chapter,  deaf-mutism  may  be  due  either  to  congenital  or 
acquired  conditions ;  the  larger  proportion  of  the  cases  belong  in  the  lat- 
ter class.  When  congenital,  deaf-mutism  may  result  from  ostitis,  or 
periostitis  of  the  temporal  bone,  encroaching  upon  the  cavity  of  the 
middle  ear,  from  ankylosis  of  the  ossicles,  from  absence  of  the  internal 
ear  or  any  of  its  parts.  There  may  also  be  colloid  degeneration  of  the 
labyrinth.  It  may  result  from  atrophy  of  the  auditory  nerve,  and  it 
may  be  due  to  a  lesion  of  the  brain.     These  congenital  conditions  are 


772  DISEASES  OF  THE   NERVOUS  SYSTEM. 

often  liereditary.  Acquired  deaf-mutism  is  most*  frequently  tlie  result 
of  scarlet  fever,  and  is  due  to  otitis.  The  second  important  cause  is 
cerebro-spinal  meningitis,  where  it  may  be  due  to  a  lesion  of  the  brain, 
the  auditory  nerve,  or  the  ear.  It  occasionally  follows  mumps,  diph- 
theria, measles,  and  other  infectious  diseases.  It  may  result  from  re- 
peated attacks  of  acute  otitis  associated  with  adenoid  growths  or  chronic 
rhino-pharyngitis. 

The  younger  the  child  at  the  time  the  deafness  occurs  the  sooner  the 
power  of  speech  is  lost.  In  most  of  the  infectious  diseases,  if  the  attack 
occurs  before  the  fifth  year  speech  is  lost.  According  to  Love,  total  deaf- 
ness is  rare  among  deaf-mutes;  hearing  for  speech  is  present  to  a  useful 
degree  in  about  twenty-five  per  cent  of  the  cases,  while  hearing  by  cranial 
conduction  exists  in  nearly  all  cases.  Deaf-mutism  should  be  suspected 
if  a  cliild  not  idiotic  shows  at  the  end  of  two  years  no  signs  of  beginning 
to  talk.  A  careful  distinction  should  l:e  made  between  deaf-mutism 
and  idiocy  resulting  either  from  congenital  conditions  or  acquired  dis- 
ease. 

It  is  necessary  that  this  condition  be  recognised  as  early  as  possible, 
in  order  that  the  child  may  have  the  advantages  of  proper  training 
during  his  early  years.  The  physician  should  insist  upon  the  child  being 
sent  as  early  as  the  third,  and  certainly  by  the  fourth  year  to  an  institu- 
tion where  it  may  be  taught  to  speak. 

The  treatment  is  mainly  prophylactic.  The  most  important  relates 
to  the  care  of  the  ears  in  scarlet  fever,  and  the  removal  of  adenoid  vegeta- 
tions of  the  pharynx  and  other  causes  which  produce  attacks  of  acute  or 
chronic  otitis.  For  the  condition  itself  education  is  the  only  thing  to 
be  considered. 


CHAPTER    IV. 
DISEASES  OF   THE  SPINAL   CORD. 

MALFORMATIONS. 

Malformations  of  the  cord  are  very  frequently  associated  with  those 
of  the  brain,  and  bear  a  certain  degree  of  resemblance  to  them.  (1) 
The  cord  may  be  absent  (amyelia)  ;  this  condition  may  exist  alone  or 
with  absence  of  the  brain.  (2)  The  lack  of  development  may  be  only 
partial  (atelomyelia),  as  where  some  of  the  tracts  are  wanting.  The 
most  important  one  is  defective  development  of  the  lateral  tracts,  which 
may  be  a  cause  of  spastic  paraplegia  (Charcot).  (3)  There  may  be  a 
malposition  of  some  of  the  gray  matter  (heterotopia).  (4)  There  may 
be  a  double  cord  (diplomyelia)  ;  the  division  is  generally  incomplete, 
and  is  attributed  to  an  abnormal  development  of  the  central  canal;  it  is 


.       MALFORMATIONS  OF  THE   SPINAL  CORD.  773 

usually  associated  with  other  deformities.     All  of  these  inal formations 
are  extremely  rare  and  of  very  little  practical  iiitei-est. 

There  remains  to  he  mentioned  the  only  one  which  is  rcallv  iiiij)or- 
tant — spina  hifida. 

Spina  Bifida. — This  is  a  malformation  of  the  vertebral  canal  with  a 
protrusion  of  some  part  of  its  contents  in  the  form  of  a  lliiid  tumour. 
The  tumour  is  elastic,  compressible,  usually  increased  by  ci-ying.  and 
sometimes  by  pressure  upon  the  anterior  fontanel.  The  contained  fluid 
is  clear  serum,  resembling  in  all  respects  the  cerebro-spinal  llnid.  It  is 
one  of  the  most  frequent  congenital  deformities. 

According  to  Humphrey,  spina  bifida  is  due  to  an  early  failure  in 
development — in  most  cases  before  the  cord  is  segmentated  from  tlie 
epiblastic  layer  from  which  it  is  developed.  Hence  it  remains  adherent 
to  the  epiblastic  covering,  and  the  structures  which  should  be  formed 
between  the  cord  and  the  skin  are  undevelo[)ed.  For  this  reason  there 
is  in  the  wall  of  the  sac  a  fusion  of  tlie  elements  of  the  cord,  nerves, 
meninges,  vertebral  arches,  muscles,  and  integument.  H  the  error 
in  development  occurs  later,  the  cord  and  nerves  may  be  attached 
to  the  sac,  but  not  intimately  fused  with  it;  in  still  other  cases  the 
cord  does  not  enter  the  sac  at  all.  The  malformation  may  occur  before 
the  central  canal  is  closed;  or,  if  closed,  it  may  reopen  from  the  accu- 
mulation of  fluid.  It  is  probable  that  the  accumulation  of  fluid  flrst 
occurs,  and  that  this  prevents  the  union  of  the  parts  of  the  vertebral 
arches. 

Although  the  tumour  is  generally  associated  with  a  bifid  spine,  this 
is  not  necessarily  the  case.  The  protrusion  may  take  place  through  the 
intervertebral  notch  or  foramen,  or  there  may  be  ^ 

a  fissure  of  the  bodies  of  the  vertebrae,  and  an  an- 
terior tumour  projecting  into  the  cavity  of  the 
thorax,  abdomen,  or  pelvis — spina  bifida  oc- 
culta. The  principal  anatomical  varieties  are 
meningocele,  meningo-myelocele,  and  syringo- 
myelocele. 

Meningocele. — In  this  form  there  is  a  protru- 
sion of  the  membranes  only  (Fig.  148).  The  ac-  fig.  148.  —  Meningocele 
cumulation  of  fluid  is  either  in  the  arachnoid  cav-  J%*^"^„^;;f~f  ^ 
ity  or  the  subarachnoid  space  posterior  to  tlie  ^j^'^  gpj,jj^i  p^rd;  C  the 
cord.     IMie  opening  of  communication  between      integument      The  ac- 

^  *=       .  „    .       ,,  •  cumulation  of  fluid  IS  be- 

the  tumour  and  the  spmal  canal  is  small  in  tins      ^.^^^  ^^^^  ^^^^.^  ^j^j^^j^  ^j^^g 
variety,  usually  being  about  one-twelfth  to  one-      not  enter  the  sac. 
sixth  of  an  inch  in  diameter.     There  may,  how- 
ever, be  no  communication.     The  skin  is  usually  fully  developed   (Fig. 
149).    The  tumour  is  frequently  globular,  sometimes  pedunculated,  and 
may  attain  a  very  large  size,  being  as  much  as  five  or  six  inches  m  diam- 


774 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


eter.     This  is  because  spontaneous  rupture  is  not  likely  to  occur,  and 
the  tumour  does  not  become  infected  except   by  ojjerative  interference. 

With  such   tumours  patients  may 


live  to  adult  life.  This  variety  is 
most  frequently  seen  in  the  cervi- 
cal region.  It  has  the  best  chance 
of  natural  recovery,  and  in  it  o|)- 
eration  gives  the  best  results. 


Fig.  149. 


-Meningocele,  in  a  Child  One 
Year  Old. 


Fig.  150. — Meningo-myelocele  (partially 
diagrammatic).  A,  the  membranes;  S, 
the  cord;  C,  the  integument.  The  accu- 
mulation of  fluid  is  in  front  of  the  cord, 
the  filaments  of  which  are  spread  out, 
forming  a  part  of  the  wall  of  the  sac. 


Meningo-myelocele. — This  is  by  far  the  most  frequent  variety  of 
spina  bifida,  occurring  in  thirty-five  of  the  fifty-seven  cases  reported  by 
Demme.  It  is  the  form  usually  seen  in  the  sacro-lumbar  region.  The 
accumulation  of  fluid  takes  place  in  the  anterior  subarachnoid  space, 
less  frequently  in  the  anterior  arachnoid  cavity  (Fig.  150).  In  this  form 
the  cord  is  contained  in  the  sac,  and  usually  forms  a  part  of  its  wall. 
The  tumour  is  smaller  than  the  meningocele,  the  usual  size  being  that 
of  a  mandarin  orange.  It  is  sessile,  never  pedunculated.  As  a  nile  it  is 
only  partly  covered  by  skin,  but  has  a  centVal  area,  elliptical  in  shape, 
where  there  is  only  a  thin,  translucent  membrane.  This  surface,  which  is 
known  as  the  central  cicatrix,  is  sometimes  covered  with  granulations, 
and  frequently  ulcerates.  The  tumour  often  has  a  vertical  furrow  or 
a  central  umbilication,  corresponding  to  the  attachment  of  the  cord 
on  its  inner  surface.  The  usual  relation  of  the  parts  is  for  the  cord  to 
run  horizontally  across  the  upper  part  of  the  tumour  to  the  central 
cicatrix,  with  which  it  becomes  blended,  and  from  which  again  the  nerves 
arise.  These  re-enter  the  canal  at  the  lower  part  of  the  tumour,  and  are 
distributed  below  as  usual.  In  other  cases  the  cord  joins  the  wall  of  the 
sac  soon  after  its  entrance,  and  its  attenuated  fibres  are  found  spread  out 
all  over  the  sac,  coming  together  again  below  and  entering  the  spinal 
canal. 


MALFORMATIONS  OF  THE  SPINAL  CORD. 


775 


The  following  case,  upon  which  T  made  an  autopsy,  is  a  good  ex- 
ample of  the  common  variety:  The  child  died  on  the  third  day  after  hirth 
from  rupture  of  the  sac.  The  tumour  occupied  tiu;  sacral  region.  The 
first  sacral  vertebra  was  normal,  and  l)eneath  this  the  cord  passed  out  of 
the  spinal  canal,  terminating  in  the  cauda  ecpiina  soon  after  entering  the 
sac,  and  continued  back  to  the  central  cicatrix.  Here  nerve  filaments 
blended  with  the  other  tissues  in  an  indefinite  structure,  from  which 
again,  with  tolerable  distinctness,  the  nerve  structures  could  he  seen  to 
pass  over  the  wall  of  the  sac  and  return  to  the  canal.  The  afferent  and 
efferent  nerves  and  the  part  of  the  membranes  tiiey  carried  with  them 
formed  several  septa,  making  a  smaller  separate  sac  within  the  larger 
one.  The  large  sac  was  clearly  a  dilatation  of  the  anterior  subarach- 
noid space,  and  communicated  freely  with  the  same  space  in  the  cord 
above. 

Syringo-myelocele. — In  this  variety  the  accumulation  of  fluid  is  in 
the  central  canal  of  the  cord,  the  lining  of  the  sac  being  here  the  at- 
tenuated and  atrophied  cord  elements.  This  is  the  rarest  form  of 
tumour,  but  the  one  most  frequently  associated  with  hydrocephalus,  and 
consequently  having  the  worst  prog- 
nosis. It  may  be  found  in  the  dorsal 
or  dorso-lumbar  region  as  well  as  in 
the  lumbo-sacral  (Fig.  151). 

With  spina  bifida  other  deformi- 
ties are  frequently  associated,  the 
most  common  being  club-foot,  hy- 
drocephalus, more  rarely  encephalo- 
eele  or  cerebral  meningocele,  and 
hare-lip.  If  hydrocephalus  exists, 
there  is  in  most  cases  a  dilatation  of 
the  central  canal  of  the  cord  and 
a  direct  communication  between  the 
tumour  and  the  lateral  ventricles  of 
the  brain.  Pressure  upon  the  ante- 
rior fontanel  causes  an  increase  in 
the  size  of  the  tumour,  and  con- 
versely. Club-foot  is  usually  dou- 
ble, most  frequently  talipes  equino- 
varus.     In  a  number  of  cases  there 

is  a  history  of  some  deformity  in  other  members  of  the  family.    I  once 
saw  two  successive  children  in  the  same  family  with  spina  bifida. 

Symptoms.— The  tumour  in  spina  bifida  is  present  at  birth,  and  is 
most  frequently  lumbo-sacral.  Paralysis  is  frequent  in  myelocele  and 
syringo-myelocele,  but  is  not  seen  in  meningocele;  its  degree  and  its 
location  depend  upon  the  situation  of  the  tumour  and  the  extent  to 


Fig.  151. —  .Syringo-myelocele  of  the 
Mid-dorsal  Region,  in  a  Child 
Four  Months  Old,  who  also  had 
Hydrocephalus. 


776 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


which  the  cord  is  involved.  It  is  rare  in  cervical  tumours,  and  most 
marked  in  those  situated  in  the  lumbo-sacral  region.  In  the  worst 
cases  there  is  complete  paraplegia,  with  paralysis  of  the  bladder  and 
rectum.  If  the  tumour  is  sacro-lumbar  or  sacral,  only  the  cauda  equina 
is  likely  to  be  involved,  and  this  but  partially,  so  that  the  paralysis 
of  the  extremities  is  incomplete,  and  the  bladder  and  rectum  may 
escape. 

In  Fig.  158  is  shown  a  very  remarkable  case  of  sacral  spina  bifida 
in  a  boy  of  five  years,  who  came  under  observation  for  incontinence  of 

faeces.  The  tumour  was  a  little 
more  to  the  left  than  to  the  right 
side,  and  had  been  overlooked.  It 
had  evidently  pressed  upon  the 
lower  branches  of  the  sacral  plexus, 
so  as  to  affect  the  sphincter  and 
the  gluteal  muscles  of  the  left  side. 
The  atrophy  was  very  marked,  as 
shown  in  the  illustration. 

The  natural  course  of  spina  bi- 
fida is  to  increase  steadily  in  size; 
and  if  the  tumour  is  covered  by 
skin,  its  growth  may  be  almost  un- 
limited. It  has  been  known  to  at- 
tain a  circumference  of  twenty-two 
inches.  If  the  integument  is  want- 
ing, and  the  sac  wall  is  very  thin, 
rupture  is  pretty  certain  to  take 
place,  either  spontaneously  or  by 
some  accident,  in  the  course  of  the 
first  few  months;  death  then  re- 
sults from  convulsions  owing  to 
the  rapid  draining  away  of  the  cerebro-spinal  fluid,  or  from  second- 
ary infection.  In  a  large  number  of  cases  death  is  due  to  marasmus 
dependent  upon  the  associated  conditions.  Infection  of  the  tumour 
may  take  place  without  rupture,  the  germs  passing  through  tlie  wall  of 
the  sac.  If  the  opening  communicating  with  the  spinal  canal  is  small, 
this  infection  may  excite  an  inflammation  limited  to  the  wall  of  the 
sac,  and  result  in  a  cure  of  the  spina  bifida,  usually  with  sloughing.  I 
have  now  under  observation  a  girl  ten  years  old  in  whom  this  occurred 
in  infancy.  The  site  of  the  former  tumour  is  marked  by  a  large  dense 
cicatrix,  and  there  still  remains  partial  paralysis  of  the  legs.  If  the  open- 
ing into  the  spinal  canal  is  large,  inflammation  of  the  sac  is  usually 
followed  by  spinal  meningitis,  which  may  extend  upward  and  involve 
also  the  meninges  of  the  brain. 


Fia.  152. — Sacbal  Spina  Bifida. 


MALFORMATIONS  OF  THE  SPINAL  CORD.  777 

Prognosis.— This  depends  chiefly  upon  the  anatomical  variety  and 
the  existence  of  complications.  Simple  meningocele,  when  covered  by 
integument,  gives  the  best  prognosis,  and  complete  recovery  may  occur. 
In  meningo-myelocele,  especially  if  complete  paralysis  exists,  the  prog- 
nosis is  bad;  and  if  there  is  hydrocephalus,  the  case  is  ho])eless.  In 
quite  a  number  of  eases  in  which  cure  of  the  spina  bifida  has  followed 
operation,  hydrocephalus  has -subsequently  developed.  Of  fifty-seven 
cases  reported  by  Demme,  twenty-five  were  operated  upon,  witli  seven 
recoveries  and  fifteen  deaths,  while  three  were  unimproved :  of  the  tliirty- 
two  cases  not  operated  upon,  twenty-eight  died  within  tlie  first  month, 
and  not  one  lived  over  two  years — the  causes  of  deatli  being  nuirasnuis, 
rupture  of  the  sac,  and  meningitis. 

Diagnosis. — It  is  usually  easy  to  recognise  spina  bifida,  but  it  is  often 
difficult  to  distinguish  between  the  different  varieties.  Tlie  al)sence  of 
a  palpable  fissure  in  the  spine,  perfect  translucency,  and  a  ])edunculated 
tumour,  all  point  strongly  to  meningocele.  Paralysis  of  the  sphincters 
and  lower  extremities,  umbilication  of  the  centre  of  the  tumour,  a  sessile 
tumour,  a  palpable  bony  fissure,  and  a  large  central  cicatrix,  point  to 
meningo-myelocele.  The  coexistence  of  hydrocephahis  points  to  syringo- 
myelocele. 

Treatment. — In  all  cases  the  tumour  should  be  protected  from  pres- 
sure, and  care  taken  where  it  is  not  covered  by  integument,  that  the  sur- 
face is  kept  absolutely  clean  and  aseptic.  It  should  l)e  covered  with 
some  antiseptic  powder  and  surrounded  by  a  large  pad  of  absorbent  cot- 
ton, or  a  rubber  ring-cushion.  Complete  paraplegia  with  involvement  of 
the  bladder  and  rectum,  hydrocephalus,  or  extreme  marasmus — all  con- 
traindicate  operative  interference.  If  these  are  absent,  operation  should 
be  considered.  The  time  of  operation  will  depend  somewhat  upon  the 
nature  of  the  tumour.  If  it  is  covered  by  integument  and  growing 
slowly,  it  is  well  to  wait  until  the  child  is  at  least  six  months  old.  In 
other  cases  delay  is  dangerous,  because  of  the  liability  to  spontaneous  or 
accidental  rupture. 

The  treatment  by  injection  has  now  been  entirely  superseded  by  the 
operation  of  excision  of  the  sac.  For  a  description  of  this  and  the 
various  plastic  operations  that  have  been  proposed  in  connection  with 
it  the  reader  is  referred  to  works  upon  operative  surgery.  In  operating, 
it  should  not  be  forgotten  that  in  the  great  proportion  of  the  cases  (nine- 
ty-five per  cent,  according  to  the  London  Clinical  Society's  Report, 
which,  however,  refers  only  to  fatal  cases)  some  part  of  the  cord  is  in 
the  sac.  The  cord  is  often  present  in  tumours  situated  below  the  third 
lumbar  vertebra,  owing  to  its  attachment  to  the  sac. 

Although  recovery  may  follow  operation,  in  a  very  large  nund^er  of 
cases  it  is  incomplete;  some  degree  of  paralysis,  with  atrophy,  contrac- 
tures, and  deformities,  remaining  because  of  the  implication  of  cord  ele- 


778  DISEASES  OF  THE   NERVOUS  SYSTEM. 

ments  in  the  sac.  In  a  considerable  proportion  of  cases,  hydrocephalus 
subsequently  develops,  as  after  similar  operations  upon  cerebral  menin- 
gocele. 

SPINAL   MENINGITIS. 

In  acute  meningitis  usually  only  the  pia  mater  is  involved.  This 
rarely  occurs  alone,  unless  it  is  due  to  traftmatisra.  It  is  most  frequently 
associated  with  inflammation  of  the  pia  of  the  brain,  and  may  occur 
either  with  the  meningococcus  or  the  tuberculous  variety.  A  certain 
amount  of  acute  inflammation  of  the  pia  mater  accompanies  most  of  the 
cases  of  acute  myelitis. 

Chronic  spinal  meningitis  in  children  usually  involves  the  dura  only. 
Inflammation  of  the  external  layer  (external  pachymeningitis)  is  usually 
secondary  to  caries  of  the  vertebraB.  This  is  considered  in  the  article  on 
Compression- Myelitis. 

Symptoms. — The  symptoms  of  inflammation  of  the  spinal  membranes, 
no  matter  with  what  pathological  condition  it  may  be  associated,  are  due 
to  irritation  of,  or  pressure  upon,  the  cord  or  nerve  roots.  Those  which 
are  most  common  are:  pain  in  the  back,  which  is  increased  by  move- 
ment, and  usually  by  pressure  upon  the  spinous  processes;  radiating 
pains  following  the  course  of  the  spinal  nerves,  felt  in  the  extremities  or 
in  the  trunk ;  rigidity  of  the  spinal  column  due  to  spasm  of  the  spinal 
muscles,  or  rigidity  of  the  muscles  of  the  extremities ;  and  hypersesthesia 
along  the  spine,  which  may  be  quite  acute.  When  pressure  upon  the 
cord  is  added,  there  is  paralj^sis  or  paresis,  sometimes  muscular  atrophy 
and  anaesthesia.  Any  of  the  above  symptoms  may  be  acute  or  chronic, 
according  to  the  nature  of  the  primary  disease. 

The  diagnosis  between  spinal  meningitis  and  myelitis  is  often  not 
easy,  for  except  in  acute  cases  the  two  processes  are  usually  associated; 
and  in  a  given  case  it  may  be  difficult  to  decide  whether  the  lesion  of  the 
cord  or  of  the  membranes  is  the  more  important  one.  In  meningitis, 
pain,  tenderness,  spasm,  and  irritative  symptoms  are  generally  more 
prominent,  while  loss  of  power  and  anaesthesia  are  usually  partial.  In 
myelitis  the  pain,  tenderness,  and  other  irritative  symptoms  are  less 
marked,  while  paralysis  and  anaesthesia  may  be  complete. 

Treatment. — This  relates  first  to  the  disease  witii  which  it  is  asso- 
ciated ;  in  addition,  counter-irritation  by  means  of  the  Paquelin  cautery, 
rest  in  bed,  and  in  severe  cases  even  immobilisation  of  the  spine  by  a 
mechanical  support.    Iodide  of  potassium  is  often  useful. 

MYELITIS. 

Myelitis  is  a  rare  disease  in  children,  with  the  exception  of  two  vari- 
eties which  are  discussed  under  separate  heads,  viz.,  compression-myelitis 


MYELITIS.  779 

and  acute  poliomyelitis.  Otherwise  myelitis  usually  results  horn  injury, 
but  it  may  occur  as  a  complication  of  any  of  ihv  acute  infectious  dis- 
eases, especially  typhoid  or  scarlet  fever,  and  diphtheria,  and  even  as 
a  primary  disease,  when  it  is  attributed  to  exposure  or  cold,  but  when 
it  is  probably  infectious.  Clironic  myelitis  may  be  due  to  hereditary 
syphilis. 

Myelitis  usually  occurs  in  children  over  ten  years  of  age.  In  situa- 
tion, it  may  be  transverse,  diffuse,  or  disseminated ;  the  process  may  be 
acute,  subacute,  or  chronic.  The  lesions  and  the  symptoms  are  essen- 
tially the  same  as  when  the  disease  occurs  in  the  adult. 

Symptoms. — Myelitis  usually  comes  on  rather  gradually,  with  only 
local  symptoms;  but  the  onset  may  be  quite  acute,  with  severe  general 
symptoms — fever,  pain,  prostration,  and  localised  or  general  convul- 
sions. The  local  symptoms  vary  with  the  seat  and  the  extent  of  the 
disease. 

In  transverse  myelitis  loss  of  power  and  anaesthesia  are  present  below 
the  level  of  the  lesion ;  either  of  these  may  be  partial  or  complete.  At  the 
level  of  the  lesion  there  is  a  zone  of  hypersesthesia  and  "  girdle-pains." 
All  the  reflexes  below  the  seat  of  the  lesion  are  exaggerated.  Those 
at  the  level  of  the  lesion  are  lost.  There  may  be  loss  of  control 
of  the  sphincters,  bed-sores,  degenerative  changes  in  the  paralysed 
muscles,  contractures,  and  vaso-motor  disturbances.  The  paralysed  mus- 
cles may  be  rigid  or  flaccid,  according  to  the  seat  and  extent  of  the 
lesion. 

When  transverse  myelitis  is  situated  in  the  cervical  region  there  are 
paralysis  and  anaesthesia  of  the  arms,  legs,  and  trunk.  All  the  reflexes 
are  exaggerated,  and  there  is  general  rigidity  of  the  paralysed  muscles. 
There  are  incontinence  of  faeces  and  retention  of  urine,  followed  by  in- 
continence from  overflow.  The  pupils  are  frequently  contracted,  and 
there  may  be  optic  neuritis.  Atrophy,  when  present,  usually  affects  the 
muscles  of  the  arms,  and  indicates  that  the  cord  to  a  considerable  extent 
is  involved.  There  is  great  danger  to  life,  owing  to  paralysis  of  the 
muscles  of  respiration. 

When  the  seat  of  disease  is  the  dorsal  region,  the  symptoms  are  simi- 
lar to  those  above  described,  with  the  exception  that  the  arms  escape, 
and  that  the  eye-symptoms  are  usually  wanting.  This  is  the  most  fa- 
vourable seat  of  the  disease. 

When  the  disease  is  situated  in  the  lumbar  region,  in  addition  to 
paraplegia  and  anaesthesia  of  the  legs,  there  is,  from  the  beginning,  in- 
continence of  urine  and  faeces.  The  knee  reflexes  are  lost;  the  muscles 
atrophy,  and  usually  give  the  reaction  of  degeneration.  Bed-sores  are 
frequent. 

In  diffuse  myelitis  the  symptoms  are  a  combination  of  the  above 
groups.     If  a  large  part  of  the  cord  is  involved,  there  are  general  paral- 


780  DISEASES  OP  THE  NERVOUS  SYSTEM. 

ysis  and  anaesthesia,  loss  of  reflexes,  marked  trophic  disturbances,  bed- 
sores, etc. 

The  course  of  myelitis  is  slow,  and  it  usually  progresses  steadily  from 
bad  to  worse.  Death  is  due  to  exhaustion  or  complications — cystitis,  bed- 
sores, or  hypostatic  pneumonia — or  to  some  intercurrent  disease.  In  a 
small  proportion  of  the  cases  there  may  be  partial  recovery,  but  very 
rarely  is  this  complete.  The  diagnosis  is  to  be  made  from  spinal  menin- 
gitis, tumours,  and  haemorrhage. 

Treatment. — The  treatment  of  the  early  stage  consists  in  the  use  of 
ice  to  the  spine,  or  counter-irritation  by  means  of  dry  cups,  mustard,  or 
the  Paquelin  cautery.  Later,  the  iodide  of  potassium  should  be  given  in 
all  cases ;  improvement  may  follow  its  use,  even  when  there  is  no  suspi- 
cion of  syphilis,  but  large  doses  are  required,  and  for  a  long  period. 
Electricity  is  contraindicated  except  in  chronic  cases,  and  then  but  little 
improvement  is  likely  to  result  from  its  use.  In  these  patients  the  most 
important  thing  is  careful  attention  to  cleanliness  and  to  posture,  in 
order  to  prevent  bed-sores,  cystitis,  and  pneumonia. 

COMPRESSION-MYELITIS 

(Pressure-paralysis  of  the  Spinal  Cord;  Pottos  Paraplegia.) 

Compression-myelitis  is  sometimes  traumatic,  but  usually  follows 
caries  of  the  spine.  It  most  frequently  complicates  this  disease  when  the 
cervical  or  upper  dorsal  vertebrae  are  involved,  rarely  when  the  lower  half 
of  the  spinal  column  is  affected.  This  difference  is  probably  due  to  the 
smaller  size  of  the  spinal  canal  in  its  upper  portion.  According  to  Gib- 
ney,  paraplegia  is  seen  in  fifty  per  cent  of  the  cases  of  caries  of  the  upper 
half  of  the  spine.  Essentially  the  same  condition,  so  far  as  the  cord  is 
concerned,  may  result  from  tumours  of  the  spinal  cord,  or  from  anything 
else  causing  pachymeningitis.  These,  however,  are  exceedingly  rare  in 
childhood. 

Lesions. — In  spinal  caries  there  occurs  as  a  result  of  tuberculous  dis- 
ease a  softening  of  the  bodies  of  the  vertebrae,  which  fall  together  from 
the  pressure  due  to  the  superincumbent  weight  of  the  body.  This  causes 
a  backward  projection  known  as  the  kyphosis,  or  angular  deformity.  The 
spinal  canal  is  encroached  upon  by  the  remains  of  the  vertebral  bodies 
whose  ligamentous  attachments  have  been  loosened,  and  also  by  inflam- 
matory products  the  result  of  periostitis,  and  localised  inflammation  of 
the  dura  mater,  chiefl}'  of  the  external  layer,  but  which  sometimes  affects 
the  internal  layer  also.  All  these  conditions  lead  to  the  production  of  a 
mass  of  inflammatory  material,  often  containing  tuberculous  deposits, 
which  is  chiefly  in  front  of  the  cord,  but  may  surround  it.  The  compres- 
sion takes  place  slowly  in  most  of  the  cases,  from  the  gradual  progress  of 
the  lesions  mentioned.     In  a  small  number  of  cases  there  may  be  a 


COMPRESSION-MYELITIS.  781 

sudden  pressure  from  the  slipping  backward  ol'  one  oi'  the  vertebi'al 
bodies. 

In  recent  eases  the  cord  at  the  seat  of  compression  is  a  little  smaller 
than  normal.  It  is  usually  involved  to  the  extent  of  from  half  an  inch 
to  two  inches.  Paraplegia  may  have  existed  when  the  changes  found  in 
the  cord  are  very  slight,  and  sometimes  when  no  changes  are  visible  to 
the  naked  eye.  In  more  protracted  and  more  severe  cases,  the  cord  is 
much  smaller  at  the  point  of  disease,  and  under  the  microscope  shows 
the  changes  of  interstitial  myelitis  (Gowers)  with  meningitis.  In  old 
cases  there  are  degeneration  of  the  nerve  elements,  atrophy,  and  sometimes 
disappearance  of  the  ganglion  cells,  with  more  or  less  destruction  of  the 
nerve  fibres ;  sometimes  all  distinction  between  the  gray  and  white  sub- 
stance is  lost.  In  addition  to  these  marked  changes  at  the  point  of  pres- 
sure, there  may  be  ascending  or  descending  degeneration,  as  from  other 
focal  lesions.  There  is  usually  inflammation  of  tlie  nerve  roots,  which 
have  also  suffered  compression.  It  is  in  many  cases  sur])rising  to 
see  to  what  degree  the  cord  may  be  compressed  and  still  preserve  its 
functions. 

Symptoms. — In  caries  of  the  cervical  region  the  symptoms  of  com- 
pression-myelitis not  infrequently  precede  the  deformity,  and,  in  fact,  the 
other  objective  symptoms  of  bone  disease.  The  earliest  symptoms  of 
caries  usually  arise  from  irritation  of  the  nerve  roots,  and  consist  of 
acute  pains  not  often  referred  to  the  spine,  but  radiating  to  the  different 
regions  to  which  these  nerves  are  distributed.  They  are  felt  in  the  neck, 
in  the  chest,  in  the  epigastrium,  and  sometimes  in  the  loins.  Accom- 
panying these  pains,  there  is  noticed  a  gradual  weakness  in  the  lower 
extremities,  and  sometimes  also  in  the  arms,  according  to  the  location 
of  the  disease.  This  may  steadily  increase  for  several  weeks  until  there 
is  complete  paralysis.  Other  symptoms  are  then  commonly  present. 
There  is  usually  some  degree  of  anaesthesia,  and  there  may  be  numbness, 
tingling,  formication,  and  pain.  The  sphincters  are  not  often  involved. 
When  the  disease  is  in  the  upper  half  of  the  cord,  there  are  rigidity  of  the 
extremities  and  great  exaggeration  of  all  the  reflexes,  with  marked  ankle- 
clonus.  In  the  rare  cases  in  which  the  lumbar  enlargement  is  involved, 
there  may  be  loss  of  reflexes,  paralysis  of  the  sphincters,  and  bed-sores. 

The  distribution  of  the  paralysis  will  depend  upon  the  point  of  com- 
pression. If  this  is  in  the  cervical  region,  all  four  extremities  will  be 
paralysed ;  if  in  the  dorsal  region,  only  the  legs.  According  to  the  extent 
of  the  secondary  lesions  in  the  cord,  there  may  occur  muscular  atrophy 
and  contractures.  With  disease  in  the  upper  cervical  region,  death  may 
result  from  sudden  pressure  upon  the  cord,  owing  to  a  dislocation  of  the 
odontoid  process;  or  there  may  be  vomiting,  pupillary  symptoms,  irri- 
tation of  the  phrenic  nerve  causing  hiccough,  or  pressure  causing  paral- 
ysis of  the  diaphragm. 


782  DISEASES  OF  THE   NERVOUS  SYSTEM. 

Course  and  Prognosis. — These  depend  much  upon  the  treatment  of 
the  case.  In  many  cases  of  paralysis  occurring  early  in  caries,  complete 
recovery  takes  place  in  the  course  of  a  few  weeks,  sometimes  in  a  few 
days,  after  the  application  of  a  proper  mechanical  support.  In  the  cases 
which  have  been  long  neglected,  or  those  in  which  the  paralysis  develops 
while  proper  mechanical  treatment  is  being  carried  out,  the  chances  are 
not  so  good.  Gibney  gives  the  following  statistics  of  133  cases  under  his 
personal  observation :  31  proved  fatal ;  9  dying  from  myelitis,  14  from 
other  diseases  8ubse(}uent  to  recovery  from  the  paralysis,  and  6  from  tu- 
berculosis before  complete  recovery;  7-1  recovered  from  the  paraplegia; 
27  were  recorded  as  improved  or  still  under  treatment.  Eelapses  oc- 
curred in  about  fifteen  per  cent  of  the  cases.  The  usual  duration  of  the 
disease  is  from  three  months  to  two  years.  Recovery  has  often  taken 
place  in  cases  that  have  persisted  for  four  or  five  years. 

Diagnosis. — This  is  rarely  difficult.  Spinal  caries  should  be  suspected 
in  every  case  when  the  symptoms  point  to  transverse  myelitis  coming 
on  without  definite  cause. 

Treatment. — The  indications  are  the  removal  of  pressure  and  the 
fixation  of  the  spine  by  a  proper  mechanical  support.  Other  measures 
to  be  advised  are  the  Paquelin  cautery  and  the  internal  use  of  potassium 
iodide.  From  his  very  extensive  experience,  Gibney  has  more  confidence 
in  this  drug  than  in  all  else  except  mechanical  treatment.  Large  doses 
are  required,  often  from  sixty  to  ninety  grains  being  given  daily  for 
months.  The  iodide  should  always  be  largely  diluted.  Patients  should 
be  kept  scrupulously  clean,  and  the  position  changed  frequently  to  pre- 
vent the  formation  of  bed-sores.  Electricity  is  contraindicated.  When 
the  paralysis  develops  rapidly  or  occurs  suddenly,  relief  may  sometimes 
be  obtained  by  the  operation  of  laminectomy;  but  little  is  to  be  expected 
from  this  in  the  slow  cases. 

ACUTE   POLIOMYELITIS. 

(Epidemic  Poliomyelitis;  Acute  Infantile  Paralysis.) 

There  are  few  diseases  regarding  which  our  knowledge  has  increased 
so  rapidly  during  recent  years  as  acute  poliomyelitis.  The  first  great 
step  in  advance  was  made  by  Landsteiner  and  Popper,  who,  in  the  sum- 
mer of  1909,  succeeded  in  producing  the  disease  in  a  monkey  by  intra- 
peritoneal inoculation  with  the  spinal  cord  of  a  patient  dying  of  acute 
poliomyelitis.  They  were  not  successful  in  carrying  the  transmission 
further.  But  shortly  after  this  Flexner  and  Lewis,  using  the  intra- 
cranial method  of  inoculation,  had  no  difficulty  in  reproducing  the  dis- 
ease and  transmitting  it  through  an  indefinite  series  of  monkeys.  No 
other  animals  seem  to  be  susceptible.  These  observations,  now  many 
times  repeated,  have  not  only  definitely  established  the  infectious  char- 


ACUTE  POLIOMYELITIS.  783 

acter  of  poliomyelitis,  but  have  cleared  up  many  doulitful  points  in  its 
pathology. 

Acute  poliomyelitis  is  now  regarded  as  a  communicable,  infectious 
disease  which  prevails  both  epidemically  and  sporadically.  Although 
possibly  its  most  characteristic  lesions  are  in  the  anterior  horns  of  the 
cord,  any  part  of  the  central  nervous  system  may  be  affected.  The 
changes  in  the  cord  substance  are  preceded  hy  lesions  of  the  meninges. 
Although  the  name  poliomyelitis  is  still  retained,  the  scoj)e  of  tlie  term 
has  been  greatly  widened. 

This  disease  is  characterised  by  an  acute  onset,  with  fever  and  usu- 
ally other  marked  constitutional  and  nervous  symptoms,  from  which 
there  may  be  rapid  recovery;  but  generally  there  follows  early  and  ex- 
tensive loss  of  power.  After  this  there  is  usually  seen  a  gradual  im- 
provement, and  sometimes  complete  recovery.  ^More  often,  however, 
there  is  left  some  permanent  paral^'sis  in  certain  grou])s  of  muscles, 
which  undergo  rapid  and  marked  atropliy.  Formerly,  poliomyelitis  was 
seen  chiefly  as  a  Bporadic  disease;  but  since  the  year  19(1.5  epidemics  have 
occurred  with  increasing  frequency  in  various  parts  of  the  world,  and 
especially  in  the  United  States  since  19U7.  As  it  is  most  frequently 
seen  in  very  young  children,  and  as  it  is  altogether  the  most  common 
form  of  paralysis  at  this  period,  the  old  term  of  "  acute  infantile  paral- 
ysis "  is  perhaps  the  most  appropriate  clinical  designation. 

Etiology. — Fully  eighty  per  cent  of  the  cases  are  seen  in  the  first 
three  years  of  life,  the  greatest  incidence  being  in  the  second  year.  Per- 
sons of  any  age  may  be  attacked,  and  in  some  epidemics  the  proportion 
of  adult  cases  is  quite  large.  Epidemics  thus  far  observed  have  invariably 
occurred  in  the  warm  months ;  those  in  the  United  States,  from  July  to 
October.  Fully  four-fifths  of  the  sporadic  cases  also  are  seen  during 
these  same  months. 

Bartlett  and  myself >  could  find  recorded,  previous  to  1905,  but  34 
epidemics  or  outbreaks  of  this  disease.  Most  of  these  were  small  in  ex- 
tent, and  the  total  number  of  cases  reported  in  all  was  only  889. 

The  prevalence  of  poliomj^elitis  in  an  epidemic  form  really  begins 
with  the  outbreaks  in  Sweden  and  Norway  in  1905  and  1906.  These 
were  follow^-l  in  1907  by  the  epidemic  occurring  in  Xew  York  City  and 
vicinity  which  was  the  most  extensive  yet  known;  there  were  observed 
from  July  to  October  between  2,000  and  3,000  cases.  Since  that  time 
poliomyelitis  has  been  gradually  spreading  to  nearly  all  parts  of  the 
United  States  and  in  its  progress  has  distinctly  followed  lines  of  travel. 
It  has  been  especially  prevalent  in  Massachusetts  and  Ehode  Island; 
in  Minnesota,  Wisconsin  and  Iowa,  and  in  Pennsylvania.     In  the  year 

1  See  American  Journal  of  the  Medical  Sciences,  May,  1908.  Also  Archives  of 
Paediatrics,  September,  1910. 


784 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


1910  nearly  9,000  cases  were  reported  in  tlie  United  States,  While  the 
greatest  number  of  outbreaks  of  this  disease  have  been  seen  in  this 
country,  some  of  considerable  size  have  occurred  in  Australia  and  in 
Germany.  The  same  locality  has  rarely  been  the  seat  of  an  epidemic  in 
two  successive  seasons. 

The  instances  recorded,  now  numerous,  of  the  occurrence  of  several 
successive  cases  in  a  family,  strongly  suggest  that  the  disease  is  directly 


r/2    V5    Vl0yi9lB 


V3    V6    Vl0Vu\G 
V4    ^/22|I> 

V4    VlO  Vie  Vl7  V23lE 

|V8    V20  V2I  ^/27  V28|F 

/IV22  ^/24  V4IH 

^-rinonsiG  —I    V29    II 


^/i2  Vie  V20  V22  |K 

7/15   V23  V24IL 


V20]M 


IV20  V24  ^/27]B  \\\^'"|yio  yi9"V20]N 

V/I8  V23IQ 

Fig.  153. — Trostena  Epidemic  of  Poliomyelitis.  (After  Wickman.)  The  epidemic 
was  observed  in  a  rural  community  of  500  persons  in  which  49  cases  occurred  in  six 
weeks.  The  letters,  A,  B,  C,  etc.,  represent  the  different  families  in  which  cases 
occurred.  The  figures  give  month  and  day  of  onset  of  each  case.  Heavy  figures 
indicate  cases  with  paralysis;  lighter  figures,  abortive  cases.  The  relation  of  the 
families  to  the  school  is  indicated  by  lines;  in  those  connected  by  solid  lines  the  chil- 
dren who  attended  school  were  first  attacked;  in  those  connected  by  dotted  lines, 
some  child  attended  the  school,  but  the  school  child  was  not  the  first  one  attacked. 
The  first  case  occurred  in  Family  A,  the  child  attending  school  while  suffering  from 
the  early  symptoms  of  the  disease.  In  only  two  families  (R  and  S)  did  cases  occur 
in  which  there  was  no  association  with  the  school  or  with  families  whose  children  went 
to  school. 


communicable.  In  some  epidemics,  notably  those  of  York  Nebraska, 
and  Trostena,  Sweden  (see  Fig.  153),  the  evidence  of  contagion  would 
seem  to  be  almost  conclusive.  There  are  also  instances  in  which  the  dis- 
ease apparently  was  carried  by  a  third  person. 

It  is  at  present  difficult  to  reconcile  the  facts  indicating  a  high  degree 
of  communicability,  such  as  has  been  witnessed  in  some  epidemics,  with 
what  has  been  observed  at  other  times  and  in  other  places.  In  many  of 
the  epidemics,  when  the  disease  has  prevailed  extensively,  it  has  not  been 
possible  to  trace  any  connection  between  the  different  cases.     In  the 


ACUTE   POLIOMYELITIS.  785 

majority  of  the  families  but  one  case  occurred,  although  other  cliihlren, 
quite  as  susceptible  by  reason  of  age,  were  closely  exposed.  For  yvdm 
we  have  received  these  affected  children  in  tiie  acute  stage  into  iiospital 
wards  with  other  patients,  and  1  have  never  yet  known  a  secon(Uiry  case 
to  develop.  Until  recently,  no  effort  whatever  was  made  to  isolate  cases. 
At  present  we  are  able  to  recognise  no  differences  between  the  sporadic 
and  epidemic  forms  of  the  disease  except  in  comnmnicability  and  se- 
verity, which  point  to  a  greater  virulence  of  the  infection  in  the  latter 
variety.  Both  etiologically  and  pathologically,  the  sporadic  and  epidemic 
forms  seem  to  be  identical.  In  all  tliese  respects  the  analogy  to  cerebro- 
spinal meningitis  is  a  very  close  one. 

The  occurrence  during  epidemics  of  many  unrelated  cases  strongly 
suggests  some  other  mode  of  contracting  the  disease  than  directly  from 
an  infected  person  or  a  human  carrier.  Tiie  fact  that  ei)idemics  are 
seen  only  during  the  summer  and  early  autumn  points  in  the  same  direc- 
tion. Eecent  experiments  of  Flexner  and  Clark  give  some  reasons  for 
suspecting  the  house  fly  as  a  carrier.  The  question  remains  to  be  solved 
by  future  investigation. 

The  period  of  incubation  of  the  experimental  disease  in  monkeys 
varies  from  four  to  thirty-three  days,  the  average  being  ten  days.  In 
man,  also,  it  is  variable,  but  in  most  instances  the  second  case  in  a  family 
has  followed  the  first  one  within  ten  days. 

The  Specific  Virus. — It  belongs  to  the  class  of  filtrable  viruses,  closely 
resembling,  in  many  respects,  the  virus  of  rabies.  It  passes  through  the 
finest  porcelain  filter.  It  can  not  be  seen  with  the  highest  power  of  the 
microscope,  nor  has  it  yet  been  cultivated  outside  the  body.  That  it  is  a 
living  organism  is  proven  by  the  fact  that  it  is  destroyed  by  heat.  It  is 
present  in  largest  quantity  in  the  diseased  nerve  structures,  particularly 
the  spinal  cord.  In  the  earliest  stages  of  the  attack  it  is  also  found  in  the 
cerebro-spinal  fluid,  but  disappears  at  about  the  time  paralysis  occurs. 
It  exists  to  some  degree  in  other  tissues  of  the  body,  particularly  the 
lymph  nodes.  The  disease  can  be  transmitted  to  animals  regularly  and 
with  certainty  only  by  inoculation  with  an  affected  spinal  cord,  in  which 
the  virus  persists  for  months  after  the  acute  attack.  Experiments  indi- ' 
cate  that  the  path  of  entrance  may  be  the  nasal  mucous  membrane,  and  at 
times  the  intestinal  tract.  Osgood  and  Lucas  have  shown  that  the  virus 
persisted  in  the  nasal  mucous  membrane  of  monkeys,  in  one  instance  for 
five  months,  in  another  for  one  and  a  half  months,  after  the  acute  attack ; 
which  suggests  that  this  may  not  only  be  an  avenue  of  entrance,  but  a 
mode  of  elimination  of  the  infection,  and  indicates  that  the  duration  of 
the  infective  period  may  at  times  be  a  very  long  one. 

Lesions. — As  a  result  of  the  investigations,  particularly  of  Flexner 
and  Lewis  upon  animals,  and  those  of  Ilarbitz  and  Scheel,  Strauss,  and 
others  upon  the  disease  in  man,  the  pathology  of  acute  poliomyelitis  is 
51 


786  DISEASES  OF  THE   NERVOUS   SYSTEM. 

now  well  known.  This  knowledge  has  greatly  aided  our  clinical  under- 
standing of  the  disease. 

The  virus  of  acute  poliomyelitis  first  attacks  the  meninges,  especially 
of  the  cord  and  medulla,  setting  up  a  cellular  inflammation  of  the  pia, 
which  becomes  infiltrated  with  small,  round  cells.  These  changes  are 
most  marked  about  the  blood-vessels.  Besides  this  the  walls  of  the  ves- 
sels themselves  are  infiltrated  and  their  lumen  narrowed.  The  lesion 
also  affects  the  vessels  entering  the  nerve  structures.  As  a  result  of  the 
vascular  lesions  anaemia,  oedema,  and  haemorrhages  are  present,  some- 
times small  and  circumscribed,  sometimes  quite  diffuse  and  extensive. 
Thrombosis  does  not  occur.  But  more  important  still  are  the  degener- 
ative changes  in  the  nerve  cells,  the  site  and  extent  of  which  are  deter- 
mined by  the  vessels  involved  and  the  intensity  of  the  changes  in  them. 
The  lesions  in  the  pons,  medulla,  and  cerebrum,  like  those  in  tlie  cord, 
are  secondary  to  the  vascular  lesions. 

The  transient  paralysis  in  cases  that  recover  may  lie  due  to  oedema  or 
to  temporary  vascular  obstruction  from  pressure  outside  the  vessels 
causing  a  local  anaemia.  Permanent  paralysis  depends  upon  severe  de- 
generation and  actual  destruction  of  ganglion  cells;  its  extent,  there- 
fore, will  vary  with  the  number  of  the  ganglion  cells  affected.  Any  part 
of  the  central  nervous  system  may  be  affected,  and  the  lesions  are  gen- 
erally more  extensive  than  the  symptoms  would  lead  one  to  expect.  The 
gross  appearances  give  but  little  idea  of  their  severity.  The  process 
often  involves  nearly  the  whole  length  of  the  cord,  being,  however,  gen- 
erally most  marked  in  the  cervical  and  lumbar  enlargements.  The 
changes  are  chiefly  in  the  gray  matter  of  the  anterior  horns,  and  consist 
in  acute  degeneration  of  ganglion  cells,  usually  marked  and  extensive. 
These  cells  in  certain  parts  may  disappear  altogether,  being  replaced  b}^ 
leucocytes.  The  entire  cord,  however,  may  be  involved.  There  is  seen, 
but  to  a  much  less  degree,  infiltration  with  small  round  cells  of  the  pos- 
terior horns,  the  columns  of  Clarke,  and  the  white  matter  of  the  cord, 
everywhere  closely  related  to  the  blood-vessels.  There  are  regularly 
found  changes  in  the  spinal  ganglia  of  a  similar  character  to  those 
described  in  the  cord. 

Lesions  like  those  of  the  cord,  though  generally  less  marked,  are 
seen  in  the  pons,  the  medulla,  the  cerebellum,  and  even  in  the  cerebral 
hemispheres.  They  are,  as  in  the  cord,  especially  related  to  the  pia  and 
the  blood-vessels.  There  is  seen  acute  destruction  of  ganglion  cells 
and  areas  of  cell  infiltration  with  lymphocytes.  Tiie  changes  are  espe- 
cially marked  about  the  nuclei  of  the  cranial  nerves,  and  in  the  gray 
matter  about  the  fourth  ventricle.  In  some  cases  the  basal  ganglia 
are  also  involved.  Areas  of  infiltration,  sometimes  quite  diffuse,  may 
be  seen  in  the  cortex,  with  also  some  slight  degeneration  of  ganglion 
cells. 


ACUTE   POLIOMYELITIS.  787 

Thus,  in  the  severe  and  fatal  cases  there  is  present  a  diffuse  inflam- 
mation of  the  entire  cord  and  its  memhranes,  also  of  the  medulla,  pons, 
and  basal  ganglia,  with  less  marked  changes  in  the  cerel)runi,  always 
accompanied  by  changes  in  the  pia.  In  the  milder  cases  it  is  probable 
that  the  inflammatory  changes  are  limited  to  the  cord,  though  in  some 
patients  dying  later  from  other  causes  Harbitz  and  Scheel  discovered 
changes  in  the  upper  centres,  though  no  symptoms  pointing  to  them 
had  been  present.  From  this  account  of  the  lesions  it  would  appear 
that  we  can  no  longer  distinguish  between  tiie  lesions  of  acute  ])olio- 
niyelitis,  acute  bulbar  paralysis  and  acvite  polience{)halitis  inferior.  They 
represent  varying  phases  of  one  and  the  same  disease.  In  recent  acute 
cases  no  changes  are  usually  found  in  the  nerves  except  degeneration  of 
bundles,  corresponding  to  the  degenerated  areas  in  the  cord,  and  prob- 
ably secondary  to  them.  Lesions  in  other  organs  are  often  present,  the 
most  frequent  being  broncho-pneumonia  and  acute  parenchymatous  de- 
generation of  the  liver  and  kidneys,  similar  to  what  is  seen  in  other 
severe  general  infections.  The  thymus,  the  solitary  follicles  of  the  in- 
testine, and  the  mesenteric  glands  may  be  much  swollen. 

In  autopsies  made  upon  cases  of  long  standing  the  affected  part  of 
the  cord,  which  is  often  only  one  lateral  half,  is  smaller  than  normal. 
The  general  changes  are  those  of  a  sclerotic  character.  The  ganglion 
cells  of  the  affected  anterior  horn  have  either  disappeared  altogether,  or 
they  are  few  in  number  and  so  shrunken  as  to  be  hardly  recognisable. 
The  white  matter  also  is  smaller  than  in  the  sound  part  of  the  cord. 
The  anterior  nerve  roots  are  degenerated  quite  to  the  muscles.  The 
affected  muscles  are  atrophied,  and  in  extreme  cases  there  may  be  a 
complete  disappearance  of  muscle  fibres,  their  place  being  taken  by  adi- 
pose and  fibrous  tissue.  In  places  where  the  lesion  is  less  severe  the 
fibres  are  small.  The  affected  limb  is  shorter  and  the  bones  smaller 
than  upon  the  sound  side. 

Symptoms. — The  onset  of  a  well  marked  attack  of  acute  poliomyelitis 
is  usually  abrupt,  being  ushered  in  with  fever,  prostration,  vomiting, 
rarely  with  convulsions.  There  may  be  diarrhcea,  but  more  often  there 
is  obstinate  constipation,  and  there  may  be  retention  of  urine.  Severe 
pains  are  usually  present  in  the  neck,  the  spine,  and  the  extremities. 
There  may  be  marked  hyperaesthesia  with  so  much  rigidity  of  the  neck 
and  extremities  as  strongly  to  suggest  cerebro-spinal  meningitis.  The 
mind  is  usually  clear,  but  there  may  be  active  delirium  or,  rarely, 
drowsiness  or  stupor.  The  temperature  usually  ranges  between  102° 
and  103.5°  F.  Such  symptoms  may  continue  for  three  or  four  days 
and  then  gradually  subside  and  the  patient  recover  without  any  paralysis 
having  developed.  Or  there  may  be  for  a  few  days  a  general  muscular 
weakness  somewhat  greater  and  lasting  a  little  longer  than  would  be 
expected  in  an  illness  of  such  severity.     These  are  known  as  "  abortive 


788  DISEASES  OF  THE   NERVOUS  SYSTEM. 

eases."  In  most  of  them  the  constitutional  and  nervous  symptoms  are 
similar,  but  not  quite  so  severe  as  those  just  described.  How  frequent 
the  abortive  type  of  the  disease  occurs  it  is  impossible  to  say;  but  in 
epidemics  these  cases  are  not  uncommon  and  doubtless  may  equal  the 
number  of  the  paralytic  cases.  Except  when  associated  with  the  latter 
they  are  very  difficult  of  recognition. 

Instead  of  following  such  a  course  as  that  described  there  develops, 
usually  on  the  third  or  fourth  day  of  the  attack,  marked  muscular  weak- 
ness most  frequently  in  the  lower  extremities.  This  increases  for  three 
or  four  days  until  there  may  be  complete  paralysis,  which  may  affect 
one  or  both  lower,  or  all  four  extremities,  or  only  the  upper  ones.  There 
may  also  be  marked  weakness  or  even  true  paralysis  of  the  neck  and 
trunk.  But  there  is  no  anaesthesia.  The  fever  and  other  constitutional 
symptoms  rarely  last  more  than  six  or  seven  days,  and  often  but  three 
or  four.  The  early  symptoms  are  not  characteristic,  and  a  positive  diag- 
nosis before  the  occurrence  of  paralysis  is  seldom  made.  The  extent  of 
the  primary  paralysis  is  generally  in  proportion  to  the  severity  of  the 
constitutional  symptoms. 

Instead  of  such  marked  constitutional  and  local  symptoms,  even  in 
epidemics  many  milder  attacks  are  seen,  and  when  the  disease  occurs 
sporadically  most  of  the  cases  are  of  the  milder  type.  There  is  usually 
a  period  of  indefinite  indisposition  lasting  one  or  two  days,  at  the  end 
of  which  time  the  paralysis  is  noticed.  Sometimes  there  is  only  a  single 
restless  night,  following  which  the  paralysis  is  seen  in  the  morning.  In 
two  cases  of  which  I  have  notes  the  paralysis  apparently  came  on  while 
the  child  was  walking  in  the  street,  and  was  able  to  reach  liome  only  with 
considerable  difficulty,  there  having  been  no  previous  symptoms  ob- 
served. In  cases  of  this  type  the  loss  of  power  is  usually  limited  to 
one  limb,  often  to  a  single  group  of  muscles. 

In  the  types  just  described  the  symptoms  are  chiefly  due  to  the  spinal 
cord  lesion.  In  others,  however,  involvement  of  the  cranial  nerves  in- 
dicates a  bulbar  lesion.  Cases  of  this  type  are  seldom  seen  except  in 
epidemics,  when  their  occurrence  is  not  uncommon.  In  this  form  the 
early  symptoms  may  be  like  those  just  described  or  there  may  be  con- 
vulsions followed  by  delirium  or  stupor.  The  early  paralysis  may  in- 
volve the  extremities  only,  but  soon  the  muscles  of  the  trunk  and  neck 
become  affected.  There  may  then  develop  paralysis  of  the  face,  marked 
disturbance  of  the  respiration  or  of  the  action  of  the  heart,  and  some- 
times difficulty  in  deglutition.  The  bladder  and  rectum  may  be  in- 
volved, causing  retention  of  urine  and  incontinence  of  faeces.  Death  may 
take  place  quite  suddenly  by  failure  of  the  heart  or  respiration  usually 
from  the  fourth  to  seventh  day,  or  at  a  later  period  death  may  be  due 
to  broncho-pneumonia.  Cases  of  this  kind,  when  they  occur  sporadic- 
ally, are  often  miscalled  Landry's  paralysis. 


ACUTE   POLIOMYELITIS. 


789 


Extent  and  Distributiori  of  the  Primanj  I'urali/sis. — Tn  ."iGO  sporadic 
cases  in  which  this  point  was  noted  tlie  distribution  was  as  follows: 

One  lower  extremity 229  cases. 

Both  lower  extremities 176  " 

General  paralysis  of  all  extremides,  and  more  or  less  of  trunk.  79  " 

One  lower  and  one  upper  extremity 3G  " 

Both  lower  extremities  and  on.  upp?r  extremity 16  " 

One  upper  extremity  alone 14  " 

All  other  varieties 10  " 


In  paralysis  of  the  trunk,  tlie  abdominal  muscles,  tlie  diaphragm,  and 
other  respiratory  muscles  are  rarely  affected.  In  combinations  of  an  upper 
and  a  lower  extremity,  the  limbs  are  more  frequently  alfected  upon  oppo- 
site sides  than  upon  the  same  side.    The  sphincters  usually  escape. 

Course  of  the  Disease. — After  the  constitutional  symptoms  have  dis- 
appeared there  is  a  period  of  from  one  to  three  weeks'  duration  in  which 
little  change  is  seen.  This  is  followed  by  spontaneous  improvement, 
which  usually  begins  in 
the  muscles  last  affected, 
and  readies  its  limit  in 
about  three  months.  The 
paralysis  remaining  after 
this  time  is  likely  to  be 
l^ermanent.  By  the  end 
of  six  or  eight  weeks 
atrophy  is  present  in  the 
paralysed  muscles.  The 
affected  limb  is  distinctly 
smaller  than  its  fellow, 
this  being  quite  appar- 
ent even  in  infants.  Ex- 
cept in  the  early  stage, 
sensory  disturbances  are 
absent;  tlie  knee-jerk  is 
lost  in  paraplegic  cases, 
and  in  those  in  which  the 
extensors  of  the  thigh  are 
paralysed.  There  is  ar- 
rested growth  in  the  whole 
limb  (Fig.  154).  It  be- 
comes much  smaller  and 
shorter  than  its  fellow.  The  great  relaxation  of  the  ligaments  at  the 
joints  may  allow  subluxation,  especially  at  the  knee  and  at  the  shoulder. 
The  circulation  in  the  affected  limb  is  poor;  it  is  often  blue  and  cold, 
but  bed-sores  are  never  seen. 


Fig.  154. — An  Old  Case  of  Infantile  Spinal  Paraly- 
sis OF  THE  Entire  Left  Lower  Extremity. 
Showing  extreme  atrophy  of  the  thigh  and  leg,  and 
a  very  characteristic  deformity  of  the  foot. 


790 


DISEASES  OF  THE   NERVOUS   SYSTEM. 


Electrical  Reactions. — Very  early  in  the  disease  the  atropliied  mus- 
cles begin  to  lose  their  power  to  respond  to  faradism.  In  the  muscular 
groups  which  are  to  be  permanently  paralysed,  the  faradic  response  may 
be  lost  in  a  week.  The  muscles  in  which  recovery  is  to  take  place  often 
preserve  a  certain  degree  of  contractility,  although  this  is  less  than 
normal,  and  improves  later.  The  response  to  the  galvanic  current  may 
be  increased  for  a  few  months,  and  then  slowly  fail  as  the  muscular 
fibres  themselves  degenerate,  and  at  the  end  of  two  or  three  years  it  may 
disappear  altogether.  The  reaction  of  degeneration  is  present  with  great 
uniformity  in  the  atrophied  muscles,  but  in  them  alone. 

Residual  Paralysis  and  Deformity. — ^This  is  most  frequently  of  one 
lower  extremity.  The  extensors  both  of  the  thigh  and  of  the  leg  are 
nearly  always  involved  to  a  greater  degree  than  the  flexors.    The  muscles 

most  frequently  affected  are  the  anterior 
tibial  group.  Paralysis  of  one  upper  ex- 
tremity rarely  occurs  alone,  but  is  asso- 
ciated with  paralysis  of  one  or  both  lower 
extremities.  Complete  paralysis  of  an 
arm  is  very  rare.  Of  single  muscles,  the 
one  most  frequently  involved  is  the  del- 
toid. From  paralysis  of  the  muscles  of 
the  trunk  or  shoulder  of  one  side,  lateral 
curvature  may  develop  (Fig.  155). 

Diagnosis. — The  recognition  of  acute 
poliomyelitis  before  the  occurrence  of 
paralysis  is  impossible  except  by  lumbar 
puncture.  If  this  is  performed  early,  the 
cerebro-spinal  fluid  is  found  to  be  opal- 
escent or  slightly  turbid,  owing  to  the 
presence  of  many  mononuclear  cells.  It 
may  coagulate  s])ontaneously.  Noguchi's 
globulin  test  gives  a  positive  reaction. 
By  the  time  paralysis  appears  the  cells 
have  diminished  greatly  in  number 
and  soon  the  fluid  shows  no  changes  by  which  it  can  be  distinguished 
from  the  normal.  Very  exceptionally  there  has  been  seen  early  in  the 
disease  a  marked  turbidity  and  an  excess  of  polymorphonuclear  cells. 
Such  cases  are  distinguished  from  meningitis  by  the  absence  of  the  char- 
acteristic organisms.  The  early  symptoms — vomiting,  constipation,  or 
diarrhoea  and  fever — usually  lead  to  the  opinion  that  this  attack  is  only 
one  of  acute  indigestion.  When  there  are  added  muscular  pains,  general 
hyperaesthesia,  rigidity,  and  high  fever,  cerebro-spinal  meningitis  is  often 
suspected,  and  can  be  excluded  only  by  lumbar  puncture.  Early  cerebral 
symptoms,  convulsions,  stupor,  etc.,  may  closely  simulate  tuberculous 


Fig.  155. — An  Old  Case  of  In- 
fantile Spinal  Paralysis  of 
THE  Left  Arm  and  Shoulder 
Muscles,  with  Resulting  Lat- 
eral Curvature. 


ACUTE  POLIOMYELITIS.  791 

meningitis,  and  I  have  known  doubt  to  exist  for  several  days.  Lumbar 
puncture  and  the  examination  of  the  fluid  should  settle  the  diagnosis. 

The  later  manifestations  of  poliomyelitis  are  a  flaccid  type  of  paralysis 
with  marked  atrophy  and  with  the  characteristic  electrical  reactions,  but 
without  sensory  symptoms.  Seen  late,  poliomyelitis  may  be  confounded 
with  cerebral  palsies,  multiple  neuritis,  or  tlie  pseudo-paralysis  of  rickets. 
In  cerebral  palsies  there  is  usually  rigidity;  there  is  no  reaction  of 
degeneration;  other  cerebral  symptoms  are  commonly  present,  or  there 
is  a  history  of  an  onset  with  cerebral  symptoms,  and  the  atrophy  is 
less  marked.  Multiple  neuritis  is  rare  in  children  except  after  diph- 
theria, and  is  more  gradual  in  its  onset.  The  type  of  paralysis  and  the 
electrical  reactions  may  be  the  same  as  in  poliomyelitis. 

Certain  birth  palsies,  especially  those  resulting  from  injuries  received 
during  delivery,  may  closely  resemble  poliomyelitis  when  the  deltoid  or 
shoulder  group  of  muscles  is  involved.  Without  a  clear  history  a  differ- 
ential diagnosis  may  be  impossible. 

The  muscular  weakness  of  rickets  is  general ;  there  is  no  reaction 
of  degeneration  and  no  history  of  acute  onset.  Scurvy  is  distinguished 
by  the  very  acute  hyperaesthesia,  by  the  swellings,  and  by  haemorrhages 
from  the  gums  or  other  mucous  membranes  together  with  a  history  of  im- 
proper feeding.    The  child  refuses  to  move  his  legs  only  because  of  pain. 

Prognosis. — It  was  once  thought  that  few,  if  any,  cases  recovered 
perfectly,  and  on  the  other  hand  that  there  was  very  little  danger  to 
life.  Wider  observations  which  recent  epidemics  have  made  possible 
have  shown  that  complete  recovery  may  occur  even  in  cases  in  which 
the  onset  is  acute  and  early  loss  of  power  extensive.  Such  a  result  is, 
however,  not  the  common  one.  The  great  majority  of  the  cases  have 
unfortunately  some  residual  paralysis.  Of  the  1,659  cases  occurring  in 
epidemics  collected  by  Bartlett  and  myself  the  mortality  was  twelve 
per  cent.  During  the  recent  Xew  York  epidemic  I  saw  personally  four 
cases  which  ended  fatally.  The  discrepancy  between  the  mortality  figures 
just  mentioned  and  the  opinion  formerly  held  is  possibly  explained  in 
part  by  the  fact  that  in  epidemics  the  more  severe  types  of  the  disease 
are  seen,  but  I  believe  is  chiefly  due  to  a  failure  to  recognise  the  most 
severe  forms,  especially  bulbar  cases,  as  examples  of  this  disease.  Pre- 
vious statistics  have  been  gathered  chiefly  from  neurological  out-patient 
clinics,  where  the  types  which  end  fatally  are  seldom  seen. 

An  important  question  in  early  prognosis  is  that  which  relates  to 
the  extent  of  the  permanent  paralysis.  The  significant  symptoms  are 
the  amount  of  wasting  and  the  electrical  reactions.  Muscles  which  in 
ten  days  have  lost  completely  their  faradic  contractility  are  almost  cer- 
tain to  waste  rapidly  and  severely.  The  best  indication  of  coming  im- 
provement is  the  return  of  faradic  contractility.  If  this  is  completely 
lost  for  six  months,  recovery  is  doubtful;  if  for  one  year,  improvement 


792  DISEASES  OF  THE   NERVOUS  SYSTEM. 

in  these  muscles  is  not  to  be  expected.  If  faradic  contractility  has  never 
been  lost,  very  great  and  early  improvement  in  the  paralysed  muscles 
may  be  confidently  predicted.  After  three  months  but  little  spontaneous 
improvement  is  to  be  looked  for,  and  after  two  years  none  at  all. 

Treatment. — So  little  is  as  yet  known  of  the  mode  of  acquiring 
poliomyelitis  that  not  much  can  be  said  regarding  prophylactic  meas- 
ures. Inasmuch  as  the  nasal  mucous  membrane  is  known  to  be  at  least 
a  possible  channel  of  elimination  of  the  virus,  it  follows  that  all  nasal 
discharges  of  patients  should  be  carefully  disinfected  and  destroyed. 
Persons  in  contact  with  active  cases  should  use  some  antiseptic  nasal 
spray.  Strict  quarantine  of  sporadic  cases  does  not  as  yet  seem  to  be 
necessary.  In  epidemics,  however,  immediate  quarantine  should  be 
instituted  and  strictly  maintained  for  at  least  a  month.  Further  than 
this  it  is  not  now  possible  to  make  positive  statements. 

Even  when  recognised  early,  it  is  doubtful  whether  much  can  be 
done  to  limit  the  inflammation.  The  most  important  indication  is  to 
secure  complete  rest.  Counter-irritation  may  be  used  over  the  spine  by 
means  of  mustard  or  a  Paquelin  cautery,  or  an  ice-bag  may  be  employed; 
yet  it  is  very  doubtful  if  tliey  have  any  influence  upon  the  course  of 
the  disease.  The  results  depend  rather  upon  the  severity  of  the  attack 
than  the  treatment  employed.  The  natural  course  of  the  disease  is  to 
be  kept  in  mind,  for  the  tendency  is  to  overestimate  the  effect  upon 
the  paralysis  of  the  drugs  used  in  the  early  stage.  In  animals  if  hexa- 
methylenamine  (urotropin)  is  given  simultaneously  with  or  shortly  after 
the  injection  of  the  virus  in  many  instances  no  paralysis  follows.  Its 
curative  effects  in  man  have  not  yet  been  demonstrated.  It  should,  how- 
ever, be  tried,  and  administered  in  full  doses  as  soon  as  the  diagnosis  can 
be  made.  To  a  child  of  three  years  from  twenty  to  twenty-five  grains 
daily  may  be  given  in  divided  doses.  It  is  doubtful  wliether  drugs  have 
any  influence  upon  the  paralysis  after  its  full  development. 

After  all  acute  s3'mptoms  have  subsided,  or  at  the  end  of  two  or 
three  weeks,  electricity  may  be  used,  but  its  curative  effects  have  been 
very  greatly  overestimated.  No  amount  of  electrisation  can  preserve 
muscles  whose  ganglion  cells  have  completely  disappeared.  These  muscles 
continue  to  waste  and  lose  their  faradic  contractility,  no  matter  liow  early 
electricity  is  begun  nor  how  faithfully  it  is  continued.  Faradism  may 
be  used  for  such  groups  as  respond  to  it ;  otherwise  galvanism  should  be 
employed.  The  beneficial  results  from  electricity  are  to  be  obtained 
chiefly  in  the  first  six  months.  Friction,  massage,  and  manipulation  are 
of  undoubted  value  in  improving  the  circulation  and  the  nutrition  of  a 
limb,  and  should  be  faithfully  continued  twice  a  day  for  a  long  period. 

Mechanical  Treatment. — Mechanical  appliances  are  useful  to  prevent 
deformity,  also  to  furnish  support  to  the  limb  in  order  to  enable  the 
child  to  walk.     By  such  means  many  get  about  with  tolerable  comfort 


SYRINGO-MYELIA.  793 

for  whom  locomotion  without  ap])aratus  i?  impossible  witliout  crutches. 
To  overcome  existing  deformities  in  neglected  cases,  braces  are  employed 
in  conjunction  with  myotomy  or  tenotomy  of  the  various  shortened  ten- 
dons, excision  of  portions  of  elongated  tendons,  and  tbe  production  of 
artificial  anchylosis  in  cases  of  "  flail  joints."  By  these  means  the 
orthopaedic  surgeon  is  able  to  give  a  great  deal  of  relief  to  these  unfor- 
tunate and  sometimes  helpless  patients. 

TUMOURS  OF   THE   SPINAL   CORD. 

Tumours  of  the  cord  are  exceedingly  rare  in  childhood,  and  almost 
unknown  in  infancy.  The  most  common  varieties  seen  in  early  life  are 
glioma,  sarcoma,  and  tuberculous  tumours.  Eisenschitz  has  reported  a 
case  of  tuberculous  tumour  in  the  dorsal  region  occurring  in  a  child  of 
three  and  a  half  years.  There  was  a  similar  growth  in  the  cerebellum. 
The  symptoms  were  essentially  those  of  compression-myelitis. 

In  my  service  at  the  Babies'  Hospital  I  had  a  case  of  glioma  of 
the  cord  in  a  child  only  one  year  old,  which  was  in  many  respects 
unique.  The  early  symptoms  were  gradual  paralysis  of  the  upper  ex- 
tremities, to  which  were  added  later,  stiffness  of  the  neck,  and  finally 
immobility  of  the  head — the  position  being  that  of  typical  cervical  caries. 
During  the  sixteen  days  of  observation  there  was  high  fever,  from  101°  to 
104°  F.  There  were  no  pupillary  or  vaso-motor  symptoms.  At  the  autopsy 
the  cord  was  found  to  be  thd  seat  of  a  diffuse  gliosis.  In  the  cervical 
region  there  was  marked  enlargement,  the  cord  being  fully  four  times  its 
natural  size.  A  microscopical  examination  by  Dr.  C.  A.  Herter  showed 
that  the  growth  apparently  began  in  the  vicinity  of  the  central  canal, 
arid  that  the  gliomatous  process  involved  the  entire  length  of  the  cord. 

A  somewhat  similar  case  has  been  reported  by  Miura  in  a  boy  of 
eight  years. 

The  diagnosis  of  tumours  of  the  spinal  cord  in  infancy  is  practically 
impossible.  In  later  childhood  they  are  apt  to  be  mistaken  for  Pott's 
disease,  but  the  symptoms  are  the  same  as  those  seen  in  tumours  of 
adult  life. 

SYRINGO-MYELIA. 

Syringo-myelia,  although  a  rare  disease,  is  sometimes  seen  in  early 
life.  The  term  is  applied  to  a  condition  in  which  there  is  a  cavity  in 
the  cord  the  result  of  a  pathological  process,  in  contradistinction  to  the 
cases  in  which  a  cavity  is  the  result  of  a  malformation,  or  hydromyelus, 
although  it  is  not  infrequent  for  the  two  conditions  to  be  associated. 
The  pathological  process  which  precedes  the  cavity  formation  is  now 
thought  to  be,  in  most  cases  at  least,  an  infiltration  of  the  substance  of 
the  cord  with  gliomatous  cells.  The  process  is  somewhat  similar  to  that 
just  described  in  the  case  of  tumour  of  the  spinal  cord,  with  the  excep- 


794  DISEASES  OF   THE   NERVOUS  SYSTEM. 

tion  that  wlien  it  results  in  cavity  formation  it  is  slower.  The  infiltra- 
tion in  these  cases  usually  begins  near  the  central  canal.  It  is  followed 
by  a  degeneration  and  breaking  down  of  the  infiltrated  areas,  beginning 
at  the  centre.  As  the  cavity  forms  it  extends,  and  usually  first  invades 
the  gray  matter  of  the  commissure,  later  the  posterior  gray  horns,  the 
posterior  columns,  or  the  anterior  horns.  The  resulting  cavity  is  usu- 
ally irregular  in  shape,  and  may  be  very  small,  or  may  extend  through 
a  large  part  of  the  length  of  the  cord.  It  is  most  frequently  situated 
in  the  lower  cervical  and  upper  dorsal  regions.  It  is  filled  with  fluid, 
and  surrounded  by  gliomatous  tissue. 

According  to  Starr,  the  essential  symptoms  are  of  three  kinds:  (1) 
There  is  progressive  muscular  atrophy,  with  paralysis  of  some  or  all  the 
muscles  of  one  limb,  usually  extending  to  the  opposite  limb  and  to  the 
trunk,  sometimes  accompanied  by  the  reaction  of  degeneration;  (2)  vaso- 
motor and  trophic  disturbances  in  the  affected  limb,  such  as  cyanosis, 
coldness,  bullous  eruptions,  ulceration,  abscesses,  atrophy,  and  sometimes 
fragility  of  the  bones  and  diminution  of  perspiration;  (3)  sensory  dis- 
turbances, whicli  are  probably  the  most  characteristic  symptoms  of  the 
disease — there  is  loss  of  the  sense  of  pain  and  of  temperature  in  the 
atrophied  part,  while  the  sense  of  touch  and  of  location  may  be  preserved. 
The  extent  and  distribution  of  these  symptoms  will  of  course  depend 
upon  the  site  of  the  disease. 

The  course  of  syringo-myelia  is  essentially  chronic,  the  duration  be- 
ing usually  several  years;  and  although  spontaneous  arrest  sometimes 
occurs  the  disease  is  in  most  cases  steadily  progressive. 

The  cause  is  unknown,  and  it  is  not  influenced  by  any  form  of 
treatment. 

FRIEDREICH'S  ATAXIA. 

This  is  a  chronic  disease  of  the  spinal  cord  and  medulla,  which  begins 
most  frequently  in  childhood  or  about  puberty.  The  lesion  affects  first 
the  posterior  columns,  afterward  the  crossed  pyramidal  tracts,  the  direct 
cerebellar  tracts  in  the  lateral  columns,  and  Clarke's  columns  in  the  gray 
matter  of  the  cord.  There  is  probably  some  disease  of  the  medulla,  the 
pons,  and  possibly  of  the  cerebellum  and  the  posterior  nerve-roots.  In 
advanced  cases  other  parts  of  the  cord  may  be  involved.  The  disease 
is  seen  in  certain  families,  often  affecting  several  members  in  succession 
at  about  the  same  age.  It  occurs  particularly  in  families  where  alcohol- 
ism, insanity,  and  other  nervous  diseases  are  frequent. 

Bramwell,  in  his  monograph  upon  this  disease,  gives  the  following 
as  the  characteristic  symptoms:  There  is  ataxia,  first  of  the  lower  ex- 
tremities, but  gradually  extending  to  the  upper  extremities  and  the 
face.  Early  in  the  disease  there  is  some  weakness  in  the  legs,  especially 
in  the  anterior  group  of  muscles.     In  the  late  stages  this  is  marked 


LANDRY'S   PARALYSIS.  795 

and  accompanied  by  atrophy.  The  gait  is  peculiar,  like  that  of  ordinary 
ataxic  patients,  the  difficulty  in  walking  being  (kie  to  the  ataxia  and  not 
to  the  paresis.  After  a  time  there  is  producetl  a  charac'teristic  deformity 
of  the  foot — it  is  shortened,  as  if  from  pressure  against  the  toes  and 
the  heel,  the  instep  is  high,  and  the  extensor  tendon  of  the  great  toe 
stands  out  prominently.  This  deformity  is  seen  (luite  early  in  the  dis- 
ease. There  is  often  lateral  curvature  of  the  spine.  The  knee-jerk  is 
absent.  Unprovoked  and  uncontrollable  laughter  is  quite  a  character- 
istic symptom  of  the  disease.  The  patient  is  unable  to  stand  with  his 
eyes  closed.  There  are  palpitation,  occipital  headache,  and  sometimes 
vertigo.  In  the  later  stages  speech  is  slow  and  difficult,  and  the  patient 
talks  like  one  intoxicated.  The  expression  of  the  face  is  vacant,  and 
often  nystagmus  is  present.  There  may  be  choreic  movements.  The 
symptoms  steadily  progress  until  the  patient  may  be  helpless,  although 
the  general  health  may  remain  good  for  years. 

The  disease  is  distinguished  from  locomotor  ataxia  by  the  absence 
of  the  "  lightning  pains,"  and  of  the  bladder,  rectal,  or  genital  symp- 
toms, the  pupillary  changes,  the  optic-nerve  atrophy,  and  the  trophic 
changes  in  the  bones  and  joints.  It  is  distinguished  from  cerebral 
tumour  by  the  absence  of  headache,  vomiting,  and  optic  neuritis,  and 
by  its  longer  course.  The  progress  of  the  disease  is  slow  but  steady. 
It  may  last  from  twenty  to  thirty  years.    It  is  incurable. 

LANDRY'S  PARALYSIS. 

(Acute  Ascending  Paralysis.) 

This  rare  disease  is  occasionally  seen  in  early  life.  In  regard  to  its 
etiology  but  little  is  definitely  known,  the  usual  causes  assigned  being  the 
same  as  those  of  myelitis.  Many  cases  diagnosticated  Landry's  paralysis 
are  undoubtedly  examples  of  poliomyelitis.  There  is,  however,  no  doubt  of 
the  existence  of  an  acute  ascending  paralysis  distinct  from  poliomyelitis. 

It  is  characterised  by  a  paralysis — sometimes  preceded  by  general 
symptoms  of  malaise,  fever,  etc. — which  begins  in  the  legs  and  spreads 
rapidly  to  the  muscles  of  the  trunk  and  upper  extremities ;  finally  it  may 
involve  the  neck,  diaphragm,  and  muscles  of  articulation.  The  paralysis 
develops  quite  rapidly,  often  attaining  its  height  in  from  twenty-four  to 
forty-eight  hours,  sometimes  even  proving  fatal  within  this  time.  In 
other  cases  it  comes  on  gradually,  and  may  be  two  or  three  weeks  in 
reaching  its  maximum.  There  is  dyspno?a  from  involvement  of  the 
muscles  of  respiration.  The  paralysed  muscles  are  flaccid.  There  is 
hypersesthesia,  followed  by  partial  or  complete  anaesthesia  and  loss  of 
reflexes.  There  are  no  changes  in  the  electrical  reactions,  no  atrophy, 
no  bed-sores,  and  usually  no  involvement  of  the  sphincters.  Occasionally 
the  arms  may  be  affected  before  the  legs,  and  even  the  bulbar  symptoms 


796  DISEASES  OF  THE  NERVOUS  SYSTEM. 

may  be  the  first  noticed.  Death  is  the  most  frequent  termination,  and 
in  fatal  cases  the  disease  lasts  from  two  days  to  a  week.  If  recovery 
takes  place,  it  is  after  two  or  three  months  of  illness. 

The  indications  for  treatment  are  the  same  as  in  acute  myelitis,  for 
in  the  beginning  the  two  diseases  can  not  usually  be  distinguished  from 
each  other. 

THE   MUSCULAR  ATROPHIES. 

These  cases  may  be  broadly  divided  into  two  groups,  following  in  the 
main  the  classification  of  Sachs:  (1)  those  dependent  upon  disease  of 
the  spinal  cord — the  spinal  atrophies;  (2)  those  which  are  primarily 
diseases  of  the  muscles  themselves — the  idiopathic  atrophies. 

In  the  group  of  atrophies  of  spinal  origin  belong  (1)  the  "hand 
type  "  of  Aran  and  Duchenne,  which  has  been  shown  to  be  dependent 
upon  a  lesion  of  the  spinal  cord;  (2)  the  "peroneal  type"  of  Charcot, 
Marie,  and  Tooth,  which  as  yet  lacks  positive  pathological  proof  of  its 
spinal  origin,  although  its  etiology,  symptoms,  and  course  leave  Imt  little 
doubt  that  it  belongs  in  the  same  category  with  the  hand  type. 

In  the  second  (idiopathic)  group  are  included  (1)  muscular  pseudo- 
hypertrophy, and  (2)  the  so-called  "juvenile  atrophy"  of  Erb,  wliich 
is  a  much  less  frequent  condition.  These  two  varieties  have  the  follow- 
ing features  in  common:  There  is  progressive  wasting,  beginning  early 
in  childhood,  and  associated  at  some  period  with  hypertrophy  of  certain 
muscles.  There  are  no  fibrillary  contractions,  no  reaction  of  degenera- 
tion, and  no  lesions  in  the  cord.  From  a  pathological  point  of  view 
these  diseases  might  be  more  properly  considered  elsewhere,  but  they  are 
so  closely  associated  clinically  with  the  spinal  atrophies  that  it  has 
seemed  better  to  describe  them  in  this  connection. 

Progressive  Muscular  Atrophy  of  the  Hand  Type. — This  disease  is 
characterised  by  a  very  slow  but  progressive  wasting,  which  usually 
begins  in  the  muscles  of  the  ball  of  the  thumb  of  one  or  both  hands. 
Then  the  palmar  group  of  muscles  belonging  to  the  little  finger  are 
affected,  and  later  the  interossei.  When  the  wasting  has  reached  a  cer- 
tain degree,  there  is  produced  a  peculiar  and  characteristic  deformity 
of  the  hand  known  as  main  en  griff e,  or  "  claw-hand."  Following  these 
muscles,  those  of  the  forearm  may  be  affected.  At  this  point  the  dis- 
ease is  sometimes  arrested,  or  the  atrophy  may  extend  to  the  nmscles 
of  the  arm  and  shoulder,  especially  the  deltoid,  and  finally  to  those  of 
the  back.  Exceptionally,  the  atrophy  begins  in  the  nmscles  of  the 
shoulder  group  or  even  in  those  of  the  leg.  The  wasting  takes  place 
very  slowly,  the  muscles  disappearing  fibre  by  fibre,  but  the  degree  which 
may  be  reached  is  often  extreme.  The  only  other  characteristic  s3Tnptoms 
are  fibrillary  contractions  in  the  muscles  which  are  soon  to  atrophy.  The 
patient  is  not  conscious  of  them,  but  they  are  visible.     The  faradic 


THE   MUSCULAR   ATROPHIES.  797 

contractility  is  preserved  just  in  proportion  to  the  amount  of  muscle 
remaining.     If  the  atrophy  is  complete,  it  is  entirely  lost. 

The  course  of  the  disease  is  a  very  chronic  one,  covering  many  years. 
It  is  incurable.  In  rare  cases  the  process  may  extend  to  the  muscles  of 
the  tongue,  affecting  deglutition  and  articulation,  and  death  may  occur 
from  interference  with  respiration;  otherwise  the  disease  does  not  tend 
to  shorten  life. 

In  this  form  of  atrophy  heredity  is  an  important  etiological  factor. 
The  disease  may  occur  in  children,  but  very  often  does  not  begin  until 
after  puberty.  The  lesion  consists  in  an  atrophy  of  the  ganglion  cells  of 
the  anterior  horns  of  the  spinal  cord,  followed  by  secondary  degeneration 
of  the  anterior  nerve-roots. 

Progressive  Muscular  Atrophy  of  the  Peroneal  Type. — This  is  much 
less  frequent  than  the  variety  just  described.  In  this  form,  the  first  to 
waste  are  the  anterior  muscles  of  the  leg,  especially  the  extensor  longus 
hallucis  and  extensor  communis  digitorum,  afterward  the  peroneal 
group.  The  small  muscles  of  the  foot  are  next  affected,  and  the  disease 
may  then  go  on  to  involve  the  muscles  of  the  calf.  At  this  point  it 
may  be  arrested  permanently,  or  for  several  years,  after  which  the  thigh 
muscles  may  waste  like  those  of  the  leg.  After  many  years  the  hands 
are  in  some  cases  involved  as  in  the  type  previously  described,  and  even 
the  muscles  of  the  forearm.  As  a  rule,  the  supinator  longus,  the  muscles 
of  the  shoulder,  neck,  trunk,  and  face,  escape  altogether.  The  atrophy  is 
generally  S3'mmetrical,  but  not  invariably  so.  The  cutaneous  reflexes  are 
usually  present.  There  is  no  pain.  The  reaction  of  degeneration  is 
present  in  some  of  the  muscles,  and  fibrillary  contractions  are  frequent, 
but  not  always  seen. 

In  this  variety  also  the  influence  of  heredity  may  often  be  traced.  It 
is  said  that  boys  usually  inherit  the  disease  through  the  mother.  Like 
the  previous  type,  it  begins  late  in  childhood  or  not  until  after  puberty. 

As  stated  above,  positive  proof  that  this  disease  is  due  to  a  central 
lesion  in  the  cord  is  as  yet  lacking.  Analogy,  however,  leads  to  the  belief 
that  it  depends  upon  changes  in  the  ganglion  cells  of  the  anterior  horns 
in  the  lumbar  region,  similar  to  those  found  in  the  cervical  region  in  the 
hand  type.  The  course  of  the  disease  is  very  chronic,  and  it  is  incur- 
able. The  resulting  deformity  resembles  that  seen  after  poliomyelitis, 
and  may  require  the  same  mechanical  treatment,  with  similar  operations 
for  relieving  contractions. 

Muscular  Pseudo-Hypertrophy  (Pseudo-Hypertrophic  Paralysis). — 
This  is  tlie  most  frequent  and  best-known  variety  of  the  idiopathic 
atrophies.  It  is  a  disease  of  certain  families,  often  three  or  four  children 
being  affected,  the  boys  much  more  frequently  than  tlie  girls.  The  symp- 
toms as  a  rule  come  on  early  in  childhood,  nearly  always  before  the 
tenth  year.     The  earlier  symptoms  relate  to  a  general  weakness  of  the 


798 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


lower  extremities,  wliicli  is  accompanied  by  a  marked  increase  in  tiie 
size  of  certain  muscular  groups,  usually  those  of  the  calves,  but  some- 
times more  of  the  thighs  or  the  gluteal  regions.  Children  walk  late 
and  unsteadily,  and  fall  very  easily.     They  have  special  difficulty  in 

rising  from  the  floor  and  in  mounting 
stairs.  The  method  of  rising  is  quite 
characteristic :  the  patient  lifts  his  body 
until  he  touches  the  floor  only  with  tbe 
liands  and  feet;  then  he  proceeds  to 
"  climb  up  himself  "  by  jnitting  first  one 
liand  upon  the  knee,  and  tiien  the 
otber,  gradually  moving  his  hands 
higher  and  higher  up  the  thighs  un- 
til the  erect  })osition  is  attained.  This 
is  seen  in  most  of  the  cases,  but  not 
in  all. 

The  size  attained  by  the  calves  is 
sometimes  very  great.  Gowers  mentions 
a  case  in  which  a  boy  of  twelve  had 
calves  measuring  fourteen  and  a  half 
inches  in  circumference.  The  enlarge- 
ment may  affect  almost  any  muscular 
group  of  the  lower  extremity.  In  the  up- 
per extremity,  the  infra-spinatus  is  most 
frequently  enlarged,  next  the  supra-spi- 
natus  and  the  deltoid.  The  pectorals 
and  latissimus  dorsi  are  never  enlarged, 
but  are  generally  markedly  wasted.  Most 
of  these  patients  exhibit  while  standing 
a  marked  degree  of  lumbar  lordosis,  due 
to  the  weakness  of  the  extensors  of  the 
hip.  This  is  well  sliown  in  Fig.  156. 
The  patient  may  be  so  weak  upon  his 
legs  that  the  slightest  touch  will  cause 
him  to  fall,  even  with  his  a])parently 
immense  muscular  development.  The 
small  muscles  are  generally  weaker  than 
those  which  are  enlarged. 
Later  in  the  disease  marked  atrophy  occurs  with  a  corresponding 
weakness  of  all  the  affected  groups,  and  the  patient  may  be  unable  to 
walk  or  even  stand.  With  the  exception  of  the  use  of  his  hands,  he  may 
be  absolutely  helpless.  The  knee-jerk  is  at  first  normal,  but  gradually 
diminishes  until  it  is  finally  lost.  The  electrical  reactions  are  normal 
until  marked  wasting  occurs,  when  there  is  a  lessened  response  to  fara- 


FiQ.  156. — Muscular  Pseudo-hy- 
pertrophy. Showing  to  a  mod- 
erate degree  the  large  calves  and 
gluteal  regions  with  a  marked 
lordosis.  (From  a  photograph  by 
Dr.  M.  A.  Starr.) 


THE   MUSCULAR   ATROPHIES.  799 

dism  and  galvanism,  but  never  the  reaction  of  dc^jonoration.  Tliorc  are 
no  fibrillary  contractions,  and  no  sensory  distui-hanccs.  'I'lic  jji-ooross  of 
the  disease  is  generally  slow,  and  sometimes  irregular.  It  is  often  more 
rapid  in  early  childhood,  and  slower  after  puberty.  Many  of  these  chil- 
dren, though  apparently  bright,  are  distinctly  below  the  axcrage  for  their 
ages. 

The  lesions  are  confined  to  the  muscles.  At  autopsy  they  appear 
yellow,  and  microscopically  there  is  found  very  marked  atroi)hy  of  the 
muscle  fibres,  which  in  places  have  been  almost  entirely  replaced  by  fat; 
there  may  be  no  trace  of  muscle  left,  tlie  structure  resembling  adipose 
tissue.  In  other  places  there  is  an  accumulation  of  fat  between  the 
atrophied  muscle  fibres,  and  a  very  great  increase  of  the  interstitial 
tissue. 

The  prognosis  is  grave,  most  patients  dying  before  adult  life  is 
reached.  The  diagnosis  is  generally  easy  from  the  apparent  hypertrophy 
and  actual  weakness  of  the  muscular  gi-bups.     The  disease  is  incurable. 

The  Juvenile  Form  of  Muscular  Atrophy, — This  is  much  less  frequent 
than  the  form  just  described,  but,  like  it,  begins  in  childhood  or  early 
youth.  It  is  characterised  by  progressive  wasting  of  certain  muscular 
groups,  especially  those  about  the  shoulders  and  pelvis,  and  hypertrophy 
of  others.  Of  the  shoulder  and  upper  extremity,  the  muscles  affected  are 
the  pectorals,  the  trapezius,  the  latissimus  dorsi,  the  serrati,  the  rhom- 
boidei,  the  muscles  of  the  upper  arm,  and  the  subscapularis.  The  deltoid, 
infra-spinatus  and  supra-spinatus  for  a  long  time  escape,  and  may  be 
hypertrophied.  The  hand  and  forearm  are  not  involved.  In  the  lower 
extremity,  the  muscles  of  the  pelvis,  thighs,  and  gluteal  regions  are 
affected,  while  those  of  the  leg  and  foot  escape.  With  tliis  atrophy  there 
may  be  associated  a  true  or  pseudo-hypertrophy  of  certain  muscular 
groups.  In  this  disease  there  are  no  fibrillary  contractions,  no  reaction 
of  degeneration,  and  no  sensory  disturbances.  The  course  and  result  of 
this  form  are  essentially  the  same  as  in  the  preceding  variety.  It  is  now 
generally  regarded  as  closely  allied  to  it  in  its  pathology,  the  most  im- 
portant difference  being  that  of  localisation. 

There  has  been  described,  chiefly  by  Landouzy  and  Dejerine,  another 
form  of  atrophy  known  as  the  infantile  facial  type.  In  this,  wasting 
begins  in  the 'muscles  of  the  face;  the  lips  are  thickened,  but  all  the 
rest  of  the  facial  muscles  are  markedly  atrophied,  giving  a  peculiar 
expression  to  the  mouth  known  as  "  the  tapir  mouth."  Later,  the 
atrophy  extends  to  the  shoulders  and  arms,  but  does  not  involve  the 
supra-spinatus  or  infra-spinatus,  or  the  flexors  of  the  hand  and  forearm. 
This  is  sometimes  described  as  beginning  in  the  shoulders,  or  even  in 
the  legs.  The  description  therefore  corresponds  to  the  juvenile  form 
of  Erb,  with  the  addition  of  facial  symptoms,  and  it  is  probably  a  variety 
of  the  same  disease. 


800  DISEASES  OF  THE   NERVOUS  SYSTEM. 

CONGENITAL   MYATONIA. 
(Oppenheim's  Disease.) 

This  disease  was  first  described  by  Oppenhcini  in  1900.  It  is  a 
congenital  condition  and  is  usually  noticed  soon  after  birtli.  The  strik- 
ing characteristic  is  the  loss  of  muscular  power  which  always  affects  the 
lower  extremities  and  these  chiefly.  The  arms  are  less  frequently  and 
less  seriously  involved.  In  many  instances  the  trunk  and  intercostal 
muscles  are  also  affected,  but  the  diaphragm,  the  muscles  of  deglutition 
and  those  supplied  by  the  cranial  nerves  usually  escape.  The  loss  of 
power  is  apparently  complete,  but  by  close  observation  a  few  feeble 
contractions  may  sometimes  be  made  out.  The  limbs  are  flaccid  and 
flail-like.  The  electrical  reactions  are  feeble  but  the  reaction  of  degen- 
eration is  not  present.  All  the  reflexes  are  diminished  and  the  patellar 
and  Achilles  reflexes  absent.  There  are  apparently  no  subjective  symp- 
toms. The  infants  are  usually  well  nourished  and  may  even  be  very 
fat.  In  those  who  live  for  several  months  or  years  the  intelligence  is 
apparently  normal  and  control  over  the  sphincters  complete.  The  major- 
ity of  the  children  suffering  from  this  disease  die  during  the  first  few 
months  frequently  of  pneumonia,  to  which  they  are  predisposed  by 
reason  of  the  condition  of  the  respiratory  muscles.  Some  few  that 
survive  beyond  this  period  show  a  slow  but  progressive  improvement. 
How  long  this  may  continue  is  as  yet  unknown. 

The  lesions  are  chiefly  in  the  muscles,  which  may  waste  to  fibrous 
cords  or  may  largely  be  replaced  by  connective  tissue  and  fat.  In 
several  of  the  cases  the  cells  of  the  anterior  horns  of  the  cord  have  been 
reduced  in  number,  sometimes  almost  absent,  and  the  anterior  nerve 
roots  atrophic.  The  nervous  lesion  is  regarded  as  a  failure  of  develop- 
ment rather  than  a  degeneration.  It  is  believed  by  some  to  be  the 
primary  condition,  the  lack  of  muscular  development  being  the  result 
of  deficient  innervation.  Little  can  be  expected  from  any  form  of 
treatment. 


CHAPTER    V. 
DISEASES  OF  THE  PERIPHERAL  NERVES. 

MULTIPLE   NEURITIS. 

Under  the  term  multiple  neuritis  are  included  those  cases  in  which 
several  nerves  are  involved  in  an  inflammatory  process,  which  may  at 
times  be  general.  In  its  distribution  multiple  neuritis  is  usually  sym- 
metrical, but  it  is  not  necessarily  so. 

Etiology. — The  chief  cause  of  multiple  neuritis  in  children  is  diph- 
theria, although  it  is  occasionally  seen  after  other  infectious  diseases. 


MULTIPLE   NEURITIS.  801 

especially  malaria,  typhoid  or  scarlet  fever,  measles,  and  mumps.  In 
diphtheria  the  inflammation  is  (hie  to  the  direct  action  of  the  toxines 
upon  the  nerve  structures,  since  it  can  he  induced  in  animals  l)y  injecting 
toxines  into  the  circulation.  There  is  little  doul)t  that  in  all  infectious 
diseases  the  inflammation  is  excited  in  a  similar  way.  The  metallic 
poisons,  lead  and  arsenic,  are  rarely  the  cause  of  multiple  neuritis  in 
early  life,  and  the  same  is  true  of  alcoliol,  although  a  marked  case  from 
this  cause  has  come  under  my  observation  in  a  child  only  three  years  old.^ 
Lastly,  there  are  cases  in  which  the  cause  assigned  is  simply  exposure 
to  cold — those  classed  as  rheumatic. 

Lesions. — Almost  any  nerves  in  the  body  may  be  affected,  although 
the  distribution  varies  somewhat  with  the  cause  of  the  disease.  The 
musculo-spiral  and  the  anterior  tibial  nerves  are  most  frequently  in- 
volved, but  the  inflammation  may  affect  any  of  the  spinal  nerves,  includ- 
ing the  phrenic,  and  occasionally  the  cranial  nerves,  especially  the  pneu- 
mogastric,  hypoglossal,  oculomotor,  and  abducens.  Several  nerves  in 
different  parts-  of  the  body  are  usually  affected,  the  lesion  being  in  most 
cases  symmetrical. 

The  affected  nerve  is  sometimes  red  and  swollen,  owing  to  acute  con- 
gestion and  oedema  or  a  sero-fibrinous  exudation.  In  other  cases  the 
changes  are  almost  entirely  degenerative.  The  microscope  shows  the 
changes  sometimes  to  be  chiefly  interstitial  and  sometimes  chiefly  paren- 
chymatous. There  is  an  exudation  of  cells  into  the  sheath,  between  the 
sheath  and  the  nerve  fibres,  and  even  between  the  nerve  fibres  themselves. 
The  myeline  breaks  up  into  granules,  and  in  places  may  completely  dis- 

^  This  case  was  in  many  respects  a  remarkable  one.  The  boy  completely  emptied 
a  decanter  containing  twelve  ounces  of  whisky,  but  almost  immediately  vomited  the 
greater  part  of  it.  He  soon  after  showed  the  symptoms  of  alcoholic  intoxication,  and 
in  a  few  hours  became  comatose,  in  which  condition  he  continued  for  twelve  hours. 
After  this  he  gradually  lost  power  in  his  legs,  and  at  the  end  of  a  week  was  unable  to 
walk  at  all.  He  had  convulsions,  and  after  this  there  developed  the  usual  symptoms 
of  meningitis  at  the  convexity,  with  which  he  was  admitted  to  the  Babies'  Hospital, 
three  weeks  after  drinking  the  whisky.  The  child  was  then  unconscious  and  there 
was  present  incomplete  paralysis,  affecting  all  four  extremities,  with  anaesthesia  of 
the  arms.  The  active  inflammatory  symptoms  continued  for  six  weeks  longer, 
during  which  time  there  were  repeated  convulsions,  continuous  stupor,  fever,  gradu- 
ally increasing  deformities,  marked  atrophy,  loss  of  reflexes,  and  great  diminution  in 
the  faradic  contractility  of  all  the  paralysed  muscles;  in  the  thighs,  left  leg,  and 
abdominal  muscles  there  were  no  responses  to  a  strong  current,  but  there  was  nowhere 
the  reaction  of  degeneration.  The  child  was  at  death's  door  for  three  or  four  weeks. 
Three  months  after  the  attack  the  first  signs  of  improvement  were  observed  in  the 
cerebral  symptoms.  Shortly  afterward  he  began  to  use  his  hands,  and  at  the  end  of 
six  weeks  he  was  walking  alone  and  talking  freely.  The  improvement  was  very 
rapid,  and  eight  weeks  from  the  date  of  the  first  change  for  the  better,  and  five  months 
from  the  time  of  taking  the  whisky,  he  was  as  well  as  ever.  The  diagnosis  was  mul- 
tiple alcohoUc  neuritis,  with  a  convexity  meningitis.  (Fig.  157  is  from  a  photograph 
taken  while  the  sjonptoms  were  at  their  height.) 
62 


802  DISEASES  OF  THE   NERVOUS  SYSTEM. 

appear.  The  late  changes  are  those  of  subacute  or  chronic  degeneration 
of  the  nerve  fibres. 

With  these  changes  in  the  nerves  there  are  associated,  in  some  cases, 
inflammatory  and  degenerative  changes  in  the  ganglion  cells  of  the 
spinal  cord,  although  they  are  much  less  severe  than  are  the  lesions  in 
the  nerves.  However,  they  were  once  regarded  as  the  explanation  of 
some  of  these  cases,  particularly  of  diphtheritio  paralysis. 

Symptoms. — The  onset  of  multiple  neuritis  is  in  most  cases  a  grad- 
ual one,  it  being  usually  from  two  to  four  weeks  before  the  paralysis 
reaches  its  height.  Very  exceptionally  the  onset  may  be  abrupt,  with 
fever,  and  marked  paralysis  in  a  few  days.  It  is  characteristic  of  this 
disease  that  both  motor  and  sensory  symptoms  are  present,  and  that  they 
are  the  same  in  their  distribution.  The  symptoms  are  usually  symmet- 
rical. There  is  first  noticed  a  general  weakness  in  the  affected  muscles, 
which  slowly  increases  to  complete  paralysis.  As  the  extensor  groups 
of  the  hands  and  feet  are  apt  to  be  affected,  there  are  wrist-drop  and 
foot-drop  (Fig.  157).     The  paralysis  may  begin  in  the  feet  and  hands, 


Fio.  157.— Alcoholic  Neuritis,  showing  Characteristic  Dropping  of  the  Feet. 
This  position  of  the  lower  extremities  was  maintained  for  over  a  month.  Boy  three 
years  old. 

and  gradually  extend  until  it  involves  not  only  the  four  extremities,  but 
even  the  muscles  of  the  trunk  and  the  neck,  although  this  is  rare.  The 
child  may  then  be  absolutely  helpless,  unable  to  sit  up,  or  even  to  support 
his  head.  In  such  cases  the  head  seems  loosely  attached  to  the  body,  and 
rolls  about  on  the  shoulders  like  a  ball.  Weakness  of  the  spinal  muscles 
leads  to  deformities  (Fig.  158),  which  I  have  seen  mistaken  for  Pott's 
disease,  even  by  experienced  observers.  In  most  of  the  muscular  groups 
the  paralysis  is  incomplete.  The  symptoms  whicli  relate  to  the  phrenic 
and  the  cranial  nerves  will  be  described  with  Diphtheritic  Paralysis,  for 
they  are  rarely  seen  in  any  other  form.'  It  is  characteristic  of  multiple 
neuritis  that  the  bladder  and  rectum  escape. 


MULTIPLE   NEURITIS. 


803 


The  sensory  symptoms  are  marked  only  in  the  early  stage  of  the  dis- 
ease, while  the  paralysis  is  increasing;  they  inijn-ove  so  much  more  rap- 
idly than  the  motor  symptoms,  that  they 
may  be  altogether  wanting  at  the  time 
that  the  paralysis  is  at  its  height.  In 
some  cases  they  are  so  slight  as  to  be 
overlooked.  There  is  usually  pain  along 
the  course  of  the  affected  nerves,  which 
is  sharp  and  neuralgic  in  character,  and 
generally  associated  with  acute  tender- 
ness of  the  nerve  trunks  and  of  the  mus- 
cles. Often  there  is  a  general  hyperges- 
thesia  in  the  early  part  of  the  attack, 
followed  by  partial  anaesthesia.  The 
sensations  of  touch,  pain,  temperature, 
and  the  muscular  sense  are  all  about 
equally  affected. 

Ataxia  is  not  uncommon,  and  may 
be  a  more  striking  symptom  than  the 
loss  of  power.  All  the  reflexes  are  di- 
minished or  lost,  especially  the  knee- 
jerk,  as  the  legs  are  usually  most  af- 
fected. Sometimes,  particularly  after 
diphtheria,  there  is  loss  of  the  knee-jerk, 
when  there  is  no  other  symptom  of  neu- 
ritis. In  the  severe  cases  muscular  tre- 
mor is  frequent. 

Atrophy  is  a  prominent  symptom  of 
neuritis,  and  it  is  evident  early  in  the 
disease,  often  being  quite  as  rapid  as  in 
poliomyelitis.  The  electrical  reactions 
are  altered — every  grade  of  reduction  in 
the  responses  being  seen,  from  a  slight  diminution  in  the  reaction  to  fara- 
dism  to  the  complete  reaction  of  degeneration.  Vaso-motor  symptoms, 
such  as  oedema  of  the  affected  parts,  glossiness  of  the  skin,  etc.,  are  often 
present.  Deformities  from  muscular  contraction  occur  early;  they  may 
be  severe,  and  in  some  cases,  permanent. 

Course  and  Prognosis. — The  usual  course  of  the  disease  is  for  the 
symptoms  gradually  to  increase  for  three  or  four  weeks  and  then  im- 
prove, sometimes  rapidly,  but  more  often  slowly,  the  case  usually  going 
on  to  complete  recovery  in  the  course  of  a  few  months.  Exceptionally 
the  paralysis  may  be  permanent.  The  sensory  symptoms  always  disap- 
pear before  the  motor  ones.  Multiple  neuritis  may  prove  fatal,  from 
paralysis  of  the  heart  or  the  muscles  of  respiration,  or  death  may  be  due 


Fig.  158.  —  Multiple  Neuritis 
AFTER  Diphtheria  in  a  Child 
Four  Years  Old.  The  position 
of  the  head  and  spine  is  due  to 
partial  paralysis  of  the  trunk  and 
neck.    The  legs  were  also  affected. 


804  DISEASES  OF  THE   NERVOUS  SYSTEM. 

to  asphyxia  from  the  entrance  of  food  or  foreign  hodies  into  the  air 
passages,  owing  to  anaesthesia  of  tiie  epiglottis  and  paralysis  of  the  mus- 
clgs  of  deglutition.  Death  sometimes  follows  from  complications,  espe- 
cially pneumonia.  The  electrical  reactions  are  of  much  prognostic  value 
in  regard  to  the  persistence  of  the  paralysis.  If  the  reaction  of  degenera- 
tion is  present  the  paralysis  is  certain  to  last  many  months,  and  some 
muscles  are  sure  to  be  permanently  affected.  Wliere  there  is  simply  a 
diminution  in  the  faradic  responses,  even  though  accompanied  by  marked 
atrophy,  complete  recovery  may  be  expected,  although  it  is  often  slow. 

Diagnosis. — The  diagnostic  features  of  multiple  neuritis  are  the  com- 
bination of  motor  and  sensory  symptoms  with  the  same  distribution,  the 
occurrence  of  atrophy,  and  the  diminution  in  the  electrical  responses, 
even  the  reaction  of  degeneration.  The  gradual  onset  and  the  wide- 
spread distribution  of  the  paralysis  are  also  characteristic.  If  all  four 
extremities  are  paralysed,  it  is  altogether  the  probable  disease ;  and  if  to 
this  is  added  paralysis  of  the  neck  and  spinal  muscles,  the  diagnosis  is 
almost  certain.  The  facts  that  the  paralysis  is  often  incomplete,  and 
that  it  involves  parts  distant  from  each  other,  are  also  important. 
Neuritis  may  be  mistaken  for  poliomyelitis,  for  Landry's  paralysis,  or  for 
Pott's  paraplegia ;  an  important  diagnostic  point  from  the  last  mentioned 
is  the  condition  of  the  reflexes — being  greatly  exaggerated  in  Pott's 
paraplegia,  while  they  are  diminished  or  lost  in  multiple  neuritis. 

Treatment. — As  this  disease  tends  in  the  great  majority  of  cases  to 
spontaneous  recovery,  it  is  difficult  to  estimate  the  value  of  any  method 
of  treatment.  Causes,  such  as  lead,  arsenic,  alcohol,  and  malaria,  are  to 
be  sought  and  removed  as  the  first  step.  During  the  acute  stage  the  pain 
may  be  so  severe  as  to  require  relief,  which  is  best  accomplished  by  the 
application  of  heat.  In  using  counter-irritation  care  is  necessary,  and 
such  active  measures  as  cauterisation  should  not  be  employed,  for  trouble- 
some ulceration  may  follow.  After  the  acute  stage  has  passed,  or  at 
the  end  of  three  or  four  weeks,  electricity  should  be  begun,  faradism 
being  used  if  the  muscles  respond  to  a  moderate  current,  otherwise  gal- 
vanism. This  should  be  continued  daily  until  recovery.  Strychnine  is 
much  used  in  these  cases,  but  it  is  doubtful  whether  it  has  any  specific 
influence,  although  as  a  tonic  it  is  valuable.  Other  tonics,  such  as  iron, 
quinine,  and  cod-liver  oil,  should  also  be  given.  Massage  is  also  bene- 
ficial. The  spinal  treatment  of  cardiac  and  respiratory  paralysis  will  be 
discussed  in  the  following  article. 

DIPHTHERITIC   PARALYSIS. 

This  is  not  only  the  most  frequent  variety  of  multiple  neuritis,  but 
it  has  some  peculiarities  which  make  a  separate  consideration  of  it 
desirable. 


DIPHTHERITIC  PARALYSIS.  805 

Frequency. — According  to  the  statistics  of  various  observers,  paralysis, 
including  all  varieties,  occurs  after  diphtheria  in  from  5  to  15  per  cent 
of  the  cases.  Sanne  gives  11  per  cent  in  2,448  cases;  Lennox  Browne,  14 
per  cent  in  1,000  cases  (in  neither  of  these  groups  did  the  patients  receive 
antitoxine)  ;  the  Keport  of  the  Collective  Investigation  by  the  American 
Psediatric  Society,  9.7  per  cent  of  3,384  cases  which  were  treated  by 
antitoxine. 

It  is  difficult  to  state  to  what  degree  the  frequency  of  paralytic 
sequelae  after  diphtheria  is  affected  by  the  antitoxine  treatment.  The 
figures  above  given  might  indicate  that  the  protective  power  of  the  serum 
over  the  nervous  tissues  is  not  so  great  as  over  others,  and  that  unless 
administered  very  early  it  has  little  or  no  influence.  The  more  probable 
explanation  of  the  frequency  with  which  paralysis  is  seen  after  antitoxine 
treatment  is  that  patients  now  live  long  enough  to  develop  paralysis, 
when  without  antitoxine  the  same  patients  would  have  died  during  the 
early  stage  of  the  disease. 

Being  one  of  the  direct  effects  of  the  diphtheria  toxine,  neuritis  is 
much  more  likely  to  follow  severe  than  mild  cases;  however,  its  occur- 
rence after  some  very  mild  attacks  shows  how  great  is  the  susceptibility 
of  the  nervous  tissues  to  the  action  of  this  poison.  Sometimes  the  throat 
symptoms  have  been  entirely  overlooked,  and  the  development  of  paraly- 
sis has  been  the  first  thing  to  arouse  a  suspicion  of  previous  diphtheria. 

Time  of  Occurrence. — During  the  second  week,  and  sometimes  even 
during  the  latter  part  of  the  first  week,  the  early  paralysis  occurs,  usu- 
ally affecting  the  palate.  The  most  frequent  and  most  characteristic 
paralysis — that  affecting  the  throat,  eyes,  extremities,  and  respiration — 
begins  at  a  later  period,  usually  from  one  to  three  weeks  after  the  throat 
has  cleared  off,  and  sometimes  even  later  than  this. 

Extent  and  Distribution  of  the  Paralysis. — Ross  gives  the  following 
statistics  of  171  collected  cases  of  diphtheritic  paralysis:  Palate  affected 
in  128 ;  eyes  in  77,  in  54  of  which  the  muscles  of  accommodation  were 
involved;  lower  extremities  in  113;  upper  extremities  in  60;  trunk  or 
neck  in  58;  muscles  of  respiration  in  33.  I  do  not  think  this  repre- 
sents the  actual  frequency  of  the  different  varieties  so  truly  as  do  the 
American  Paediatric  Society's  figures,  which  give  the  forms  of  paralysis 
noted  in  a  series  of  cases  collected  for  another  purpose.  In  328  cases  of 
paralysis,  the  variety  was  mentioned  in  18!) ;  in  124  the  throat  was 
affected;  in  22  the  extremities;  in  11  the  eyes;  in  5  the  muscles  of  respi- 
ration; in  32  the  heart;  in  1  the  neck  only;  in  8  the  paralysis  was 
"  general." 

Symptoms. — In  the  great  majority  of  cases  the  throat  is  affected,  and 
usually  the  paralysis  is  first  noticed  there.  It  may  involve  the  palate 
alone,  or  the  muscles  of  the  pharynx  or  larynx  in  addition.  The  muscles 
of  the  extremities  or  of  the  eye  are  often  next  attacked.    In  severe  cases 


806  DISEASES  OF  THE  NERVOUS  SYSTEM. 

there  may  also  be  involved  the  muscles  of  the  trunk  and  neck,  and  some- 
times the  diaphragm.  It  is  this  which  distinguishes  diphtheritic  paralysis 
from  other  forms  of  multiple  neuritis.  Whatever  the  extent  or  situation 
of  the  paralysis,  the  knee-jerk  is  nearly  always  lost.  The  symptoms  in  the 
extremities  and  the  trunk  do  not  differ  from  those  of  multiple  neuritis 
from  other  causes.  The  throat  paralysis  shows  itself  by  a  nasal  voice  and 
by  regurgitation  of  fluids  through  the  nose,  sometimes  by  difficulty  in 
swallowing  or  by  the  entrance  of  food  into  the  larynx,  owing  to  ana-sthesia 
of  the  epiglottis  and  paralysis  of  the  muscles  of  deglutition.  There  may 
be  difficulty  in  protruding  the  tongue  or  in  articulation.  Facial  paralysis 
is  very  rare.  On  the  part  of  the  eye  there  is  most  frequently  seen  in- 
ability to  read,  owing  to  paralysis  of  the  muscles  of  accommodation ;  there 
may  be  dilatation  of  the  pupils,  rarely  strabismus  or  ptosis. 

Respiratory  paralysis  may  be  due  to  involvement  of  the  phrenic  or  the 
intercostal  nerves,  more  frequently  the  former.  Extensive  paralysis  of 
other  parts — the  throat,  extremities,  or  trunk — usually  precedes.  The 
first  warning  is  generally  in  the  form  of  occasional  attacks  of  dyspnoea, 
sometimes  accompanied  by  cough.  Gradually  these  attacks  increase  in 
frequency  and  severity.  The  voice  is  reduced  to  a  whisper.  As  the 
diaphragm  is  usually  affected,  the  breathing  is  entirely  thoracic.  The 
respiratory  movements  are  rapid,  but  irregular,  shallow,  and  ineffectual. 
There  is  cyanosis,  also  great  subjective  as  well  as  objective  dyspnoea. 
The  anxiety,  distress,  and  apprehension  of  the  patient  are  sometimes 
terrible.  There  is  a  constant  dread  of  impending  suffocation,  and  ihe 
respiratory  movements  are  continued  only  by  the  patient's  constant  ef- 
forts, otherwise  they  would  cease  altogether.  After  a  few  hours  these 
severe  symptoms  may  subside,  to  return  after  a  short  respite.  There 
may  be  several  such  attacks  during  two  or  three  days,  in  each  of  whicli 
death  seems  imminent.  Unfortunately,  this  is  the  most  frequent  termi- 
nation. Of  thirty-three  such  cases  collected  by  Ross,  only  eight  recovered. 
Associated  with  these  respiratory  symptoms  others  may  be  present.  There 
may  be  attacks  of  abdominal  pain,  vomiting,  and  disturbance  of  the  heart's 
action — usually  an  irregular  or  intermittent  pulse,  which  may  be  either 
unnaturally  slow  or  very  rapid.  In  many  cases  the  heart  continiies  to 
beat  normally,  even  though  the  respiration  is  so  much  disturbed. 

The  premonitory  symptoms  of  cardiac  paralysis  are  an  irregular  or 
intermittent  pulse,  often  slow,  but  becoming  very  rapid  from  even  the 
slightest  exertion.  It  is  always  weak  and  compressible.  The  first  sound 
of  the  heart  is  feeble  and  may  be  reduplicated.  As  the  symptoms  increase 
there  are  marked  pallor,  coldness  of  the  extremities,  great  restlessness, 
anxiety,  precordial  distress,  and  perhaps  orthopncea.  Within  twenty- 
four  hours  from  the  beginning  of  such  symptoms  death  usually  occurs. 
In  other  cases  it  may  come  suddenly  without  any  warning,  or  with  a 
warning  so  slight  as  to  be  overlooked.     At  such  times  it  often  follows 


FACIAL  PARALYSIS.  807 

some  muscular  exertion,  such  as  getting  out  of  bed,  walking  across  the 
room,  or  so  slight  an  effort  as  sitting  up  suddenly  in  bed.  Fits  of  temper 
or  other  excitement  have  at  times  produced  it.  It  is  by  no  means  cer- 
tain that  cardiac  paralysis  is  due  to  a  lesion  of  the  cardiac  nerves. 
Toxic  myocarditis  appears  to  be  a  more  important  factor  in  producing 
the  fatal  result. 

Death  in  diphtheritic  paralysis  is  usually  due  either  to  cardiac  or 
respiratory  paralysis.  Of  171  cases  of  all  varieties  collected  by  Ross, 
forty-five  were  fatal. 

Treatment. — Cases  of  paralysis  of  the  trunk  or  extremities  are  to  be 
managed  like  others  of  multiple  neuritis.  In  severe  forms  of  throat 
paralysis  feeding  by  a  stomach  tube  should  be  employed,  on  account  of 
the  danger  of  the  entrance  of  food  into  the  air  passages.  It  must  in 
most  cases  be  continued  for  several  days.  Tlie  tube  may  be  passed 
either  through  the  mouth  or  the  nose. 

The  great  mortality  attending  paralysis  of  the  heart  and  respiration 
shows  how  unsuccessful  is  treatment  in  most  of  the  cases ;  still,  no  doubt 
there  are  instances  where  life  may  be  saved  by  judicious  treatment.  In 
cases  of  threatened  heart  paralysis,  the  drug  most  to  be  depended  upon 
is  morphine,  hypodermically ;  this  should  be  used  every  two  or  three 
hours  in  sufficient  doses  to  keep  the  patient  under  its  influence  while 
threatening  symptoms  are  present.  The  patient  sliould  be  kept  abso- 
lutely quiet,  not  even  being  allowed  to  turn  in  l)ed.  In  respiratory 
paralysis  the  general  reliance  is  upon  strychnine  used  hypodermically 
in  full  doses,  and  faradisation  of  the  respiratory  muscles,  particularly 
the  diaphragm. 

FACIAL  PARALYSIS. 

Peripheral  paralysis  of  the  face  occurring  as  a  result  of  injury  in- 
flicted during  delivery  has  already  been  described.  There  remain  to  be 
considered  here  cases  which  arise  from  causes  tliat  oi)erate  at  a  later  period. 
The  facial  nerve  may  be  affected  in  any  one  of  three  situations — after  its 
exit  from  the  cranium,  in  the  bony  canal,  and  within  the  cranium. 

In  the  first  situation,  the  principal  cause  of  neuritis  is  exposure  to 
cold  (the  "rheumatic"  cases),  but  it  occasionally  occurs  as  a  complica- 
tion of  mumps  and  disease  of  the  lymph  glands  of  this  region.  The  nerve 
is  affected  just  after  it  has  escaped  from  the'stylo-mastoid  foramen,  and 
all  the  branches  given  off  beyond  its  exit  are  involved.  There  is  paralysis 
of  the  muscles  of  the  forehead,  those  about  tlie  eye,  cheek,  nose,  and 
mouth.  The  affected  side  of  the  face  is  smooth,  there  is  inability  to 
wrinkle  the  forehead,  contract  the  eyebrows,  close  the  eye  completely, 
raise  the  nostril,  whistle,  or  blow.  The  mouth  is  drawn  to  the  healthy 
side  (Fig.  159).  If  the  paralysis  is  complete,  there  may  be  difficulty 
in  drinking  or  in  articulation.     In  partial  paralysis  the  symptoms  may 


808 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


not  be  noticeable  while  the  face  is  at  rest.  There  are  no  sensory  symp- 
toms. The  electrical  reactions  resemble  those  of  other  forms  of  neuritis ; 
there  is  diminution  in  the  response  to  the  faradic  current,  which  is  more 

or  less  marked  according  to  the  se- 
verity of  the  lesion,  and  there  may 
be  the  reaction  of  degeneration. 

In  the  bony  canal,  the  facial 
nerve  is  usually  inflamed  as  a  result 
of  disease  of  the  ear.  In  children 
this  is  much  more  frequent  than 
from  the  other  causes  just  men- 
tioned. While  it  occasionally  occurs 
with  acute  otitis,  it  generally  accom- 
"^  panics  the  chronic  form  with  caries 

of  the  petrous  bone  which  is  very 
often  tuberculous.  In  addition  to 
the  paralysis  there  is  present  or 
there  is  a  history  of  a  discharge  from 
the  ear,  and  generally  there  is  some 

Fig    159. -Facial  Paralysis  of  Right    deafness  Uiwn  the  side  affected.     The 
Side  from  Middle-ear  Disease  in  a  , 

Child  Two  AND  A  Half  Years  Old.        facial     symptoms     are     usually     the 

same  as  in  the  cases  first  described. 
However,  when  the  nerve  is  affected  between  the  stapedius  and  the  genicu- 
late ganglion,  there  is  a  disturbance  of  the  sense  of  taste,  and  of  the  secre- 
tion of  saliva.  Facial  paralysis  also  occurs  as  a  result  of  injury  to  the 
nerve  during  the  mastoid  operation. 

At  the  base  of  the  brain  the  trunk  of  the  nerve  may  be  involved  in 
cerebral  tumour,  basilar  meningitis,  and  in  fracture  of  the  skull.  In 
any  of  these  conditions  the  auditory  nerve  also  is  likely  to  be  affected. 

Prognosis. — The  result  is  greatly  modified  by  the  causes  in  the  dif- 
ferent cases.  In  those  which  are  due  to  cold,  spontaneous  recovery  usu- 
ally occurs  in  the  course  of  a  few  weeks  or  months.  In  those  depend- 
ing upon  disease  of  the  ear,  the  outlook  is  not  so  favourable,  and  though 
there  may  be  improvement,  it  is  not  rare  for  some  paralysis  to  be  per- 
manent. In  the  third  group  of  cases,  facial  paralysis  is  only  one  of  the 
symptoms,  and  the  result  depends  entirely  upon  the  nature  of  the  cause. 

Diagnosis. — Facial  paralysis  is  easily  recognised.  It  is  important  to 
separate  the  peripheral  paralysis  from  that  due  to  a  lesion  above  the 
pons,  as  in  cases  of  ordinary  hemiplegia.  In  the  latter  group  only  the 
lower  half  of  the  face  is  affected,  the  muscles  of  the  forehead  and  those 
about  the  eye  escaping,  and  the  electrical  reactions  are  unchanged. 

Treatment. — This  is  essentially  the  same  as  in  other  cases  of  neuritis. 
In  cases  due  to  ear  disease  the  primary  lesion  should  receive  appropriate 
treatment. 


SECTION  VIII. 

DISEASES  OF  THE  BLOOD,   LYMPH   NODES,  SPLEEN,  BONES, 

AND  JOINTS. 

CHAPTER    I. 
DISEASES  OF   THE  BLOOD. 

There  are  several  particulars  in  whicli  the  blood  of  infancy  and 
early  cliildhood  differs  from  that  of  older  persons. 

Specific  Gravity. — This  has  no  constant  relation  to  the  number  of 
white  or  red  corpuscles,  but  varies  with  the  amount  of  hgemoglobin.  The 
highest  specific  gravity  is  seen  in  the  blood  of  the  newly  born.  During 
the  first  two  weeks  of  life  it  sinks  rapidly  to  its  lowest  point,  where  it 
remains  until  about  the  end  of  the  second  year;  after  this  time  it  rises 
gradually  until  about  puberty.  The  average  specific  gravity  during 
childhood  is  1.050  to  1.055. 

Haemoglobin. — The  percentage  of  haemoglobin  is  highest  in  the  blood 
of  the  newly  born,  and  falls  rapidly  during  the  first  few  days  after  birth. 
Throughout  childhood  it  is  considerably  lower  than  in  adult  life.  The 
haemoglobin  is  lowest  between  the  third  month  and  the  second  year; 
after  the  second  year  it  gradually  increases  up  to  puberty.  The  usual 
range  in  young  children,  as  measured  by  the  adult  standard,  is  between 
sixty-five  and  eighty-five  per  cent,  sixty-five  per  cent  being  a  low  limit 
in  healthy  children. 

Red  Corpuscles. — The  number  of  red  corpuscles  is  highest  in  the 
newly  born.  At  this  time  it  is  from  4,350,000  to  6,500,000  in  each  cubic 
millimetre.  In  infancy  it  is  from  4,000,000  to  5,500,000 ;  in  later  child- 
hood, from  4,000,000  to  4,500,000  (Hay em).  In  size  a  much  greater 
variation  is  seen  in  the  red  cells  of  the  newly  born  than  in  those  of  older 
children  and  adults.  In  the  blood  of  the  foetus  there  are  present  nucle- 
ated red  corpuscles  or  normoblasts  (Plate  XV,  A).  These  diminish  in 
number  toward  the  end  of  pregnancy.  They  are  always  found  in  the 
blood  of  premature  infants,  but  in  infants  born  at  term  they  are  seen 
only  in  small  numbers  and  disappear  after  a  few  days.  In  later  infancy 
their  presence  is  always  pathological. 

Normal  White  Cells. — The  following  varieties  are  found  in  health: 

1.  Lymphocytes. — These  are  small  cells  about  the  size  of  a  red  blood 
cell.    The  protoplasm  is  small  in  amount,  forming  merely  a  narrow  rim 

809 


810  DISEASES  OF  THE   BLOOD. 

about  the  nucleus ;  it  stains  with  basic  dyes  rather  more  deeply  than  does 
the  nucleus.  The  nucleus  is  relatively  large,  is  centrally  situated,  and 
shows  at  times  one  or  two  nucleoli.  The  protoplasm  may  have  a  reticu- 
lar structure.  These  cells  form  in  adults  from  twenty-two  to  twenty- 
five  per  cent  of  the  white  corpuscles,  but  in  children  they  are  often  as 
high  as  fifty  or  sixty  per  cent  (Plate  XV,  B,  10). 

2.  Large  Mononuclear  Leucocytes  and  Transitional  Forms. — These 
cells  are  two  or  three  times  the  size  of  ordinary  red  cells  (Plate  XV,  D, 
10).  The  oval  nucleus  is  not  so  centrally  situated  as  in  the  lymphocytes, 
and  stains  feebly  but  rather  more  deeply  than  the  protoplasm,  which  is 
poorly  stained  by  basic  dyes.  The  protoplasm  is  homogeneous  and  rela- 
tively large  in  amount. 

The  transitional  forms  occasionally  contain  a  few  feebly  staining  neu- 
trophilic granules ;  their  nuclei  are  bent  or  curved  and  stain  more  deeply. 

3.  Polymorphonuclear  Neutrophiles. — These  are  smaller  than  the 
large  leucocytes  (Plate  XV,  B  and  C,  8).  The  nucleus  consists  of  three 
to  four  parts,  usually  connected  by  narrower  portions,  and  stains  darkly. 
The  protoplasm  stains  with  acid  dyes  and  shows  a  great  number  of 
granules  which  stain  only  with  neutral  dyes.  In  adults  these  cells  form 
about  seventy  per  cent  of  the  white  cells;  but  in  children  they  are  less 
numerous,  the  increase  in  the  lymphocytes  being  at  the  expense  of  the 
neutrophiles. 

4.  Eosinophiles. — These  are  about  the  same  size  as  the  neutrophiles 
(Plate  XV,  C,  9)  ;  they  have  deeply  staining  nuclei,  usually  divided 
into  two  parts.  The  protoplasm  has  many  large  granules  that  stain 
deeply  with  acid  dyes,  and  often  a  narrow  outer  layer  stains  more 
deeply  than  the  rest.  They  form  from  two  to  four  per  cent  of  the  total 
number  of  white  cells. 

5.  Mast  Cells. — They  are  only  occasionally  found,  their  proportion 
being  about  0.5  per  cent  of  the  white  cells;  they  are  mononuclear  or 
polymorphonuclear  cells  whose  granules  stain  only  with  basic  dyes,  not 
at  all  with  tri-acid;  often  they  are  metachromatic  (Plate  XV,  C,  13). 

Pathological  White  Cells. — Of  these  there  are  two  principal  forms: 

1.  Myelocytes. — They  have  neutrophilic  granules  and  a  single  rounded 
nucleus  (Plate  XV,  C,  11).  Ehrlich's  myelocytes  differ  from  those  of 
Cornil  in  that  the  cells  as  a  whole  are  smaller,  the  nuclei  are  more 
centrally  situated  and  stain  more  intensely. 

2.  Mononuclear  Eosinophiles. — These  resemble  the  polynuclear  eosin- 
ophiles, except  for  the  round  undivided  nucleus. 

Pathologically,  any  of  the  leucocytes  may  undergo  acute  or  chronic 
degeneration,  with  swelling  and  fragmentation,  nuclear  changes,  hydropic 
degeneration,  etc. 

The  number  of  leucocytes  in  the  blood  of  the  newly  born,  according 
to  Rieder,  is  at  birth  from  14,200  to  27,400  per  cubic  millimetre;  from 


PLATE  XV. 


B. 


Drawn  by  Dr.  F.  C.  Wood. 


A.  Blood  of  an"  Eight-Months'  Fcetus. 
C.  VON  Jaksch's  Anemia. 

1.  Red  cells,  normal. 

2.  Red  cells,  normoblasts. 

3.  Red  cells,  megaloblasts. 

4.  Red  cells,  showing  mitosis. 

5.  Red  cells,  poikilocytes. 

6.  Red  cells,  granular  degeneration. 


B.  Simple  Anemia. 

D.  Acute  Lymphatic  LEUKiEMiA.. 

7.  Red  cells,  polychromatophilia. 

8.  White  cells,  polyniiclear  neutrophiles. 

9.  "White  cells,  eosinophiles. 

10.  White  cells,  lymphocytes. 

11.  White  cells,  myelocytes. 

12.  White  cells,  mast  cells. 


LEUCOCYTOSIS.  811 

the  second  to  the  fourth  day,  from  8,700  to  12,400;  after  the  fourth  day, 
from  13,400  to  14,800.  The  variations  in  infancy  are  from  9,000  to 
14,000,  and  in  later  childhood  from  6,000  to  12,000. 

LEUCOCYTOSIS. 

By  leucocytosis  is  meant  an  increase  in  tlie  white  corpuscles  of  the 
blood.  This  may  relate  to  all  or  any  of  the  varieties;  although  it  is 
cliiefiy  of  the  polymorphonuclear  neutrophiles,  there  is  seen  m  children 
a  greater  tendency  than  in  adults  to  an  increase  in  the  lymphocytes. 

It  is  customary  to  distinguish  between  physiological  leucocytosis, 
such  as  that  which  follows  a  full  meal,  exercise,  cold  baths,  or  that  which 
occurs  in  the  newly-born  infant,  and  pathological  leucocytosis  which 
occurs  principally  in  inflammatory  and  toxic  conditions,  but  may  be  seen 
also  in  malignant  disease  and  after  serious  haemorrhage.  Digestive 
leucocytosis,  that  which  occurs  after  feeding,  is  especially  pronounced 
in  children,  the  increase  frequently  amounting  to  thirty-three  per  cent 
of  the  total  number  of  leucocytes  present.  Leucocytosis  of  the  newly 
born  has  already  been  mentioned. 

Leucocytosis  is  present  in  a  great  variety  of  pathological  conditions. 
In  many  of  them  its  significance  is  not  yet  fully  understood;  further 
study  of  it  has  not  fulfilled  the  expectations  of  those  who  had  hoped  to 
obtain  from  it  exact  information  regarding  many  pathological  processes. 

The  form  of  leucocytosis  which  is  chiefly  important  in  children  is  the 
inflammatory.  This  is  most  marked  in  acute  pneumonia,  diphtheria, 
and  in  inflammations  attended  by  the  formation  of  pus.  Leucocytosis 
is  also  frequently  present  in  scarlet  fever,  erysipelas,  acute  rheumatism, 
septic  and  cerebro-spinal  meningitis,  and  in  many  other  conditions. 
Of  the  purulent  inflammations,  it  is  especially  important  in  appendicitis, 
peritonitis,  emp3'ema,  pyaemia)  osteo-myelitis,  and  all  acute  abscesses. 
In  the  conditions  above  mentioned  the  increase  is  chiefly  or  exclusiviely 
in  the  polymorphonuclear  neutrophiles. 

There  are  other  conditions,  especially  pertussis,  hereditary  syphilis, 
and  certain  diseases  of  the  spleen,  in  which  the  proportion  of  the  lympho- 
cytes may  be  increased. 

The  eosinophiles  are  increased  in  leukaemia,  in  asthma,  with  intestinal 
parasites  especially  tapeworm,  hookworm  and  trichinae,  and  in  some 
forms  of  chronic  skin  disease. 

As  a  rule,  leucocytosis  is  absent  in  typhoid  fever,  measles,  malaria, 
influenza,  and  in  tuberculous  inflammations.  It  is  wanting  in  the  usual 
forms  of  gastro-enteritis  of  infants  although  it  is  marked  in  the  type 
known  as  "  Finkelstein's  food  intoxication." 

Leucocytosis  may  be  regarded  as  the  reaction  of  the  organism  to  the 
toxines  in  the  blood  elaborated  by  the  bacteria  concerned  in  the  inflam- 
mation or  infection,  or  to  the  bacteria  themselves.     It  thus  depends 


812  DISEASES  OF  THE  BLOOD. 

upon  two  factors:  the  severity  of  the  infection,  and  the  amount  of  re- 
sistance of  the  individual,  the  latter  being  the  more  important.  A  severe 
infection  with  a  high  degree  of  resistance  produces  the  most  marked 
leucocytosis,  while  with  very  feeble  resistance  and  the  same  infection  the 
leucocytosis  is  slight  or  possibly  absent.  The  degree  of  leucocytosis  is  also 
influenced  by  the  nature  of  the  inflammatory  process,  it  being  less  marked 
in  serous  inflammations  and  more  pronounced  in  suppurative  processes. 
In  inflammations  it  is  usually  greatest  during  the  active  stage  of  exu- 
dation. 

The  Diagnostic  Value  of  Leucocytosis. — The  following  are  the  prin- 
cipal diseases  in  which  a  leucocyte  count  may  be  of  clinical  assistance: 

Appendicitis. — A  leucocytosis  usually  exists  from  the  beginning;  a 
marked  or  steadily  increasing  leucocytosis  is  to  be  regarded  as  an  im- 
portant indication  for  operation. 

Pneumonia. — A  marked  leucocytosis  is  a  characteristic  feature  of 
this  disease;  the  exceptions  are  very  mild  cases  or  very  severe  infections 
with  little  or  no  reaction.  The  increase  begins  shortly  after  the  onset 
and  continues  during  the  stage  of  exudation,  generally  reaching  its 
maximum  shortly  before  the  crisis,  when  it  declines  rapidly.  The  usual 
number  of  white  cells  in  an  average  case  of  pneumonia  in  a  young  child 
is  from  15,000  to  30,000,  but  it  is  not  rare  for  the  count  to  run  up  to 
40,000  or  even  50,000.  I  have  seen  it  over  100,000.  The  absence  of 
leucocytosis  in  a  strong  child  who  is  acutely  ill  is  always  strong  presump- 
tive evidence  against  pneumonia.  A  well-marked  leucocytosis  is  of  much 
value  in  differentiating  pneumonia  from  typhoid  fever,  tuberculosis, 
influenza,  or  bronchitis. 

Empyema. — A  rapid  increase  in  the  leucoc}i;es  in  the  active  stage  of 
a  pneumonia  or  after  defervescence,  in  the  absence  of  physical  signs 
pointing  to  an  extension  of  the  pneumonic  process,  almost  invariably 
indicates  empyema.  After  the  acute  stage  of  empyema  has  passed  there 
may  be  no  leucocytosis  whatever. 

Typhoid  Fever. — Leucocytosis  is  regularly  absent  in  typhoid ;  its 
presence  in  an  undoubted  case  indicates  complications. 

Pertussis. — A  leucocytosis  with  a  high  proportion  of  lym))hocytes  is 
of  considerable  value  in  the  diagnosis  of  this  disease;  it  is  more  fully 
considered  in  the  special  chapter  devoted  to  Pertussis. 

Meningitis. — As  a  rule,  a  marked  leucocytosis  is  present  in  all  forms 
of  acute  meningitis  except  the  tuberculous.  In  the  latter  variety  it  is 
not  constant,  and  if  present  is  generally  less  marked  than  in  the  other 
forms. 

Tuberculosis. — Leucocytosis  is  regularly  absent  in  unmixed  tuber- 
culous infections.     It  is  occasionally  found  in  tuberculous  meningitis. 

In  surgical  diseases  the  presence  of  leucocytosis  is  considered  a  reli- 
able guide  as  to  the  existence  of  acute  suppuration,  although  not  always 


SIMPLE  ANiEMIA.  813 

as  to  its  degree.  An  increasing  leucocytosis  is  usually  an  indication  for 
operative  interference  in  cases  where  operation  is  admissible.  This 
applies  particularly  to  appendicitis. 

SIMPLE  ANiEMIA. 

This  consists  in  an  impoverishment  of  the  blood,  especially  the  red 
cells,  and  a  corresponding  diminution  in  the  specific  gravity  and  in  the 
amount  of  haemoglobin.  It  is  essentially  a  secondary  anj^mia,  and  occurs 
apart  from  disease  of  the  blood-making  organs.  Infancy  and  childhood 
are  themselves  strong  predisposing  causes  of  anaemia,  on  account  of  the 
great  demands  made  upon  the  blood  in  the  rapid  growth  of  the  body. 

Etiology. — The  causes  of  anaemia  embrace  a  wide  range  of  patholog- 
ical conditions.  A  child  born  of  a  delicate  mother  or  of  one  suffering 
from  tuberculosis  or  syphilis  may  show  marked  anaemia  at  birth.  It  may 
follow  any  severe  haemorrhage  or  occur  in  any  of  the  blood  dyscrasise, 
purpura,  scurvy,  etc. ;  also,  the  severe  drain  of  prolonged  suppuration, 
chronic  nephritis,  large  serous  effusions,  many  forms  of  diarrhoea  and  in 
malignant  disease.  Anaemia  is  often  of  toxic  origin,  sometimes  being 
due  to  mineral  poisons — lead,  mercury,  or  potassium  chlorate;  more 
frequently  it  arises  as  the  result  of  absorption  of  the  products  of  ex- 
cessive intestinal  putrefaction.  Certain  of  the  specific  infections,  nota- 
bly diphtheria,  malaria,  tuberculosis  and  rheumatism,  produce  a  marked 
degree  of  anaemia,  as  one  of  their  effects;  also  some  of  the  intestinal 
parasites,  particularly  varieties  of  the  tapeworm  and  hookworm. 

Much  more  frequent  in  young  children  than  any  of  the  above  are  the 
anaemias  due  to  improper  feeding,  rickets,  and  unhygienic  surround- 
ings. How  important  these  causes  are  and  how  severe  a  grade  of  anaemia 
may  be  produced  by  them,  is  not  usually  appreciated.  The  physician  is 
often  led  to  suspect  some  serious  organic  or  constitutional  disease  when 
none  exists  and  to  overlook  such  common  conditions  and  obvious  causes 
as  those  mentioned.  Anaemia  is  seen  when  lactation  is  unduly  prolonged. 
It  is  a  frequent  result  of  the  long-continued  use  of  milk  or  infant  foods 
as  the  sole  diet,  given,- as  these  often  are,  throughout  the  second  or  third 
year,  for  the  reason  that  the  child  will  take  no  solid  food,  because  he 
is  allowed  to  have  the  bottle.  Lack  of  fresh  air,  confinement  to  over- 
heated rooms  and  the  crowding  of  young  children  in  hospitals  and  insti- 
tutions are  common  and  important  causes  of  anaemia. 

Symptoms. — Anaemic  children  usually  exhibit  many  symptoms  of 
malnutrition.  Their  tissues  are  flabby ;  they  are  generally  below  average 
weight  and  suffer  from  digestive  disturbances  and  chronic  constipation. 
The  associated  nervous  sjTnptoms  are  many :  headaches,  indefinite  pains, 
insomnia  or  disturbed  sleep,  general  irritability  and  a  high  degree  of 
nervousness.  There  is  easy  fatigue,  shortness  of  breath  on  exertion,  and 
sometimes  fainting  attacks.    The  peripheral  circulation  is  poor ;  the  hands 


814 


DISEASES  OF  THE  BLOOD. 


and  feet  are  often  cold.  The  pulse  may  be  slightly  irregular.  AncEmie 
murmurs  are  heard  over  the  base  of  the  heart  or  the  large  vessels,  and 
may  be  so  loud  even  in  infancy  as  to  be  mistaken  for  organic  disease. 
A  venous  hum  is  sometimes  heard  in  the  neck.  Epistaxis  is  not  uncom- 
mon. The  urine  is  scanty  and  sometimes  pale.  There  may  be  enuresis. 
(Edema  is  rare  in  older  children,  but  in  severe  anaemias  of  infancy  it  is 
often  marked.  In  a  certain  number  of  cases,  even  of  moderate  severity, 
the  spleen  is  much  enlarged.  Pallor  of  the  skin  and  mucous  membranes 
is  present  in  most  cases,  but  is  not  an  accurate  guide  as  to  the  degree  of 
anaemia.    This  can  only  be  determined  by  an  examination  of  the  blood. 

The  Blood. — There  is  a  reduction  of  the  number  of  red  cells  and  to 
a  still  greater  degree  in  the  haemoglobin.  In  a  case  of  moderate  severity 
the  red  cells  are  from  4,000,000  to  4,500,000,  and  the  haemoglobin  from 
fifty  to  sixty  per  cent.  In  severe  cases  the  red  cells  may  fall  to  2,000,000 
or  2,500,000  or  even  lower,  and  the  haemoglobin  to  twenty  or  thirty  per 
cent.  These  figures  are  not  uncommon.  The  lowest  I  have  seen  is  a 
reduction  of  the  haemoglobin  to  fifteen  per  cent  and  of  the  red  cells  to 
1,400,000.  The  red  cells  are  pale.  There  is  usually  poikilocytosis  and 
anisocytosis ;  and,  especially  in  infancy,  a  few  normoblasts  and  megalo- 
cytes  may  be  found  (Plate  XV,  B). 

There  is  generally  a  slight  leucocytosis.  The  differential  count  of 
the  white  cells  shows  an  increase  in  the  lymphocytes,  chiefly  the  small 
variety;  the  polymorphonuclear  cells  are  relatively  reduced  in  number. 

Prognosis. — The  course  and  termination  of  anaemia  depend  upon  its 
cause.  If  this  is  one  that  can  be  removed,  as  in  cases  depending  upon 
improper  feeding  and  surroundings,  very  rapid  improvement  often  takes 
place  and  prompt  recovery.  In  the  most  severe  cases  death  may  occur, 
rarely  from  the  anaemia,  usually  from  some  complicating  disease. 

In  making  a  prognosis  in  a  given  case  the  general  symptoms  and  the 
cause  of  the  anaemia  are  much  more  important  than  the  examination  of 
the  blood.  If  the  digestive  organs  are  in  good  condition  and  good  sur- 
roundings can  be  secured,  often,  though  the  haemoglobin  and  red  cells 
are  very  greatly  reduced,  the  prognosis  is  good.  But  in  unfavourable 
surroundings  and  with  a  greatly  disordered  digestion,  the  outlook  is 
much  more  serious. 

Typical  blood  examinations  of  a  moderate  and  of  a  severe  case  of 
secondary  anaemia  in  a  young  child  are  as  follows: 


Severe  Anemia. 

Haemoglobin 20  per  cent. 

Red  blood  cells 2,500,000 

White  cells 12,000 

Polymorphonuclear 30  per  cent. 

Small  mononuclear 45  per  cent. 

Large  mononuclear 25  per  cent. 

Other  forms 5  per  cent. 


Moderate  AWiEMiA. 

Haemoglobin 50  per  cent. 

Red  blood  cells 4,000,000 

White  cells 10,000 

Polymorphonuclear 40  per  cent. 

Small  mononuclear 25  per  cent. 

Large  mononuclear 20  per  cent. 

Other  forms 5  per  cent. 


CHLOROSIS.  815 

The  treatment  of  all  the  forms  of  anaemia  will  be  considered  together 
at  the  close  of  the  chapter. 

CHLOROSIS. 

Chlorosis  is  a  primary  or  essential  anaemia  which  usually  occurs  in 
young  girls  about  the  time  of  puberty.  It  is  characterised  by  a  peculiar 
greenish-yellow  tint  of  the  skin,  and  is  not  accompanied  by  emaciation. 
The  changes  in  the  blood  consist  in  a  very  great  reduction  in  the  haemo- 
globin without  a  corresponding  diminution  in  the  red  corpuscles. 

Etiology. — The  exact  cause  of  chlorosis  is  not  yet  understood.  The 
disease  rarely  occurs  in  males;  it  is  usually  seen  in  girls  between  the 
fourteenth  and  seventeenth  years,  and  more  often  in  blondes  than  in 
brunettes.  Heredity  appears  to  be  a  factor  in  some  cases.  Other  causes 
are  occupations  deleterious  to  health,  such  as  employment  in  factories 
or  confinement  in  ill-ventilated  rooms ;  insufficient  food  or  clothing ; 
psychical  disturbances,  like  grief,  care,  or  fright;  excessive  mental  or 
physical  strain,  and  disorders  of  menstruation — although  the  latter  are 
perhaps  more  frequently  a  result  than  a  cause  of  the  disease.  Virchow 
first  called  attention  to  the  fact  that  chlorosis  might  depend  upon  a 
congenital  narrowing  of  the  aorta,  sometimes  associated  with  a  small 
heart.  It  is  difficult  to  reconcile  this  etiology  with  the  rapid  recovery 
under  appropriate  treatment  which  is  seen  in  most  of  the  cases.  Andrew 
Clark  has  advanced  the  view  that  the  chief  cause  of  chlorosis  is  constipa- 
tion and  the  resulting  absorption  of  toxic  materials  from  the  intestine. 

Lesions. — Chlorosis  is  rarely  fatal.  In  the  few  fatal  cases  the  lesions 
noted  have  been  dilatation  of  the  right  heart  with  hypertrophy  of  the  left 
ventricle,  a  small  aorta,  small  uterus  and  ovaries,  and  occasionally  round 
ulcer  of  the  stomach.  Under  the  microscope  there  may  be  found  a  very 
marked  degree  of  fatty  degeneration  of  the  heart  muscle,  and  sometimes 
of  the  inner  coat  of  the  blood-vessels. 

Symptoms. — The  general  symptoms  of  chlorosis  are  very  much  like 
those  of  simple  anaemia.  There  are  observed  shortness  of  breath  upon 
exercise,  palpitation,  syncope,  attacks  of  vertigo,  disturbances  of  diges- 
tion, amenorrhcea,  and  almost  invariably  constipation.  The  appetite  is 
capricious,  it  being  a  peculiarity  of  these  patients  to  crave  all  sorts  of 
indigestible  articles.  Instead  of  the  usual  pallor  of  anaemia,  the  skin 
has  a  yellowish-green  tint,  from  which  the  term  "  green-sickness  "'  has 
arisen.  Occasionally  patches  of  pigmentation  are  seen.  Anaemic  cardiac 
murmurs  may  be  heard  in  various  situations,  most  frequently  a  systolic 
murmur  at  the  base  of  the  heart,  and  usually  loudest  over  the  pulmonic 
area.  There  may  be  a  venous  hum  in  the  neck.  In  some  marked  cases 
there  is  evidence  of  slight  cardiac  dilatation,  especially  of  the  right 
heart,  and  there  may  be  hypertrophy  of  the  left  ventricle.  The  pulse  is 
weak  and  soft,  cedema  of  the  feet  is  frequent,  and  sometimes  there  is 


816  DISEASES  OF  THE   BLOOD. 

slight  albuminuria.  In  some  cases  there  is  fever.  Nervous  disturbances, 
such  as  vague,  indefinite  pains,  attacks  of  migraine,  supra-orbital  neu- 
ralgia, various  hysterical  manifestations,  and  chorea,  are  common.  Ulcer 
of  the  stomach  is  sometimes  seen  as  a  complication. 

The  Blood. — The  specific  gravity  is  reduced  in  proportion  to  the  loss 
of  haemoglobin.  The  cliaracteristic  feature  of  chlorosis  is  a  loss  of  haemo- 
globin which  is  out  of  proportion  to  the  reduction  in  the  red  cells.  The 
haemoglobin  in  an  ordinary  case  is  frequently  as  low  as  thirty-five  or 
forty  per  cent,  while  the  red  cells  may  be  3,500,000  to  4,000,000,  or  even 
higher. 

Morphologically  the  cells  are  pale  with  a  wide  central  clear  area. 
Poikilocytosis  may  be  present,  but  is  not  marked;  rarely  normoblasts 
may  be  found.  The  presence  of  megalocytes  is  disputed.  The  leuco- 
cytes are  usually  unchanged  in  number  and  proportion,  but  tlie  lympho- 
cytes may  be  relatively  increased. 

Prognosis. — The  course  of  the  disease  is  essentially  a  chronic  one, 
often  lasting  for  a  year.  Relapses  are  quite  frequent.  Except  when  de- 
pendent upon  congenital  malformations  of  the  heart  and  blood-vessels, 
these  cases  regularly  recover  when  proper  treatment  can  be  carried  out. 
A  small  number  prove  fatal  by  the  development  of  tuberculosis  or  the 
occurrence  of  gastric  ulcer. 

Diagnosis.— A  probable  diagnosis  is  in  most  cases  easily  made  from 
the  etiology,  the  functional  derangement  of  the  heart,  the  colour  of  the 
skin,  and  a  positive  diagnosis  always  by  an  examination  of  the  blood. 

PSEUDO-LEUK^MIC  AN.EMIA  OF  INFANCY. 

This  form  of  anaemia  was  first  described  by  Von  Jaksch  in  1889,  and 
is  by  him  believed  to  be  peculiar  to  infants  and  young  children.  It  is 
characterised  by  marked  leucocytosis,  marked  reduction  in  the  number 
of  red  cells  and  in  the  haemoglobin,  a  great  enlargement  of  the  spleen, 
and  sometimes  a  moderate  enlargement  of  the  liver  and  the  lymphatic 
glands.  This  disease  is  not  to  be  confounded  with  the  pseudo-leukaemia 
of  adults,  or  with  Hodgkin's  disease,  which  is  a  disease  of  the  lymphatic 
glands  with  secondary  anaemia,  but  without  any  leucocytosis. 

The  existence  of  pseudo-leukaemic  anaemia  as  a  distinct  disease  is 
denied  by  most  of  the  authorities  on  diseases  of  the  blood.  It  is  to  be 
regarded  as  a  symptom-complex.  All.  the  reported  cases  can  be  classed 
as  severe  secondary  anaemia,  pernicious  angemia,  or  leukaemia. 

Etiology. — Of  the  cases  thus  far  recorded  the  majority  have  been 
between  the  ages  of  seven  and  twelve  months.  Of  twenty  cases  collected 
by  Monti  and  Berggriin,  sixteen  showed  evidences  of  rickets  and  one 
was  syphilitic.  The  exact  cause  of  the  disease  is  still  unknown,  and 
its  essential  nature  is  a  matter  of  some  doubt.     Monti  believed  that  it 


PSEUDO-LEUKiEMlC  ANEMIA  OF  INFANCY.  817 

might  develop  from  the  more  severe  cases  of  antemia  which  are  accom- 
panied by  leucocytosis,  as  he  observed  this  condition  before  the  devel- 
opment of  pseudo-leuksemia  and  during  its  subsidence. 

Lesions. — The  most  characteristic  change  is  found  in  tlie  spleen, 
which  is  very  much  enlarged,  often  forming  an  abdominal  tumour  of 
considerable  size.  It  is  firm,  hard,  and  there  may  be  evidences  of  peri- 
splenitis. The  microscope  shows  a  simple  hyperplasia.  Enlargement  of 
the  liver  is  less  constant,  it  being  normal  in  more  than  half  the  cases. 
There  is  no  relation  between  the  size  of  the  spleen  and  that  of  the  liver. 
The  hepatic  cells  are  unchanged.  Enlargement  of  the  lymph  glands  has 
been  noted  in  about  half  the  reported  cases,  the  swelling  affecting  the 
cervical,  axillary,  or  inguinal  glands;  but  it  is  rarely  great.  Inconstant 
changes  in  the  bone-marrow  have  been  described. 

Sjonptoms. — The  Blood. — The  number  of  reported  cases  is  as  yet  too 
small  to  make  positive  statements  possible  upon  all  points.  The  main 
features  noted  thus  far  are  the  following  (Plate  XV,  C)  : 

The  specific  gravity  is  lowered,  the  usual  range  being  between  1 .  035 
and  1 .  044.  The  reduction  of  the  haemoglobin  is  very  great ;  in  many  of 
the  cases  it  has  been  as  low  as  thirty  per  cent,  and  in  a  few  below  twenty- 
five  per  cent. 

The  red  cells  are  always  diminished ;  in  six  of  twenty  cases  they  were 
below  1,600,000  (Monti  and  Berggriin).  There  is  also  great  inequality 
in  their  size  and  shape.  Nucleated  red  cells  are  found  in  considerable 
numbers;  as  a  rule,  these  are  chiefly  normoblasts,  but  when  the  anaemia 
becomes  more  severe,  it  is  usually  the  megaloblasts  that  predominate. 
The  leucocytes  vary  from  20,000  to  50,000.  They  may  show  an  increase 
in  the  mononuclear  or  in  the  polynuclear  forms.  The  eosinophiles  are 
usually  increased,  but  not  to  the  extent  to  suggest  leukaemia.  All  vari- 
eties of  cell  degeneration  are  found. 

The  general  symptoms  of  the  disease  develop  slowly  and  with  the 
usual  signs  of  anaemia.  In  some  cases  the  infants  continue  to  be  plump 
and  well  nourished.  Pallor  is  usually  very  marked.  Enlargement  of 
the  spleen  is  so  great  that  it  can  hardly  be  overlooked  if  the  abdomen  is 
examined.  The  glandular  enlargements  are  not  marked,  and  in  many 
cases  are  wanting  altogether. 

The  course  of  the  disease  is  essentially  chronic.  Cases  have  been  seen 
in  which  pseudo-leuksemia  developed  from  an  ordinary  severe  simple 
anaemia  in  the  course  of  a  few  weeks.  The  symptoms  and  blood  changes 
generally  come  on  slowly  in  the  course  of  weeks  or  months,  and  some- 
times remain  nearly  stationary  for  as  long  a  period  as  several  months, 
and  then  slowly  improve.  In  other  cases  they  grow  gradually  worse.  In 
the  cases  going  on  to  recovery,  there  is  noticed  improvement  in  the  gen- 
eral symptoms  coincident  with  a  diminution  in  the  size  of  the  spleen,  a 
reduction  in  the  number  of  leucocytes,  an  increase  in  the  red  cells,  the 
63 


818  DISEASES  OF  THE   BLOOD. 

haemoglobin,  and  the  specific  gravity,  and  a  gradual  disappearance  of  the 
nucleated  red  cells. 

Prognosis. — In  Monti's  list  of  twenty  cases  four  proved  fatal;  one 
recovered,  in  which  the  proportion  of  leucocytes  to  tlie  red  cells  had 
been  one  to  twelve.  The  prognosis  should  be  guarded,  for,  although 
improvement  may  take  place,  many  patients  die  from  intercurrent 
disease. 

PERNICIOUS  ANEMIA. 

This  is  the  most  severe  form  of  anaemia  known.  Its  cause  and  essen- 
tial nature  are  as  yet  very  imperfectly  understood.  It  is  characterised  by 
quite  uniform  blood  changes  and  by  the  general  symptoms  of  a  very 
marked  anaemia,  and  it  tends  to  go  on  from  bad  to  worse,  terminating 
fatally  in  the  great  proportion  of  cases. 

Etiology. — Pernicious  anaemia  is  a  rare  disease  in  childhood,  and 
especially  rare  in  infancy.  In  the  cases  which  have  been  observed  in 
early  life  the  following  etiological  factors  have  been  noted :  It  has  been 
associated  with  hereditary  syphilis  and  with  severe  rickets,  especially 
when  accompanied  by  a  marked  enlargement  of  the  spleen.  It  has  fol- 
lowed other  diseases,  especially  grave  disturbances  of  nutrition.  Some- 
times simple  anaemia,  when  severe  and  of  long  standing,  has  gradually 
developed  into  the  pernicious  type.  In  a  few  instances  parasites,  partic- 
ularly tapeworms,  have  been  the  cause.  Pernicious  anaemia  has  in  some 
instances  occurred  in  patients  when  no  cause  whatever  could  be  assigned. 

Many  theories  have  been  advanced  in  explanation  of  pernicious  anae- 
mia. The  one  which  at  present  appears  to  have  most  in  its  favour  is 
that  the  disease  consists  in  a  great  destruction  of  the  red  blood-cells, 
particularly  in  the  liver,  and  that  this  is  brought  about  through  the 
agency  of  some  poison  or  poisons  taken  up  from  the  intestine  by  the 
portal  circulation.  This  has  been  advanced  by  Hunter  and  others  in 
explanation  of  the  peculiar  deposit  of  iron  found  in  the  hepatic  cells. 

Lesions. — There  is  found  a  very  high  grade  of  anaemia  in  all  the  in- 
ternal organs,  fatty  degeneration  of  the  heart  and  blood-vessels,  and 
sometimes  also  of  the  liver  and  kidneys,  with  numerous  capillary  haemor- 
rhages in  the  various  organs.  The  most  characteristic  post-mortem 
change,  however,  consists  in  the  deposit  of  iron  in  the  hepatic  cells.  Its 
distribution  is  peculiar  and  unlike  that  seen  in  any  other  disease.  The 
bone  marrow  is  also  markedly  altered. 

Symptoms. — The  Blood. — The  specific  gravity  of  the  blood  in  perni- 
cious anaemia  is  constantly  and  considerably  reduced,  and  its  coagulabil- 
ity is  feeble.  The  haemoglobin  is  always  reduced,  usually  it  is  as  low  as 
from  twenty  to  thirty  per  cent.  The  red  cells  are  always  much  dimin- 
ished in  number  and  generally  to  a  degree  greater  than  the  reduction  in 
the  haemoglobin.     Their  number  is  seldom  greater  than  2,000,000,  and 


PERNICIOUS  ANEMIA.  819 

frequently  less  than  1,000,000.  Megalocytes  are  present,  often  in  great 
numbers,  and  a  preponderance  of  them  is  regarded  essential  to  the 
diagnosis.  Microcytes  are  rare.  It  is  characteristic  of  pernicious  anae- 
mia that  owing  to  the  relatively  high  haemoglobin  content  the  red  cells 
stain  well,  usually  deeper  than  in  normal  blood.  A  striking  feature  of 
these  cases  is  the  presence  of  extreme  poikilocytosis.  Nucleated  red  cells 
are  also  present,  megaloblasts  in  greater  numbers  than  normoblasts.  The 
red  cells  do  not  collect  to  form  rouleaux. 

The  total  number  of  leucocytes  is  markedly  diminished,  but  the  lym- 
phocytes may  be  relatively  increased.  An  occasional  myelocyte  may  be 
found. 

The  general  symptoms  are  those  of  a  most  intense  anaemia.  There 
is  marked  pallor  of  the  skin  and  mucous  membranes,  with  great  weak- 
ness and  prostration.  Various  anaemic  heart  murmurs  are  heard.  There 
is  dyspnoea,  and  usually  the  urine  is  scanty  and  of  low  specific  gravity. 
There  may  or  may  not  be  emaciation.  The  late  symptoms  are  haemor- 
rhages from  the  nose  and  other  mucous  membranes,  subcutaneous  ecchy- 
moses  with  dropsy  of  the  feet  and  ankles,  and  sometimes  of  the  large 
serous  cavities  of  the  body,  but  without  albuminuria.  In  many  cases 
fever  is  present.  This  may  be  so  high  as  to  lead  to  the  suspicion  of 
some  acute  infectious  process. 

The  course  of  the  disease  is,  as  a  rule,  more  rapid  than  in  adults, 
the  duration  being  in  most  cases  but  a  few  months;  it  is  marked  by 
periods  of  exacerbation  and  remission.  During  the  exacerbations  all  the 
symptoms  are  intensified,  and  as  a  rule  some  fever  is  present.  During 
the  remissions  marked  improvement  may  take  place  in  all  the  symptoms 
and  an  increase  in  the  haemoglobin  and  red  cells  occur.  In  general,  the 
progress  of  the  disease  is  downward  and  sometimes  the  rate  is  very  rapid. 
The  only  exceptions  are  the  cases  in  which  the  disease  depends  upon 
some  intestinal  parasite,  when  improvement  and  even  recovery  may 
occur. 

Treatment  of  the  Different  Forms  of  Anaemia. — In  secondary  anaemia 
the  thing  of  the  first  importance  is  to  discover  and  treat  the  primary 
condition  upon  which  the  anaemia  depends.  In  infancy,  special  atten- 
tion should  be  given  to  diet  and  hygiene,  particularly  with  reference  to 
an  abundant  supply  of  fresh  air.  The  whole  manner  of  life  of  these 
patients  must  be  carefully  studied  and  managed  according  to  the  direc- 
tions laid  down  in  the  chapter  upon  Malnutrition,  with  which  condition, 
especially  in  infancy,  a  very  large  number  of  these  cases  are  associated. 
The  general  treatment  referred  to  is  often  more  important  than  the 
administration  of  the  preparations  of  iron,  which,  however,  should  never 
be  omitted. 

The  preparations  of  iron  available  for  infants  are  the  albuminate, 
bitter  wine,  sweet  wine,  saccharated  carbonate,  malate,  and  citrate.    The 


820  DISEASES  OF  THE  BLOOD. 

dose  should  be  regulated  according  to  the  age  of  the  child.  Older  chil- 
dren may  take  the  same  preparations  as  adults,  especially  reduced  iron 
and  Blaud's  pills.  Much  benefit  is  seen  from  combining  arsenic  with  iron, 
or  from  alternating  the  two.  In  addition  to  these  remedies,  cod-liver  oil 
should  be  given  if  the  condition  of  the  digestive  organs  will  permit. 

In  chlorosis  more  decided  results  are  seen  from  the  use  of  iron  than 
in  any  other  form  of  anaemia.  Blaud's  pills  are  here  the  favourite  method 
of  administration,  and  are  advantageously  combined  with  small  doses 
of  nux  vomica  and  aloin  to  overcome  the  tendency  to  constipation. 
Arsenic  is  useful  in  these  cases  also.  Great  benefit  in  chlorosis  results 
from  change  of  air  and  change  of  scene,  thus  removing  the  patient 
from  all  sources  of  nervous  excitement  or  disturbance.  The  general  con- 
dition, diet,  and  habits  of  life  should  also  receive  careful  attention, 
particularly  the  condition  of  the  bowels. 

Oxygen  is  a  valuable  adjuvant  in  the  treatment  of  all  anaemias  not 
yielding  to  iron  alone.  It  is  important  that  the  administration  of  iron 
should  be  continued  for  several  months  after  the  disappearance  of  all 
symptoms,  on  account  of  the  tendency  to  relapse. 

In  the  pseudo-leuJccemic  ancemia  of  infants,  arsenic  is  decidedly  the 
most  valuable  drug,  but  should  be  given  in  combination  with  iron. 
Fowler's  solution  is  the  best  preparation  for  infants ;  the  dose  should 
rarely  be  more  than  one  drop,  which  should  be  repeated  four  or  five 
times  daily  after  feeding,  and  continued  for  a  long  time.  The  general 
treatment  of  these  patients  is  the  same  as  in  cases  of  simple  anaemia. 
When  rickets  is  present  cod-liver  oil  and  phosphorus  should  be  added. 

In  pernicious  ancemia,  arsenic  offers  a  much  better  prospect  of  im- 
provement than  does  iron.  Beginning  with  small  doses,  the  amount 
should  be  gradually  increased  up  to  the  point  of  tolerance,  very  much 
as  in  cases  of  chorea. 

In  every  case  of  anaemia  the  most  careful  attention  should  be  given 
to  the  general  condition,  particularly  guarding  against  exposure  to  cold 
and  dampness.  The  feeble  circulation  of  these  patients  renders  them 
peculiarly  susceptible.  Caution  should  also  be  given  against  much  mus- 
cular exercise. 

In  many  cases  of  anaemia  of  a  severe  grade,  whether  primary  or  sec- 
ondary, transfusion  offers  a  brilliant  prospect  of  improvement  and  even 
recovery  when  no  other  treatment  is  of  any  avail. 

LEUKAEMIA. 

This  is  a  disease  in  which  the  essential  feature  is  a  great  increase  in 
the  number  of  leucocytes,  with  a  moderate  reduction  in  the  number  of 
red  corpuscles,  and  the  presence  in  the  blood  of  cellular  forms  not  found 
in  health. 


LEUK^.MIA.  821 

Etiology. — Leukaemia  is  a  rare  disease  in  cliildliood,  but  it  has  been 
seen  even  in  early  infancy.  Its  greater  frequency  in  males  holds  good 
even  in  childhood.  In  a  small  number  of  cases  heredity  seems  of  some 
importance  as  an  etiological  factor.  Ijcuka^mia  may  follow  syphilis, 
rickets,  malaria,  or  even  simple  anaemia,  or  it  may  occur  as  a  primary 
disease  in  children  previously  healthy.    The  cause  is  unknown. 

Lesions. — The  essential  lesions  of  leukaemia  are  found  in  the  s])leen, 
the  lymphatic  glands,  and  the  bone-marrow.  In  rare  cases  tbe  most 
important  changes  are  in  the  lymphatic  glands,  giving  rise  to  the 
lymphatic  form  of  leukaemia.  In  such  cases  the  changes  in  the  spleen  or 
marrow  may  be  slight  or  absent.  Changes  in  the  spleen  and  marrow  are, 
however,  usually  associated,  giving  rise  to  what  is  known  as  the  spleno- 
myelogenous  form  of  the  disease,  which  is  the  most  frequent  variety. 
The  spleen  is  usually  enormously  enlarged,  sometimes  filling  half  the 
abdominal  cavity.  In  the  early  stage  it  is  soft,  vascular,  and  of  a  dark- 
red  colour;  in  the  late  stages  it  is  firm  and  hard,  and  usually  deeply 
fissured  at  its  margin.  There  may  be  perisplenitis.  On  section,  light- 
gray  patches  of  lymphoid  tissue  may  be  seen  scattered  throughout  the 
organ,  and  in  some  instances  there  may  be  wedge-shaped  infarctions. 
The  microscope  shows  thickening  of  the  trabeculae  and  deposits  of  lym- 
phoid tissue,  especially  about  the  arteries.  In  the  lymphatic  form  any 
of  the  external  glands  of  the  body  may  be  affected,  the  cervical,  axil- 
lary, and  the  inguinal,  or  the  mesenteric,  tracheo-bronchial,  the  tonsils, 
and  even  the  lymph  nodules  of  the  tongue,  pharynx,  and  intestines.  The 
changes  in  the  glands  are  generally  those  of  a  simple  hyperplasia.  The 
liver  is  enlarged  in  very  many  of  the  cases,  chiefly  from  an  infiltration 
with  lymphoid  tissue,  which  may  be  diffuse  or  may  occur  in  patches. 
Less  frequently  similar  lymphoid  masses  are  seen  in  other  organs. 

Symptoms. — The  Blood  (Plate  XV,  D). — The  colour  is  lighter  than 
norma]  and  its  coagulability  usually  diminished.  Generally  the  red 
cells  are  much  reduced  in  number,  although  not  to  the  extent  seen  in 
pernicious  anaemia.  The  most  important  feature  is  the  great  increase 
in  the  number  of  leucocytes,  which  vary  in  form  according  as  the  type  is 
spleno-myelogenous  or  lymphatic.  The  red  cells  are  usually  of  normal 
size  and  a  moderate  number  of  normoblasts  is  found ;  the  haemoglobin  is 
diminished. 

In  the  spleno-myelogenous  form  the  white  cells  may  be  from  100,000 
to  500,000,  but,  especially  under  the  influence  of  arsenic,  a  marked  tem- 
porary diminution  may  occur,  so  that  their  number  may  be  scarcely  above 
the  normal;  both  Ehrlich's  and  Cornil's  myelocytes  are  present,  and  the 
presence  of  a  large  number  of  these  is  pathognomonic.  The  number  of  poly- 
morphonuclear neutrophiles  is  greatly  increased,  although  their  propor- 
tion is  diminished.  The  eosinophiles  are  very  much  increased  in  number, 
mononuclear  forms  being  present.     The  number  of  lymphocytes  is  in- 


822  DISEASES  OF  THE  BLOOD. 

creased,  but  they  vary  according  to  the  type  apd  stage  of  the  disease; 
this  is  true  also  of  the  large  mononuclear  leucocytes.  Mast  cells  are 
much  increased  in  number,  this  being  the  most  reliable  diagnostic  sign. 

In  the  lymphatic  form  the  lymphocytes  alone  are  increased,  so  that 
the  other  white  cells  are  relatively  diminished.  The  increase  is  usually 
in  the  small  lymphocytes,  which  form  from  eighty  to  ninety  per  cent  of 
the  leucocytes  present.  Myelocytes  and  mast  cells  are  either  present  in 
small  numbers  or  absent  altogether. 

The  other  symptoms  of  leukaemia  in  children  resemble  those  in 
adults,  with  the  difference  that,  as  a  rule,  the  progress  of  the  disease  is 
much  more  rapid  in  early  life.  In  most  of  the  cases  the  early  symptoms 
are  latent.  A  sudden  and  alarming  haemorrhage  is  sometimes  the  first 
thing  to  call  attention  to  the  serious  condition.  In  other  cases  there  are 
only  the  symptoms  of  general  weakness  and  anaemia.  Sometimes  the 
splenic  tumour  or  the  enlargement  of  the  lymphatic  glands  is  first  no- 
ticed. In  the  early  part  of  the  disease,  the  usual  symptoms  of  anaemia 
are  present — digestive  disturbances,  shortness  of  breath,  weak  and  rapid 
pulse.  Haemorrhages  may  occur  as  an  early  or  late  symptom;  they  are 
most  frequently  from  the  nose,  but  severe  haemorrhages  may  occur  from 
the  stomach,  the  mouth,  the  intestines,  or  there  may  be  ecchymoses  upon 
the  skin.  The  enlargement  of  the  spleen  may  be  sufficiently  marked  to 
form  an  abdominal  tumour,  so  as  to  attract  the  attention  even  of  the 
parents.  The  swelling  of  the  liver  is  not  so  great.  The  lymphatic  glands 
are  enlarged  only  to  a  moderate  degree,  and  in  many  cases  this  symptom 
is  absent  altogether.  They  are  painless,  movable,  and  usually  several 
groups  are  affected. 

The  late  symptoms  are  dropsy  of  the  feet  or  general  anasarca,  haemor- 
rhages, diarrhcea,  headaches,  general  weakness,  and  attacks  of  fainting. 
Fever  is  quite  constant  in  the  late  stages  of  the  disease,  and  the  tem- 
perature may  be  from  101°  to  103°  F.  The  urine  may  contain  albumin 
and  casts.  Vision  is  sometimes  disturbed  by  the  formation  of  leukaemic 
plaques  in  the  retina.  It  is  rare  that  there  are  any  symptoms  referable 
to  the  bones,  although  expansion  and  tenderness  of  the  flat  bones  have 
been  observed. 

Course  and  Prognosis. — The  course  of  leukaemia  is  chronic,  and  in 
most  cases  slowly  progressive,  but  not  always  so.  The  prognosis  is  very 
bad,  the  great  proportion  of  the  cases  in  children  proving  fatal  within  a 
year  from  the  first  symptoms,  in  infancy  sometimes  in  two  or  three 
months.  There  has  been  described  by  Epstein  and  others  an  acute  form 
of  the  disease,  proving  fatal  in  a  few  weeks.  The  usual  causes  of  death 
are  exhaustion,  haemorrhages,  and  broncho-pneumonia. 

Diagnosis. — This,  in  children,  has  to  be  made  chiefly  from  simple 
anaemia  with  leucocytosis,  and  pseudo-leukaemic  anaemia.  Without  a 
blood  examination  this  is  impossible.    The  chief  reliance  is  to  be  placed 


HEMOPHILIA.  823 

upon  the  enormous  increase  in  the  leucocytes,  and  especially  upon  the 
presence  of  numerous  mast  cells  and  myelocytes. 

Treatment. — The  general  treatment  of  leukaemia  should  be  the  same 
as  that  of  ansemia.  Of  the  drugs  now  in  use,  arsenic  has  altogether  the 
most  testimony  in  its  favour.  It  must  be  given  in  large  doses  and  for  a 
long  period.  Next  to  this  in  value  come  iron  and  cod-liver  oil.  Leu- 
kaemia, however,  is  in  most  instances  very  little  influenced  by  treatment. 
The  reported  cures  must  be  taken  with  some  allowance,  for  most  of  these 
were  published  before  the  time  when  leukaemia  was  sharply  differentiated 
from  simple  anaemia  with  leucocytosis  and  from  tlie  pseudo-leukaemic 
anaemia  of  infancy. 

HAEMOPHILIA. 

Haemophilia  is  an  hereditary  disease,  in  which  there  is  a  tendency  to 
profuse  or  even  uncontrollable  bleeding  from  slight  wounds,  or  some- 
times even  spontaneously.  In  many  cases  there  is  associated  an  inflam- 
mation of  the  joints.     Persons  so  affected  are  known  as  "  bleeders." 

Etiology. — The  hereditary  tendency  of  the  disease  is  very  strongly 
marked,  and  it  has  often  been  traced  through  seven  or  eight  generations. 
Males  are  much  more  frequently  affected  than  females,  the  proportion 
being  about  twelve  to  one.  In  the  matter  of  inheritance,  the  disease  is 
most  often  transmitted  through  the  mother,  who,  however,  usually  es- 
capes herself.  Patients  suffering  from  haemophilia  may  have  nothing  else 
about  them  that  is  abnormal.  The  exact  nature  of  the  disease  is  un- 
known. It  has  no  connection  with  either  purpura  or  scurvy.  Although 
generally  classed  among  the  diseases  of  the  blood,  it  has  not  been  estab- 
lished that  there  are  any  constant  changes  either  in  the  blood  or  in  the 
blood-vessels.  But  there  is  probably  either  a  deficiency  of  some  element 
of  the  blood  necessary  to  produce  coagulation,  or  possibly  an  excess  of 
some  element  interfering  with  coagulation. 

Symptoms. — The  first  manifestations  of  haemophilia  are  not  often 
seen  before  the  second  year.  The  haemorrhages  of  the  newly  born  have 
no  relation  to  this  condition.  The  discovery  of  the  disease  is  generally 
quite  accidental.  The  first  haemorrhage  may  be  traumatic  or  spontane- 
ous. In  traumatic  haemorrhages  there  may  be  very  severe  bleeding  after 
so  slight  a  wound  as  the  drawing  of  a  tooth;  sometimes  a  large  haema- 
toma  forms  between  the  muscles  as  the  result  of  a  moderate  contusion. 

The  following  is  the  relative  frequency  of  spontaneous  haemorrhages 
in  334  cases  collected  by  Grandidier:  Bleeding  from  the  nose  in  169, 
mouth  in  43,  intestines  in  36,  stomach  in  15,  urethra  in  16,  lungs  in  17. 
There  may  be  haemorrhage  from  the  skin  or  from  any  mucous  membrane 
of  the  body.  The  attacks  of  spontaneous  haemorrhage  are  often  peri- 
odical, and  may  be  accompanied  by  arthritic  symptoms  resembling 
rheumatism.     The  severity  of  the  haemorrhages  varies  much  in  the  dif- 


824  DISEASES  OF  THE  BLOOD. 

ferent  cases.  From  a  slight  wound  a  patient  may  bleed  until  he  is  ex- 
sanguinated, and  even  until  death  occurs.  Such  a  result  from  the  first 
haemorrhage,  however,  is  rare.  In  some  cases  the  disposition  to  bleed 
is  outgrown  in  later  life.  Grandidier  states  that,  of  153  boys,  over  one- 
half  died  before  reaching  the  seventh  year.  It  is  striking  that  when  the 
disease  affects  females  there  is  no  tendency  to  excessive  bleeding  at  men- 
struation or  parturition. 

Treatment. — The  indications  at  the  time  of  bleeding  are,  to  arrest 
the  haemorrhage  by  the  use  of  the  ordinary  surgical  means — especially 
compression.  Calcium  lactate  and  gelatine  may  be  used  as  described 
in  the  hsemorrhages  of  the  newly  bom;  but  little  benefit  is  to  be  ex- 
pected from  drugs.  In  extreme  cases  transfusion  may  be  practised.  Its 
effects  are  sometimes  very  striking.  In  convalescence  after  attacks  of 
haemorrhage,  iron  and  general  tonics  should  be  given.  In  all  patients 
who  are  bleeders  everything  which  might  by  any  means  excite  haemor- 
rhage should  be  avoided.  The  marriage  of  girls  who  inherit  the  disease 
should  be  discouraged. 

PURPURA. 

The  term  purpura  is  used  to  designate  a  condition  in  which  there  is 
a  tendency  to  spontaneous  haemorrhages  beneath  the  skin,  from  the 
various  mucous  membranes,  and  in  some  cases  into  the  internal  organs. 
The  term  purpura  simplex  is  applied  to  those  cases  in  which  the  haemor- 
rhages are  limited  to  the  skin;  purpura  Jicemorrhagica  to  those  in  which 
there  is  in  addition  bleeding  from  the  mucous  membranes  or  visceral 
haemorrhages.  It  is  impossible  to  draw  a  line  sharply  between  these  two 
classes  of  cases,  as  the  chief  difference  between  them  seems  to  be  one  of 
degree.  Purpura  is  sometimes  known  as  morbus  maculosus  or  as  Werl- 
hofs  disease. 

Symptomatic  Purpura. — This  occurs  in  quite  a  variety  of  conditions, 
the  haemorrhages  generally  being  limited  to  the  skin,  but  not  always  so. 
These  cases  may  be  grouped  in  the  following  classes : 

1.  Infectious. — This  form  of  purpura  is  very  constantly  seen  in 
malignant  endocarditis,  in  the  haemorrhagic  forms  of  the  various  erup- 
tive fevers — measles,  scarlet  fever,  variola,  vaccinia,  and  typhus — also  in 
epidemic  meningitis  and  occasionally  in  diphtheria,  pyaemia,  and  sep- 
ticaemia. The  occurrence  of  haemorrhages  in  these  cases  appears  to 
depend  upon  an  altered  condition  of  the  blood,  which  is  a  direct  result  of 
the  infection,  and  it  is  a  bad  prognostic  sign. 

2.  Cachectic. — Purpura  occurs  late  in  the  course  of  many  protracted 
and  exhausting  diseases,  especially  in  infancy.  It  is  most  frequently 
met  with  in  broncho-pneumonia, 'empyema,  tuberculosis,  ileo-colitis,  in 
both  the  tuberculous  and  the  simple  forms  of  meningitis,  and  in  malig- 
nant disease.     It  also  occurs  from  apparently  similar  causes  in  several 


PURPURA.  825 

of  the  diseases  of  the  blood,  particularly  in  leukgemia  and  pernicious 
anaemia.  In  most  cases  of  cachectic  purpura  the  ha^morrhagic  spots  are 
small,  not  very  abundant,  and  occur  either  upon  the  abdomen  or  the 
lower  extremities.  This  form  is  quite  common  in  hospital  practice,  and 
is  almost  invariably  indicative  of  a  fatal  result.  In  cachectic  purpura 
the  haemorrhages  are  usually  limited  to  the  skin.  The  condition  is  un- 
doubtedly dependent  upon  a  deterioration  in  the  blood,  possibly  also 
upon  the  condition  of  the  minute  blood-vessels. 

3.  Toxic. — Certain  drugs,  such  as  phosphorus,  quinine,  potassium 
chlorate,  and  sometimes  others,  may  in  rare  cases  produce  hsemorrhages 
when  long  continued  or  in  large  doses.  The  haemorrhage  of  jaundice 
may  also  be  considered  in  this  group. 

4.  Mechanical  haemorrhages,  such  as  those  occurring  in  pertussis  or 
epilepsy,  are  sometimes  classed  with  purpura.  In  convalescence  from 
protracted  illness  there  are  sometimes  seen,  when  patients  first  stand  or 
walk,  purpuric  spots  on  the  lower  extremities.  They  may  occur  after  the 
confinement  of  a  limb  in  bandages  or  splints.  In  both  these  cases  the 
cause  is  partly  mechanical  and  partly  due  to  the  weakened  condition  of 
the  blood-vessels. 

5.  Neurotic. — These  cases  are  occasionally  seen  in  diseases  of  the 
spinal  cord  and  sometimes  in  hysteria  in  young  adults,  but  very  rarely 
in  children. 

Primary  Purpura. — This  occurs  in  children  of  all  ages,  being  not  un- 
common in  infancy.  Haemorrhages  of  the  newly  born  have  not  gener- 
ally been  included  in  this  class,  although  there  are  some  reasons  why  they 
might  well  be.  The  age  at  which  primary  purpura  is  most  frequently 
seen  is  from  two  to  ten  years.  The  sexes  are  about  equally  affected; 
of  Steffen's  56  cases,  27  were  males  and  29  females.  The  disease  may 
occur  in  children  who  are  cachectic,  rachitic,  or  anaemic,  and  in  those 
whose  surroundings  are  poor,  but  it  has  not,  like  scurvy,  any  close  rela- 
tion to  diet.  It  may  follow  any  acute  disease,  being  associated  most 
frequently  with  derangements  of  the  stomach  and  bowels.  Quite  often 
the  disease  develops  abruptly,  without  any  assignable  cause,  in  children 
previously  healthy. 

Lesions. — The  external  haemorrhages  may  occur  upon  any  part  of 
the  body.  There  are  smaller  or  larger  ecchymoses  or  an  infiltration 
of  the  tissues  with  blood,  which  undergoes  gradual  absorption  with  the 
usual  changes.  AYith  the  haemorrhages,  various  forms  of  inflammation 
of  the  skin  may  be  associated,  especially  er3^thema  and  urticaria,  with 
sometimes  more  or  less  oedema.  Haemorrhages  from  the  mucous  mem- 
branes are  more  frequent,  because  of  the  feebler  resistance  of  the  tissues. 
There  are  seen  ecchymoses  upon  the  visible  mucous  membranes  which 
resemble  those  upon  the  skin.  At  autopsy  they  are  occasionally  seen 
in  the  trachea  or  bronchi,  but  more  often  in  the  digestive  tract.     In 


826  DISEASES  OF  THE   BLOOD. 

the  colon,  and  occasionally  in  the  small  intestine,  ulcers  may  be  found; 
but  they  are  rarely,  if  ever,  seen  in  the  stomach.  They  may  be  super- 
ficial or  deep,  and  have  even  been  known  to  cause  perforation. 

Intracranial  haemorrhages  are  rare,  and  are  usually  meningeal. 
These  may  be  sufficient  to  cause  severe  symptoms.  I  saw  one  at  the 
New  York  Infant  Asylum  in  an  infant  six  months  old,  with  an  extensive 
meningeal  haemorrhage  covering  a  large  part  of  the  brain.  In  Steflen's 
paper  several  sucl^  cases  are  mentioned. 

Pulmonary  haemorrhages  are  not  frequent.  Ecchymoses  are  found 
beneath  the  pericardium;  but  endocarditis  and  pericarditis  are  ex- 
tremely rare,  probably  occurring  only  in  the  rheumatic  cases.  The  spleen 
is  occasionally  enlarged,  but  by  no  means  uniformly  so,  and  it  may  be 
the  seat  of  haemorrhages. 

While  haematuria  is  one  of  the  most  frequent  of  the  visceral  haemor- 
rhages, severe  nephritis  is  rare.  Acute  degeneration  of  the  renal  epithe- 
lium of  the  tubes  is  quite  common.  Tliere  may  be  punctiform  ]ia?mor- 
rhages,  and  occasionally  larger  ones  beneath  the  capsule  or  in  the 
mucous  membrane  of  the  pelvis  of  the  kidney.  The  suprarenal  capsules 
may  be  the  seat  of  extensive  and  even  fatal  haemorrhage.  There  may 
be  effusions  of  a  sero-sanguineous  fluid  into  any  of  the  large  serous 
cavities,  most  frequently  into  the  peritonaeum.  The  articular  lesions 
of  purpura  may  be  of  a  rheumatic  character,  with  which  purpura  occurs 
as  a  complication;  or  there  may  be  haemorrhages  into  the  tissues  about 
the  joint,  or  even  into  the  joint  itself — usually  the  knee  or  elbow. 

Thus  far  no  constant  or  essential  changes  have  been  demonstrated 
in  the  blood,  other  than  those  which  are  due  to  haemorrhages — viz.,  a 
moderate  reduction  in  the  haemoglobin  and  the  red  corpuscles,  with  oc- 
casional irregularities  in  size  and  the  appearance  of  nucleated  red  cells. 
In  the  most  severe  cases  there  is  a  moderate  degree  of  leucocytosis. 

Pathology. — Why  it  is  that  under  certain  circumstances  the  blood- 
vessels will  not  hold  their  contents,  it  is  difficult  to  understand.  There 
have  been  described  by  Cassel,  Riehl,  Wilson,  and  others,  changes  in  the 
small  blood-vessels,  usually  a  form  of  endarteritis,  but  it  is  not  necessary 
to  assume  a  lesion  in  the  blood-vessels,  since  we  know  that  diseased 
blood  may  pass  through  even  normal  vessels.  Henoch  has  suggested 
the  vaso-motor  origin  of  purpura,  in  which  tliere  is  first  a  paralytic  dis- 
tention of  the  small  vessels,  followed  by  stasis,  hsemorrhage,  or  oedema. 
In  certain  forms,  as  in  malignant  endocarditis,  it  is  well  established  that 
the  cause  is  an  infectious  thrombosis.  Although  the  bacteriological  ex- 
aminations made  thus  far  in  purpura  are  not  numerous  enough  to  settle 
the  question  positively,  there  is  little  doubt  that  infection  is  the  essen- 
tial factor  in  some  forms  of  the  disease,  particularly  in  the  cases  charac- 
terised by  sudden  onset,  high  temperature,  and  cerebral  symptoms,  and 
which  run  a  rapidly  fatal  course.    At  the  present  time  the  exact  pathol- 


PURPURA.  827 

ogy  of  purpura  is  unknown.  There  are,  no  doubt,  now  included  under 
this  term  several  diseases  quite  distinct  from  one  another. 

The  Clinical  Types. — 1.  The  Ordinary  Form. — In  the  mild  cases  the 
haemorrhage  is  confined  to  the  skin  (purpura  simplex),  or  it  is  accom- 
panied by  slight  bleeding  from  the  mucous  membranes.  There  is  usually 
some  general  indisposition  of  an  indefinite  character  for  a  day  or  two 
before  the  purpuric  spots  are  noticed;  most  frequently  a  disturbance  of 
digestion  with  vomiting,  diarrhoea,  and  sometimes  slight  fever.  The 
haemorrhages  appear  as  small  petechiae,  varying  in  size  from  a  pin's 
head  to  a  pea,  usually  first  upon  the  lower  extremities.  There  may  be 
only  a  few  widely  scattered  spots  or  the  body  may  be  covered.  The 
colour  is  first  a  bright  red,  then  purple,  gradually  fading  in  the  course 
of  a  few  days.  New  spots  come  as  the  old  ones  disappear,  so  that  the 
amount  of  eruption  may  not  diminish.  They  do  not  disappear  upon 
pressure. 

The  course  of  these  cases  is  generally  favourable,  recovery  taking 
place  in  from  one  to  four  weeks  under  the  influence  of  general  tonic 
treatment.  Eel  apses  are,  however,  very  frequent,  and  such  attacks  may 
come  at.  intervals  of  a  few  weeks  or  months  for  a  considerable  period. 
One  must  be  guarded  in  giving  an  absolutely  favourable  prognosis  even 
in  cases  of  such  severity,  for  it  occasionally  happens  that  in  a  patient 
who  for  several  days  has  had  symptoms  of  mild  purpura,  there  suddenly 
develop  those  of  the  most  severe  type  with  a  rapidly  fatal  termination. 

2.  The  Severe  Form. — Such  cases  are  characterised  by  haemorrhages 
from  the  mucous  membranes  (purpura  haemorrhagica)  from  the  outset. 
These  may  even  appear  before  the  spots  upon  the  skin.  In  severe  at- 
tacks the  petechial  spots  are  more  likely  to  appear  suddenly,  and  large 
ecchymoses,  varying  in  size  from  a  pea  to  the  palm  of  the  hand,  are  more 
frequent.  There  may  be  bleeding  from  the  nose,  gums,  mouth,  or 
pharynx,  and  ecchymoses  may  be  seen  upon  these  mucous  menibranes, 
also  upon  the  conjunctivae.  Vomiting  of  blood  and  bloody  discharges 
from  the  bowels  are  quite  frequent  symptoms.  The  urine  may  contain 
enough  blood  to  give  it  a  bright-red  colour.  Less  frequently  there  are 
seen  haemorrhages  of  the  retina  or  choroid  and  from  the  female  genitals. 
In  one  of  my  own  cases  there  was  almost  continuous  bleeding  from  one 
ear.  Cutaneous  ecchymoses  are  increased  by  slight  injuries,  such  as  the 
pressure  from  a  bandage  or  from  scratching.  Epistaxis  may  be  copious 
enough  to  necessitate  plugging  of  the  nares.  The  amount  of  blood  vom- 
ited is  not  often  large ;  its  source  may  be  the  stomach,  the  mouth,  or  the 
pharynx.  The  blood  in  the  stools  is  usually  dark  coloured,  but  there  may 
be  some  bright-red  blood  even  when  there  are  no  ulcers  present.  In  one 
of  my  cases  so  much  blood  was  lost  by  the  bowels  as  to  produce  the  symp- 
toms of  a  very  marked  cerebral  anaemia.  In  certain  cases  the  gastro- 
intestinal symptoms  are  very  prominent,  and  there  may  be  slight  icterus. 


828  DISE.^ES  OF  THE   liLOOD. 

The  discharge  of  blood  from  the  stomach  or  intestine  may  be  accom- 
panied by  very  severe  attacks  of  colic  and  tenesmus.  In  some  of  these 
cases  there  are  pains  and  slight  swelling  of  the  joints.  Eenal  symptoms 
are  generally  present.  The  attacks  of  abdominal  pain  with  purpura  and 
the  discharge  of  blood  may  come  on  paroxysmally  every  few  days  for  a 
period  of  several  weeks.  They  have  been  ascribed  to  thrombosis  of  the 
intestinal  vessels.     This  is  sometimes  known  as  "  Henocli's  purpura." 

Constitutional  symptoms  are  present  in  most  of  the  severe  cases. 
There  is  usually  fever,  from  101°  to  103°  F.,  and  sufficient  prostration 
to  keep  the  patient  in  bed.  If  the  amount  of  blood  lost  is  large,  there 
are  the  usual  symptoms  of  severe  anaemia.  The  loss  of  blood  may  be 
sufficient  to  cause  death,  particularly  in  infants.  Cerebral  symptoms 
may  depend  upon  anaemia  or  upon  meningeal  haemorrhage.  They  are 
not  frequent  in  this  form  of  the  disease.  (Edema,  especially  of  the  face 
and  feet,  may  exist  without  albuminuria,  and  albuminuria  may  be  pres- 
ent in  cases  in  which  there  is  no  renal  haemorrhage. 

In  some  of  the  cases  beginning  with  severe  general  symptoms,  and 
occasionally  when  the  onset  is  mild,  the  patients  after  a  few  days  pass 
into  a  typhoid  condition  with  low  delirium,  great  prostration,  weak  and 
irregular  pulse,  dry,  cracked  tongue,  and  high  temperature.  Such  cases 
are  almost  always  fatal.  They  are  not  to  be  confounded  with  ordinary 
typhoid  fever  complicated  by  purpura. 

The  course  varies  much  in  the  different  cases.  It  lasts  from  one  to 
six  weeks,  the  symptoms  slowly  subsiding,  but  often  showing  a  strong 
tendency  to  recurrence.  The  prognosis  depends  upon  the  age  of  the 
patient,  the  extent  of  the  haemorrhage,  and  the  presence  or  absence  of 
septic  symptoms. 

3.  The  Hyper-acute  Form  (purpura  fulminans). — This  is  a  rare 
form,  especially  in  young  children.  Its  development  is  usually  sudden, 
with  a  chill,  vomiting,  marked  prostration,  and  high  temperature.  The 
purpuric  spots  come  out  with  great  rapidity,  and  in  the  course  of  a 
few  hours  or  a  day  they  may  be  very  extensive.  In  addition  to  the 
ordinary  subcutaneous  haemorrhages,  bloody  vesicles  may  form  upon  the 
skin.  In  many  cases  the  haemorrhages  are  limited  to  the  skin,  the  mu- 
cous membranes  and  the  viscera  escaping  altogether.  There  is  no 
tendency  to  gangrene.  Cerebral  symptoms  are  invariably  present  and 
usually  prominent;  there  may  be  delirium,  dulness,  stupor,  and  finally 
coma.  The  spleen  is  apt  to  be  enlarged.  The  urine  is  nearly  always 
albuminous.  This  form  of  purpura  has  all  the  characteristics  of  a  gen- 
eral infectious  disease,  and  it  is  almost  invariably  fatal. 

4.  The  Gangrenous  Form. — Sloughing  is  not  common  in  purpura, 
but  it  is  most  often  seen  in  the  mucous  membranes.  Osier  refers  to  two 
cases  affecting  the  uvula.  I  once  saw  a  slough  which  caused  perforation 
of  the  soft  palate.    Wickham  Legg  reports  a  case  with  gangrene  of  the 


PURPURA.  829 

prepuce.  Gangrene  of  the  skin  is  even  less  frequent,  although  cases 
have  been  reported  even  in  young  children.  Charron's  case  was  only 
three  years  old,  and  several  others  in  children  are  collected  in  Gimard's 
monograph  upon  this  subject.  The  gangrene  may  involve  the  skin  only, 
or  the  subcutaneous  tissues,  and  even  the  muscles.  It  has  been  seen 
upon  the  upper  and  lower  extremities,  and  even  upon  the  face,  and  may 
extend  over  quite  a  large  surface.  In  some  of  the  milder  forms  of  pur- 
pura, gangrene  results  from  some  slight  injury,  such  as  a  blow,  the  pres- 
sure from  a  bandage,  or,  in  the  nose,  from  the  pressure  of  a  tampon. 
These  cases  are  almost  invariably  fatal.  Those  in  which  the  sloughing 
is  confined  to  small  areas  of  the  mucous  membrane  of  the  mouth  often 
recover. 

5.  The  Eheumatic  Form. — The  term  '^ rheumatic  purpura"  (peliosis 
rheumatica)  is  applied  to  cases,  not  so  common  in  children  as  in  older 
patients,  in  which  subcutaneous  haemorrhages,  and  sometimes  bleeding 
from  the  mucous  membranes,  are  associated  with  painful  joint  swell- 
ings. These  are  to  be  regarded  as  cases  of  rheumatism  complicated  by 
purpura.  The  joints  most  frequently  affected  are  the  knee  and  the 
ankle.  The  arthritic  symptoms  are  usually  less  severe  than  in  attacks 
of  acute  rheumatism.  There  may  be  present  erythema  exudativum  or 
erythema  nodosum  or  urticaria.  Usually  there  are  throat  symptoms 
and  fever,  and  frequently  oedema  of  the  face  and  eyelids  with  albu- 
minuria. The  spleen  may  be  enlarged.  The  usual  duration  is  from  one 
to  three  weeks,  and  although  relapses  may  occur,  the  cases  usually 
recover. 

Joint  symptoms,  particularly  articular  pains,  are  not  infrequent  in 
the  course  of  milder  attacks  of  purpura  without  the  febrile  symptoms 
mentioned.  In  severe  cases  extravasations  of  blood  have  been  reported 
as  occurring  in  the  tissues  about  the  joints,  and  even  in  the  joints  them- 
selves, these  being  cases  of  true  arthritic  purpura.  It  is  probable  that, 
in  the  past,  some  cases  of  scurvy  have  been  included  in  this  group. 

Diagnosis. — The  rapid  acute  cases  may  be  confounded  with  the  haem- 
orrhagic  forms  of  the  various  eruptive  fevers.  The  ordinary  subacute  or 
passive  forms  are  chiefly  to  be  differentiated  from  scurvy.  The  diag- 
nosis is  not  difficult,  and  the  mistake  need  not  be  made  if  the  essential 
features  of  scurvy  are  borne  in  mind — its  dietetic  cause,  bleeding  gums, 
hypersesthesia,  and  deep  rather  than  subcutaneous  hagmorrhages  which 
are  usually  near  the  joints. 

Prognosis. — This  depends  very  much  upon  the  form  of  the  disease. 
Of  128  cases  of  all  varieties  occurring  in  children  in  Steffen's  collection, 
there  were  40  deaths.  In  12  cases  of  severe  primary  purpura  reported 
by  Gimard,  there  were  3  deaths  and  9  recoveries.  Purpura  simplex  is 
rarely  fatal ;  cases  of  purpura  haemorrhagica  usually  recover  unless 
marked  febrile  symptoms  are  present.     The  forms  classed  as  typhoid, 


830  DISEASES  OF  THE  LYMPH   NODES. 

gangrenous,  and  purpura  fulminans  are  almost  invariably  fatal.     The 
tendency  to  relapse  exists  in  all  varieties. 

Treatment. — The  treatment  of  symptomatic  purpura  should  have 
reference  to  the  cause  of  the  disease.  The  mild  cases  of  primary  pur- 
pura usually  recover  promptly  under  a  tonic  plan  of  treatment.  The 
more  severe  cases  require  confinement  in  bed,  absolute  quiet,  and  care  to 
avoid  exposure  and  even  the  slightest  injury  or  extra  pressure  upon  any 
part.  Drugs  do  not  seem  greatly  to  influence  the  course  of  the  disease. 
Tliose  most  frequently  employed  are  supra-renal  extract,  hydrastis, 
hamamelis,  aromatic  sulphuric  acid,  the  vegetable  acids,  ergot,  and  gal- 
lic acid.  Whether  or  not  it  is  true,  as  claimed  by  some,  that  all  haemor- 
rhagic  diseases  are  related  to  scurvy,  the  striking  improvement  seen  in 
this  disease  from  the  use  of  fresh  fruit  and  vegetables  suggests  their 
employment  in  purpura.  In  some  cases  very  decided  benefit  seems  to 
follow  their  use  in  the  acute  stage,  but  more  particularly  in  convales- 
cence. For  hyperacute  and  gangrenous  cases,  little  can  be  done  except 
to  treat  the  symptoms.  Surgical  means  of  arresting  the  haemorrhage 
are  rarely  successful.  Iron  and  arsenic  should  be  used  during  con- 
valescence. 


CHAPTER    II. 
DISEASES  OF   THE  LYMPH  NODES   {LYMPHATIC  GLANDS). 

It  is  characteristic  of  infancy  and  childhood  that  the  lymphoid  tis- 
sues— tonsils,  adenoids,  external  and  internal  lymph  glands,  and  many 
smaller  lymph  nodules  throughout  the  body — are  prone  to  swelling  and 
hyperplasia.  While  this  tendency  belongs  to  all  children,  in  certain  in- 
dividuals it  is  so  marked  as  to  deserve  a  place  as  a  distinct  diathesis. 
It  was  formerly  classed  as  one  of  the  manifestations  of  "  scrofula  "  or 
"  struma  " ;  but  the  proof  that  most  of  the  manifestations  once  called 
"  scrofulous  "  are  really  forms  of  local  tuberculosis,  makes  it  undesirable 
to  use  that  term  to  designate  the  condition  under  discussion. 

In  robust  children  infectious  processes  of  the  nose,  pharynx,  or 
bronchi  cause  acute  swelling  of  the  lymph  nodes  in  the  neighbourhood, 
which  rapidly  subside  when  the  cause  is  removed.  In  others,  in  whom 
this  vulnerability  of  the  lymphoid  tissues  exists,  the  hyperplasia  in  the 
lymph  nodes  is  out  of  proportion  to  the  exciting  cause  and  continues 
after  the  cause  has  ceased  to  operate.  Certain  children  have  at  birth  an 
excessive  development  of  lymphoid  tissue,  particularly  in  the  region  of 
the  throat  in  the  form  of  enlarged  tonsils,  adenoid  vegetations  of  the 
pharynx,  etc. 

The  influence  of  heredity  in  causing  this  condition  is  too  often  seen 


DISEASES  OF  THE  LYMPH   NODES.  831 

to  be  passed  over  as  a  coincidence.  Frequently  the  parents,  during  child- 
hood, suffered  from  the  same  condition,  and  often  every  member  of  a 
large  family  of  children  is  affected.  They  may  be  in  other  respects 
healthy,  reared  amid  good  surroundings,  and  show  no  evidence  of  any 
other  constitutional  disease.  Any  disease  in  the  parents  in  consequence 
of  which  children  are  bom  with  tissues  having  less  than  normal  re- 
sistance, may  be  regarded  in  the  light  of  a  remote  cause. 

The  condition  is  seen  to  perfection  in  children  reared  in  institutions 
and  in  crowded  tenements.  It  is  more  common  in  cities  than  in  the 
country.  Anything  which  produces  malnutrition  or  lowers  the  general 
vitality  of  the  tissues  may  be  ranked  as  a  cause.  Rickets  is  often  asso- 
ciated; sometimes  it  is  to  be  reckoned  as  a  cause,  and  sometimes  both 
conditions  depend  upon  the  same  causes. 

During  infancy,  the  lymphoid  structures  most  frequently  affected  are 
those  connected  with  the  gastro-enteric  and  the  bronchial  mucous  mem- 
branes; in  later  childhood  it  is  those  which  are  connected  with  the 
pharynx  and  tonsils. 

The  degree  of  enlargement  of  the  lymph  nodes  which  is  sometimes 
found  in  the  different  situations  has  often  led  to  a  misinterpretation  of 
them,  particularly  by  those  who  only  seldom  see  autopsies  upon  infants  or 
young  children.  They  have  often  been  connected  with  pathological  condi- 
tions or  clinical  symptoms  with  which  they  have  really  nothing  to  do. 

Enlargement  of  the  mesenteric  glands  and  of  the  solitary  follicles 
of  the  large  and  small  intestine  is  very  frequently  seen  in  infants  who 
have  died  from  marasmus,  and  has  been  regarded  as  the  cause  of  the 
wasting,  while  in  reality  it  was  only  the  consequence  of  the  chronic 
intestinal  indigestion  which  is  an  almost  constant  accompaniment  of 
that  condition. 

As  age  advances  we  usually  see  retrograde  changes  in  the  different 
groups  of  glands  unless  they  become  the  seat  of  tuberculous  infection. 
Those  connected  with  the  digestive  tract  generally  begin  to  diminish 
after  the  second  year,  and  by  the  fifth  or  sixth  year  the  enlargement  has 
almost  disappeared;  while  the  tonsils,  adenoid  growths  of  the  pharynx, 
and  enlarged  cervical  glands  are  usually  stationary  after  the  seventh  or 
eighth  year,  and  undergo  quite  a  marked  atrophy  about  the  time  of  pu- 
berty. The  presence  of  these  enlarged  lymph  nodes  and  the  catarrhal 
condition  of  the  mucous  membranes  with  which  they  are  associated,  are 
important  in  relation  to  all  acute  infectious  diseases  which  affect  these 
mucous  membranes.  They  bring  about  an  increased  susceptibility  to 
scarlet  fever,  measles,  diphtheria,  diarrhoeal  diseases,  and  most  of  all  to 
tuberculosis. 

In  the  following  table  are  given  the  situation  and  drainage  areas  of 
the  various  groups  of  lymph  nodes  of  the  head  and  neck  which  play  so 
important  a  role  in  infancy  and  childhood. 


832 


DISEASES  OF  THE   LYMPH   NODES. 


10 


Name  of  the 
Gbocp. 


Sub-occipi- 
tal. 
Mastoid. 


Parotid. 


Submaxil- 
lary. 

Supra- 
hyoid. 

Superficial 
cervical. 


Deep  cervi- 
cal, upper 
set. 


Deep  cervi- 
cal, lower 
set. 

Sub-hyoid. 


Retro-phar- 
yngeal 


Number  and  Situation. 


One  or  two;  at  nape  of  neck. 

Four  or  five  small  ones;  in 
mastoid  region. 

Five  to  ten;  on  the  surface 
and  in  the  substance  of 
the  parotid  gland. 

Twelve  to  fifteen ;  along  base 
of  jaw,  beneath  cervical 
fascia. 

One  or  two;  median  line  be- 
tween chin  and  hyoid 
bone. 

Five  or  more;  along  external 
jugular  vein,  beneath  pla- 
tysma,  but  superficial  to 
the  sterno-mastoid. 

Ten  to  sixteen;  about  bifur- 
cation of  common  carotid 
and  along  internal  jugular 
vein.  They  are  just  above 
upper  border  of  the  thy- 
roid cartilage  and  on  a 
level  with  the  hyoid  bone. 

A  chain  in  the  supra-clavicu- 
lar fossa. 


A  few  small  glands  below 
hyoid  bone  and  near  me- 
dian line. 

Two  small  glands  in  front  of 
spine  and  upon  preverte- 
bral muscles. 


Organs  or  Areas  from  which  they 
Receive  Lymphatics. 


Scalp,  posterior  portion. 

Receive  efferent  vessels  from  group  1. 

and  through  them  from  part  oi 

scalp. 
Scalp,  frontal  and  parietal  portions; 

orbit,  posterior  part  of  nasal  fossa, 

upper  jaw,    posterior  and  upp)er 

part  of  pharynx. 
Mouth,  lower  Up,  gums. 


Chin  and  middle  portion  of  lower  lip. 


Auricle,  part  of  scalp,  skin  of  face 
and  neck,  and  some  efferent  ves- 
sels from  groups  1  and  2. 

Lower  part  of  pharynx,  larynx,  pal- 
ate, tonsils  and  part  of  tongue, 
part  of  nasal  fossa,  deep  muscles  of 
head  and  neck,  and  from  inside  the 
cranium.  Receive  also  efferent 
vessels  from  groups  3  and  4. 

Connect  with  axillary  group  by  a 
chain  along  axillary  artery;  also 
with  glands  of  mediastinum  and 
with  groups  7  and  9. 

Communicate  with  group  8,  and  may 
connect  below  with  chain  of  bron- 
chial glands. 

Pharynx  and  part  of  nasal  fossa. 


STATUS  LYMPHATICUS. 

This  condition  is  known  also  by  some  writers  as  "  lymphatism " ; 
while  in  its  marked  form  it  is  quite  distinct  from  that  just  described,  the 
two  conditions  have  many  points  of  resemblance,  have  often  been  con- 
founded, and  in  fact  shade  into  each  other.  The  term  "  status  lymphati- 
cus  "  is  applied  to  a  very  definite  pathological  condition  which  is  asso- 
ciated with  clinical  manifestations,  less  constant  and  not  characteristic. 
The  relation  between  the  lesions  and  the  symptoms  is  little  understood, 
and  almost  notliing  is  known  of  the  etiology  or  pathogenesis.  The  most 
striking  part  of  the  lesion  is  the  great  enlargement  of  the  thymus  gland, 
with  which  is  found  a  hyperplasia  of  the  lymphoid  tissues  throughout  the 
body,  more  marked  than  is  seen  in  any  other  condition  in  childhood.  The 
two  most  frequent  symptoms  are  convTilsions  and  attacks  of  asphyxia. 

The  status  lymphaticus  is  most  often  seen  between  the  sixth  and 
twelfth  months,  but  may  be  met  with  in  children  of  any  age.    Enlarge- 


STATUS  LYMPHATICUS. 


833 


ment  of  the  thymus  to  a  degree  sufficient  to  be  regarded  as  pathological,  is 
not  an  infrequent  condition.  An  association  with  rickets  is  often  observed, 
but  it  is  doubtful  whether  this  is  anytliing  more  than  a  coincidence. 

Since  the  large  thymus  is  so  important  a  lesion,  it  is  desirable  to 
know  what  may  be  regarded  as  normal.    The  most  extensive  observations 


\ 

Fig.  160. — Enlarged  Thymus.  The  lungs,  heart,  and  thymus  are  shown  in  the  picture. 
The  lungs  have  been  turned  back,  showing  the  two  lateral  lobes  of  the  thymus  over- 
lapping the  heart;  the  central  lobe,  above,  covers  the  trachea.  History. — Breast  fed, 
male  child,  nine  months  old,  well  developed;  ill  less  than  twenty-four  hours;  dyspncBa, 
clight  cyanosis,  with  death  from  asphyxia.  T.  103°  F.  ^utops^/.— Besides  the  large 
thymus  there  were  present  the  general  lesions  of  the  status  lymphaticus  to  a  marked 
degree;  lungs  deeply  congested. 


upon  this  point  have  been  made  by  Bovaird  and  Nicoll,  who  weighed 
the  thymus  in  495  consecutive  autopsies  in  children  under  five  years. 
They  found  that  the  weight  was  greatest  at  birth,  the  average  being 
7.7  grams.  After  this  time  the  change  in  weight  was  very  slight  for 
the  period  of  five  years,  the  average  for  the  entire  495  observations  being 
5.9  grams,  which  was  about  the  same  as  the  average  for  each  of  the  years 
taken  separately.  Excluding  cases  in  wdiich  the  organ  was  so  large  as  to 
be  considered  abnormal  (10  grams  or  over),  the  average  weight  at  birth 
was  6.5  grams;  during  infancy  and  early  childhood,  4  grams.  The  re- 
54 


834  DISEASES  OF  THE  LYMPH  NODES. 

suits  of  tliese  observations  do  not  differ  essentially  from  those  of  Fried- 
leben,  which  have  been  so  extensively  misquoted.  It  may  therefore  be 
assumed  that  the  average  weight  of  the  normal  thymus  at  birth  is  from 
6  to  7  grams;  from  birth  to  five  years,  from  3  to  4  grams.  Anything 
over  10  grams  may  be  considered  abnormal. 

In  the  status  lymphaticus  the  thymus  is  often  from  five  to  ten  times 
larger  than  normal.  In  the  marked  cases  its  weight  is  from  30  to  40 
grams;  in  the  less  marked  cases  from  10  to  20  grams.  The  appearance 
of  the  enlarged  thymus  is  well  shown  in  the  accompanying  illustra- 
tion (Fig.  160).  A  thymus  of  the  size  shown  weighs  about  45  grams, 
or  1^  ounces.  In  this  instance  it  was  nearly  as  large  as  one  of  the  lobes 
of  the  lung.  In  general  appearance,  the  enlarged  thymus  is  rather  more 
vascular  than  normal,  but  other  than  hyperplasia,  shows  no  constant  or 
essential  changes,  either  by  gross  or  microscopical  examination. 

The  lymph  nodes  of  the  tracheo-bronchial  region  are  greatly  enlarged, 
often  to  the  size  of  small  cherries,  and  are  found  in  great  clusters.  Those 
of  the  mesenteric  region  may  be  still  larger.  Peyer's  patches  are  very 
prominent,  and  the  solitary  follicles  of  the  small  intestine  appear  like 
mustard  seeds  upon  the  folds  of  the  mucous  membrane.  Those  of  the 
colon  are  also  very  prominent.  The  lymphoid  tissues  about  the  pharynx 
and  all  the  lymph  nodes  of  the  body  are  greatly  hypertrophied.  The 
spleen  is  usually  enlarged,  with  prominent  follicles.  There  are  no  other 
constant  changes.  Those  present  are  usually  accidental,  depending  upon 
the  cause  of  death. 

Symptoms. — In  very  early  infancy  this  is  one  of  the  explanations  of 
sudden  death  occurring  after  slight  causes,  and  in  some  cases  w'ithout 
any  apparent  cause. 

Death  may  be  attributed  to  overlying,  to  asphyxia  from  food,  or  to 
some  other  condition  affecting  respiration,  or  infants  are  simply  found 
dead  in  their  cribs. 

Even  in  those  who  live  until  they  are  several  months,  sometimes 
several  years,  old,  there  may  be  nothing  in  their  condition  to  indicate 
the  presence  of  the  status  lymphaticus  until  something  acute  occurs. 
This  may  be  in  the  nature  of  a  slight  accident,  a  surgical  operation 
of  a  trivial  character,  the  administration  of  an  anaesthetic,  or  some  acute 
disease,  frequently  one  affecting  the  respiratory  tract.  The  symptoms 
associated  with  this  condition  are  most  frequently  of  a  nervous  char- 
acter, usually  attacks  of  con\'ulsions,  or  they  affect  the  respiration,  caus- 
ing paroxysms  of  dyspnoea,  cyanosis,  and  even  asphyxia.  A  frequent 
history  is  somewhat  as  follows:  A  child  previously  regarded  as  healthy, 
often  well  nourished  and  perhaps  entirely  breast  fed,  is  taken  with  con- 
vulsions followed  by  high  fever,  preceding  which  there  may  have  been 
some  pulmonary  symptoms  suggesting  a  commencing  broncho-pneu- 
monia.    The  convulsions  recur  at  short  intervals;  the  temperature  re- 


STATUS  LYMPHATICUS.  835 

mains  steadily  high;  the  signs  in  the  hiiig  are  few  and  not  proportionate 
to  the  other  symptoms;  and  death  occurs  in  from  twelve  to  thirty-six 
hours  often  in  convulsions. 

In  other  cases  convulsions  are  absent  and  the  prominent  symptom 
is  asphyxia,  which  comes  in  paroxysms  and  may  be  so  complete  as  to 
lead  to  the  suspicion  of  laryngeal  obstruction.  If  intubation  or  trache- 
otomy is  performed,  no  relief  follows.  The  child  may  die  in  the  first 
severe  attack,  which  may  be  preceded  for  a  few  hours  by  moderate 
dyspnoea,  or  may  come  on  almost  without  warning.  It  is  more  frequent, 
however,  for  the  first  attack  to  be  less  severe,  the  child  perhaps  being 
resuscitated  with  some  effort,  after  which  he  may  breathe  almost  as  well 
as  usual.  In  a  few  hours  the  attack  of  asphyxia  is  repeated ;  after  sev- 
eral of  these,  each  one  growing  more  severe,  death  occurs.  In  these 
cases  the  elevation  of  temperature  is  usually  slight  and  may  be  wanting. 

Symptoms  similar  to  the  above  but  of  less  severity  and  resulting  in 
recovery  would  suggest  status  lymphaticus,  although  the  diagnosis  can 
not  be  established. 

The  cause  of  the  symptoms  is  not  definitely  known.  The  asphyxia 
has  been  ascribed  to  pressure  of  the  large  thymus  upon  the  lungs,  the 
trachea,  the  pneumogastric  nerves,  or  the  auricles  of  the  heart.  Pres- 
sure would  certainly  seem  to  be  one  factor  in  the  production  of  the 
dyspnoea.  Further  evidence  in  support  of  this  is  obtained  by  the  relief 
afforded  by  an  operation  in  which  the  anterior  mediastinum  is  opened 
and  the  thymus  raised  and  either  fixed  to  the  sternum  or  removed.  This 
has  been  done  in  several  instances  with  striking  benefit. 

In  other  cases,  although  the  thymus  may  be  quite  as  large  as  in  those 
just  described,  the  evidences  of  obstructive  dyspnoea  are  much  less  and 
may  scarcely  be  noticed. 

There  is  another  group  of  cases,  perhaps  the  largest  of  all,  in  which 
there  are  no  symptoms  distinctly  referable  to  the  status  lymphaticus,  and 
yet  this  condition  appears  to  be  the  factor  which  determines  the  fatal 
outcome  of  what  was  apparently  an  infection  or  an  inflammation  of  only 
moderate  severity.  What  is  seen  here  is  simply  a  greatly  diminished  re- 
sistance to  disease.  In  these  cases  it  is  only  the  autopsy  which  reveals 
the  explanation. 

Diagnosis. — The  diagnosis  of  the  status  lymphaticus  is  very  uncer- 
tain. In  some  cases  of  marked  enlargement  it  is  possible  to  make  out 
the  enlarged  thymus  by  percussion,  but  this  is  always  difficult  on  ac- 
count of  its  proximity  to  the  lungs  and  trachea.  We  may  suspect  this 
condition  during  life;  we  can  hardly  do  more.  Marked  enlargement 
of  the  tonsils  and  the  adenoids  exists  so  frequently  without  thymus  en- 
largement, that  this  can  hardly  be  regarded  as  suggesting  the  condition. 
The  hyperplasia  of  the  tracheo-bronchial  or  mesenteric  lymph  nodes  or 
of  the  follicles  of  the  intestine  produces  no  especial  symptoms. 


836  DISEASES  OF  THE   LYMPH   NODES. 

Prognosis. — While  this  condition  apparently  may  exist  for  an  in- 
definite time  without  producing  any  symptoms,  it  undoubtedly  often 
determines  a  fatal  outcome  of  what  might  otherwise  have  been  a  mild 
illness  or  a  trivial  accident.  It  is  especially  important  in  connection 
with  acute  bronchitis  and  broncho-pneumonia,  with  attacks  of  convul- 
sions, with  the  shock  of  slight  operations,  and  with  the  administration  of 
anaesthetics,  particularly  chloroform.  It  is  one  of  the  most  frequent 
explanations  of  unexpected  death  from  slight  causes,  such  as  an  explor- 
atory puncture  or  the  injection  of  antitoxine. 

At  present  no  known  treatment  has  any  injfiuence  upon  the  condition. 

SIMPLE  ACUTE   ADENITIS. 

This  is  an  acute  inflammation  of  the  lymph  nodes  which  in  infancy 
frequently  terminates  in  suppuration.  A  certain  amount  of  inflamma- 
tion of  the  lymph  nodes  occurs  in  children  in  all  acute  processes  affect- 
ing the  mucous  membranes,  especially  when  they  are  severe  or  prolonged. 
Those  in  connection  with  the  various  internal  organs  are  considered  with 
the  diseases  of  the  organs.  Acute  inflammation  of  the  external  nodes 
is  of  sufficient  frequency  to  require  separate  consideration.  While  this  is 
probably  always  secondary  to  some  pathological  process  in  the  skin  or 
nmcous  membranes,  the  primary  condition  may  be  so  slight  as  to  be 
overlooked,  and  the  adenitis  may  be  the  more  important  condition  or  may 
even  assume  the  appearance  of  a  primary  disease.  It  is  particularly  in 
infants  that  this  is  seen,  and  it  depends  upon  the  unusually  active  ab- 
sorption and  upon  the  susceptibility  of  the  lymphoid  tissues  at  this  age. 
The  cervical  glands  are  frequently  affected,  and  occasionally  those  of  the 
axillary  and  inguinal  regions. 

Etiology. — Acute  adenitis  occurs  in  children  of  all  ages  in  connection 
with  diphtheria,  scarlet  fever,  measles,  and  influenza.  In  such  cases  it 
is  often  severe,  and  after  scarlet  fever,  frequently  terminates  in  sup- 
puration. With  the  simple  acute  catarrhal  processes  of  the  pharynx 
and  rhino-pharynx  adenitis  also  occurs,  but  it  is  usually  mild  and  rarely 
ends  in  suppuration.  In  infancy,  on  the  other  hand,  acute  adenitis 
from  simple  catarrh  is  not  only  very  common  but  often  severe,  and 
frequently  terminates  in  suppuration.  Ulcerative  stomatitis,  carious 
teeth,  eczema  of  the  scalp  or  traumatism,  may  excite  adenitis  in  chil- 
dren of  all  ages.  Axillary  adenitis  may  result  from  vaccination;  ingui- 
nal adenitis,  from  vaginitis. 

Of  109  cases  of  acute  adenitis  from  my  records,  not  including  any 
associated  with  diphtheria,  measles,  or  scarlet  fever,  more  than  three- 
fourths  occurred  in  the  first  two  years,  and  half  of  them  in  the  first  year 
of  life.  This  susceptibility  of  infants  is  very  striking.  The  disease 
occurs  frequently  in  those  who  are  in  other  respects  perfectly  healthy, 


SIMPLE  ACUTE  ADENITIS. 


837 


and  often  when  the  evidences  of  disease  of  the  mucous  membrane  are 
slight.  This  is  true  not  only  of  the  cases  of  cervical  adenitis,  but  also 
of  others  in  which  the  inguinal  glands  are  involved.  The  inflammation 
is  excited  in  most  of  these  cases  by  the  absorption  of  pyoi^cuic  germs, 
usually  staphylococci  or  streptococci,  from  the  mucous  membranes  or 
skin. 

Lesions. — The  changes  taking  place  in  the  glands  are  acute  conges- 
tion, with  swelling,  oedema,  and  active  liyperplasia  of  the  lymphoid  ele- 
ments. The  process  may  terminate  in  resolution  or  in  suppuration 
according  to  the  intensity  of  the  infection  and  the  susceptibility  of  the 
tissues.  When  severe  enough  to  cause  suppuration,  the  adenitis  is  ac- 
companied by  considerable  inflammation  of  the  surrounding  cellular 
tissue. 

In  the  series  of  109  acute  cases  to  which  I  have  referred,  not  includ- 
ing the  specific  infectious  diseases,  96  were  cervical,  9  were  inguinal, 
and  4  axillary;  sixty-two  per  cent  terminated  in  su})puration,  the  latter 
being  nearly  all  in  infancy.  Suppurative  otitis  was  present  in  sixteen 
per  cent  of  the  cases.  Suppurative  retro-pharyngeal  adenitis  (retro- 
pharyngeal abscess)  was  seen  in  several  cases. 

In  infancy  the  disease  is  usually  unilateral,  or,  if  bilateral,  the 
glands  of  one  side  are  more  severely  affected  than  those  of  the  other. 
Suppuration  is  nearly  always  of  one 
side,  and  usually  the  abscess  starts 
in  a  single  gland. 

Symptoms. — The  symptoms  and 
course  of  the  adenitis  of  the  specific 
infectious  diseases  belong  to  their 
clinical  history.  Suppuration  is  in- 
frequent, except  after  scarlet  fever. 
It  is  very  rare  after  diphtheria. 

The  typical  cases  of  acute  ade- 
nitis are  those  whicli  occur  in  in- 
fancy. There  are  present  the  symp- 
toms of  the  original  disease — usually 
catarrh  of  the  nose  or  rhino-pharynx, 
mouth,  or  ear,  which  may  not  be  very 
severe,  and  sometimes  is  overlooked. 
The  glands  most  frequently  af- 
fected are  the  deep  cervical  group. 
The  tumour  appears  just  below  the 
angle  of  the  jaw  at  the  anterior  border  of  the  sterno-mastoid  muscle 
(Fig.  161).  The  swelling  during  the  acute  catarrh  is  not  rapid  or  great, 
but  continues  after  the  original  process  has  subsided  until  it  reaches  the 
size  of  a  walnut  or  even  larger.    In  the  most  acute  cases  there  is  marked 


Fig.  161. — Acute  Suppurative  Ade- 
nitis IN  AN  Infant  One  Year  Old. 
Showing  the  most  frequent  situation  of 
the  tumour  in  the  cervical  region. 


838 


DISEASES  OF  THE   LYMPH   NODES. 


Fig.  162.  —  Acute  Suppurative  Ade- 
nitis (inguinal)  in  an  Infant  Three 
Months  Old. 


inflammation  of  the  periglandular  cellular  tissue,  with  pain,  tenderness, 
and  extra  heat.  If  suppuration  occurs,  it  is  generally  evident  in  the 
latter  part  of  the  second  week,  but  sometimes  it  may  be  as  late  as  the 

third  or  even  the  fourth  week.  In 
the  axillary  or  inguinal  region 
(Fig.  162)  the  symptoms  of  ade- 
nitis are  essentially  the  same  as  in 
the  neck.  In  the  inguinal  cases 
the  degree  of  catarrh  of  the  mu- 
cous membrane  is  often  very  slight. 
Most  cases  run  their  course  with 
slight  fever  and  few  general  symp- 
toms; but  in  young  infants  the 
constitutional  symptoms  are  often 
severe  and  the  physician  may  he  in 
doubt  whether  the  local  process  is 
sufficient  to  explain  them.  The 
temperature  may  be  from  102°  to 
104°  F.  for  several  days,  with  con- 
siderable prostration,  which  is  much 
increased  if  there  is  complicating 
otitis.  After  suppuration,  if  freely 
opened  at  the  proper  time,  the  abscess  heals  rapidly  and  permanently,  a 
sinus  being  rare.  Occasionally  infection  extends  from  one  gland  to  an- 
other, and  a  succession  of  these  glandular  abscesses  occurs. 

In  the  non-suppurative  cases  the  swelling  may  be  even  greater  than 
in  those  which  suppurate;  but  it  is  less  diffuse  and  apparently  limited 
to  the  gland.  It  subsides  slowly  in  the  course  of  from  four  to  eight 
weeks,  often  leaving  a  small  tumour  which  may  be  apparent  for  several 
months.  In  susceptible  children  recurrent  attacks  of  acute  inflammation 
may  lead  to  chronic  enlargement  which  may  last  indefinitely.  The^e 
glands  do  not  become  cheesy,  except  from  subsequent  tuberculous  in- 
fection. 

The  acute  cases  in  infancy  in  which  suppuration  occurs,  appear  to 
recover  about  as  promptly  and  quite  as  completely  as  those  terminating 
in  resolution,  although  in  the  former  the  constitutional  symptoms  are 
more  severe. 

Diagnosis. — This  is  usually  easy  if  it  is  remembered  that,  with  the 
exception  of  the  specific  infectious  diseases,  and  occasionally  local  causes 
like  eczema  of  the  scalp,  carious  teeth,  etc.,  acute  suppurative. adenitis 
is  essentially  a  disease  of  infancy.  I  have  often  seen  it  mistaken  for 
mumps  when  the  swelling  was  severe,  but  on  close  examination  there  is 
but  little  resemblance  between  the  conditions.  The  disease  is  usually 
acute,  and  has  little  in  common  with  the  slow  suppuration  seen  in  later 


SIMPLE  CHRONIC   ADENITIS.  839 

childhood  from  the  breaking  down  of  tuberculous  glands.  In  the  oc- 
casional cases  seen  in  which  the  disease  runs  a  slow  course  a  diagnosis 
from  the  tuberculous  form  may  be  aided  by  a  tuberculin  test. 

Treatment. — Prophylaxis  requires  tiiat  in  all  acute  catarrhs  the  mu- 
cous membrane  should  be  kept  as  clean  as  possible  by  the  use  of  nasal  or 
pharyngeal  sprays,  or  by  syringing  with  simple  solutions  like  Dobell's 
or  Seiler's,  or  one  of  common  salt. 

In  the  stage  of  acute  inflammation  very  hot  applications  or  an  ice- 
bag  may  be  used  for  the  relief  of  pain.  It  is  very  doubtful  whether 
either  of  these  means  has  much  influence  in  preventing  suppuration.  If 
abscess  forms,  incision  should  be  deferred  until  pointing  has  taken  place. 
If  this  plan  is  followed,  refilling  is  rare.  A  simple  incision  with  proper 
aseptic  treatment  is  all  that  is  required.  Curetting  may  be  done  if  there 
is  much  broken-down  tissue  present,  but  it  is  not  usually  necessary.  In 
most  of  the  cases  the  abscess  promptly  heals  and  a  perfect  cure  takes 
place.  In  cases  which  do  not  suppurate,  absorption  may  be  promoted 
by  the  internal  use  of  the  iodide  of  potassium  in  full  doses — gr.  x  daily 
to  an  infant  of  one  year.  I  confess  rarely  to  have  seen  any  benefit  from 
painting  with  iodine  or  from  inunctions  of  iodine  ointment  or  the  oleate 
of  mercury.  If  adenitis  is  secondary  to  carious  teeth,  eczema,  or  ulcera- 
tive stomatitis,  these  conditions  should  receive  appropriate  treatment. 
Such  cases  do  not  usually  suppurate,  but  subside  rapidly  when  the 
primary  cause  is  removed. 

SIMPLE  CHRONIC   ADENITIS. 

This  consists  in  a  simple  hyperplasia  of  the  lymph  nodes.  There  are 
considered  here  only  the  external  glands,  but  those  of  the  cavities  of  the 
body  are  affected  in  a  similar  way,  in  diseases  of  the  mucous  membranes 
with  which  they  are  connected. 

Simple  chronic  adenitis  is  not  nearly  so  frequent  as  the  acute  form 
even  in  infants  and  young  children,  and  it  is  rare  after  the  fifth  year. 
It  may  follow  one  or  more  attacks  of  acute  adenitis,  or  it  may  result  from 
subacute  or  chronic  inflammations  of  the  skin  or  of  the  various  mucous 
membranes,  infection  from  which  causes  the  acute  form.  The  most  fre- 
quent subjects  are  children  who  have  the  diathesis  described  as  "  lym- 
phatism." 

Symptoms. — The  glands  upon  both  sides  of  the  neck  are  usually  in- 
volved, and  more  often  a  group  than  a  single  gland.  The  degree  of 
swelling  is  not  generally  great,  being  much  less  than  in  acute  adenitis, 
and  usually  less  than  in  the  tuberculous  form.  There  are  no  constitu- 
tional symptoms.  Hypertrophy  of  the  tonsils  and  adenoid  growths  of 
the  pharynx  are  frequently  present.  There  is  no  tendency  to  suppura- 
tion or  caseation.  The  swelling  usually  increases  slowly  for  one  or  two 
months,  then  remains  stationary  for  about  the  same  length  of  time,  after 


840  DISEASES  OF  THE   LYMPH   NODES. 

which  it  slowly  subsides.  A  subacute  course  is  more  frequent  than  a  very 
chronic  one. 

Diagnosis. — These  cases  are  especially  to  be  distinguished  from  those 
of  tuberculous  adenitis.  The  most  important  points  for  differentiation 
are,  that  they  occur  most  frequently  in  children  under  two  years,  a 
period  when  tuberculous  adenitis  is  not  conmion;  some  definite  exciting 
cause  is  usually  present;  caseation  and  suppuration  do  not  occur;  the 
glands  do  not  become  adherent  to  the  skin  or  to  the  deeper  tissues;  they 
enlarge  much  more  rapidly  than  do  the  non-caseating  tuberculous  glands ; 
and  they  are  influenced  to  a  much  greater  degree  by  constitutional 
treatment.     The  children  do  not  respond  to  tuberculin  tests. 

Treatment. — Operative  measures  are  not  called  for  in  simple  ade- 
nitis; but  there  are  some  cases  in  which  operation  is  to  be  considered 
if  a  thorough  trial  of  other  measures  for  two  or  three  months  has  been 
without  benefit.  Local  causes  usually  found  in  the  pharynx,  nose,  or 
mouth  should  be  removed  if  possible.  Often  more  can  be  accomplished 
by  removal  to  a  climate  in  which  the  child's '  catarrhal  symptoms  are 
relieved  than  by  all  else.  Little  benefit  is  seen  from  local  applications. 
The  most  useful  internal  remedies  are,  the  syrup  of  the  iodide  of  iron 
(twenty  drops  three  times  a  day  to  a  child  of  four  years),  and  arsenic 
(two  or  three  drops  of  Fowler's  solution  three  times  a  day).  Cod-liver 
oil  should  be  given  except  during  warm  weather. 

SYPHILITIC   ADENITIS. 

It  is  quite  rare  that  a  marked  degree  of  glandular  enlargement  is 
seen  as  a  symptom  of  hereditary  syphilis ;  indeed,  it  is  so  rare  that  it  is 
often  forgotten  that  chronic  multiple  glandular  enlargements  are  ever 
due  to  this  disease.  In  the  few  examples  that  have  come  under  my  ob- 
servation, this  has  been  a  late  symptom  of  hereditary  syphilis.  The 
glandular  enlargements  were  cervical  and  multiple,  and  the  degree  of 
swelling  was  often  marked.  They  may  be  associated  with  disease  of  the 
bones  or  of  the  mucous  membrane  of  the  throat  or  of  the  nose,  or  with- 
out signs  of  such  disease.  The  diagnosis  of  syphilis  rests  upon  the  asso- 
ciation of  other  late  manifestations  of  the  disease — keratitis,  periostitis, 
deformities  of  the  teeth,  the  Wassermann  reaction,  and  the  prompt 
improvement  under  anti-syphilitic  treatment.  In  their  local  appearance 
they  resemble  tuberculous  glands. 

TUBERCULOUS  ADENITIS. 
(Scrofula.) 

Tuberculous  disease  of  the  lymph  glands  of  the  cavities  of  the  body 
is  discussed  elsewhere;  only  that  of  the  external  glands  is  here  consid- 
ered.    This  condition  i)resents  some  striking  peculiarities:   it  is  rela- 


TUBERCULOUS  ADENITIS.  841 

tively  rare  in  infancy,  although  a  frequent  form  of  tuberculosis  in  older 
children;  it  often  exists  as  the  only  apparent  tuberculous  lesion  in  the 
body.  In  the  great  majority  of  cases  it  is  the  cervical  glands  which  are 
affected. 

Etiology. — The  age  at  which  tuberculosis  of  the  cervical  lymph  glands 
is  usually  seen  is  from  three  to  ten  years.  In  my  experience  with  tuber- 
culosis in  infancy,  the  external  glands  are  rarely  involved,  while  the 
bronchial  glands  are  almost  invariably  the  seat  of  infection. 

Local  conditions  favouring  infection  are  adenoid  growths  of  the 
pharynx,  chronic  pharyngitis,  and  hypertropliied  tonsils;  less  frequently 
chronic  otitis,  chronic  conjunctivitis,  and  pathological  processes  of  the 
skin  or  the  mouth,  such  as  eczema  of  the  face  or  scalp,  ulcerative  stoma- 
titis, carious  teeth,  etc.  That  the  pharynx  is  the  most  frequent  seat  of 
primary  infection,  is  shown  by  the  fact  that  the  deep  cervical  glands  are 
generally  first  affected.  The  question  often  arises  whether  the  process 
is  at  first  a  simple  one,  and  later  becomes  tuberculous,  or  whether  it  is 
tuberculous  from  the  outset.  My  own  belief  is  that  in  most  cases  the 
process  is  a  tubercvdous  one  from  the  beginning. 

Children  Avho  are  by  inheritance  predisposed  to  tuberculosis  and  those 
also  who  are  prone  to  glandular  enlargements — two  conditions  which  are 
by  no  means  identical — are  the  ones  most  liable  to  be  affected.  Attacks 
of  acute  infectious  diseases,  particularly  measles,  scarlet  fever,  and  influ- 
enza, frequently  play  the  role  of  exciting  causes. 

The  age  of  those  affected  corresponds  very  closely  with  that  at  which 
children  are  most  often  seen  with  hypertropliied  tonsils  and  adenoid 
growths  of  the  pharynx.  The  subsidence  of  symptoms  about  the  time  of 
puberty,  is  also  characteristic  of  both  conditions.  Of  forty-five  cases  of 
tuberculous  cervical  adenitis  in  children  studied  by  Park,  twenty-five 
showed  the  human  type  of  bacillus,  and  twenty  the  bovine  type.  This 
is  in  striking  contrast  with  the  results  found  by  him  in  other  forms 
of  tuberculosis  in  children  and  points  strongly  to  food  infection  as  a 
cause. 

Lesions.— It  has  been  already  stated  that  in  the  great  majority  of 
cases  the  cervical  lymph  nodes  are  involved,  and  generally  they  are  the 
only  ones  affected.  In  155  cases  of  tuberculous  glands  in  the  series 
reported  by  Treves,  those  of  the  neck  were  the  seat  of  disease  in  145  and 
the  only  seat  in  131 ;  those  of  the  axilla  were  involved  in  17,  but  alone 
only  in  1;  the  groin  in  8,  and  alone  in  6.  The  nodes  first  affected  are 
most  frequently  the  upper  set  of  the  deep  cervical  group;  sometimes, 
however,  it  is  the  superficial  nodes  of  the  submaxillary,  or  the  parotid 
group,  and  occasionally  the  submental  or  the  pre-auricular.  The  chain 
of  deep  cervical  nodes  which  is  involved,  follows  the  carotid  artery,  and 
often  extends  some  distance  below  the  clavicle.  These  deep  nodes  are 
sometimes  connected  with  the  bronchial  group. 


842  DISEASES  OF  THE   LYMPH   NODES. 

The  process  in  all  tuberculous  glands  is  essentially  a  chronic  one, 
but  pathologically  the  cases  may  be  divided  into  two  groups,  correspond- 
ing somewhat  to  the  forms  of  disease  seen  in  the  lungs.  In  one  group 
the  process  is  more  rapid,  and  tends  to  early  caseation  and  softening; 
the  products  of  inflammation  are  mainly  cellular,  and  the  amount  of 
fibrous  tissue  is  small.  In  another  group  the  course  is  slower,  and  fibrous 
tissue  predominates,  caseation  and  softening  being  infrequent. 

In  the  first  group  the  glands  in  the  early  stage  are  swollen,  of  a  pale 
pink  colour,  and  homogeneous;  later  they  become  more  firm,  and  show, 
as  the  first  gross  evidence  of  tuberculous  deposits,  small  grayish-wliite 
spots,  which  are  generally  numerous  and  scattered  through  the  affected 
gland;  these  spots  enlarge,  and  may  coalesce  to  form  one  large  gray 
mass,  involving  nearly  the  whole  gland.  Subsequently  there  is  caseation 
and  then  softening,  usually  beginning  in  the  centre  of  the  caseous  area. 
Inflammation  within  the  gland  is  followed  by  that  of  the  surrounding 
tissues,  which  may  result  in  adhesions  or  in  the  formation  of  a  periglan- 
dular abscess.  The  first  change  in  the  gland  is  the  production  of  epithe- 
lioid and  giant  cells,  about  which  there  is  a  zone  of  small  round  cells; 
cheesy  degeneration  then  begins  in  the  centre.  The  caseous  masses  may 
become  encapsulated  by  the  production  about  them  of  fibrous  tissue;  or 
softening  may  occur  at  one  or  more  foci,  and  an  abscess  form.  Such  an 
abscess  contains  curdy  material  but  very  little  true  pus,  the  contents 
being  chiefly  detritus  from  the  broken-down  node.  Tubercle  bacilli  are 
usually  more  numerous  in  the  early  stages  of  the  process,  but  are  often 
difficult  of  detection  in  broken-down  tissues,  and  the  curdy  pus  is  some- 
times sterile.  As  the  glands  soften,  the  process  gradually  extends  from 
the  centre  to  the  surface,  and  they  become  adherent  to  the  surrounding 
structures — blood-vessels,  nerves,  or  the  fascia — they  fuse  together  and 
form  large  knotty  masses,  and  when  they  ultimately  break  down  they 
lead  to  the  formation  of  an  abscess  in  the  cellular  tissue,  finally  involv- 
ing the  skin.  In  the  form  of  suppuration  which  occurs  in  and  about 
tuberculous  nodes,  an  important  part  is  often  played  by  other  bacteria, 
usually  the  staphylococcus  or  the  streptococcus. 

In  the  second  group  of  cases,  where  the  process  goes  forward  more 
slowly,  the  changes  are  not  quite  the  same,  the  essential  difference  being 
that  the  amount  of  fibrous  tissue  is  much  greater.  These  nodes  are  not 
so  vascular;  they  are  tough  and  hard,  appearing  like  small  fibrous 
tumours.  The  capsules  are  greatly  thickened,  and  under  the  microscope 
is  seen  fibrous  tissue  arranged  in  concentric  layers,  often  inclosing  small 
caseous  masses.  These  nodes  less  frequently  form  adhesions  to  the  sur- 
rounding tissues,  and  consequently  are  freely  movable,  while  suppura- 
tion is  quite  exceptional.  Although  the  separate  tumours  are  much 
smaller  than  in  the  first  group,  the  glandular  mass  is  often  a  large  one, 
because  of  the  number  of  glands  involved. 


TUBERCULOUS  ADENITIS. 


843 


It  is  seldom  in  either  group  of  cases  that  the  process  is  limited  to  a 
single  node  or  even  to  two  or  three  nodes.  Very  often  an  entire  chain 
is  involved  (see  Fig.  163). 

Tuberculous  infection  of  the  lymph  nodes  may  terminate  in  resolu- 
tion, encapsulation,  calcification,  or  suppuration.  Tlie  inflammation 
may  subside  before  caseation  lias  taken  place 
and  the  inflammatory  products  undergo  ab- 
sorption. After  caseation  has  occurred  the 
masses  may  become  encapsulated  and  contract 
to  small  fibrous  nodules.  Calcification  of  the 
glands  in  this  location  is  rare.  In  other  cases 
caseation  is  followed  by  breaking  down,  lique- 
faction, and  an  external  abscess.  The  course 
which  the  local  disease  takes  will  depend  upon 
the  intensity  of  the  infection  and  the  general 
vigour  and  resistance  of  the  child.  There  is 
seen  in  most  cases  a  tendency  of  the  inflam- 
mation to  subside  spontaneously  about  the 
time  of  puberty.  Cure  has  sometimes  followed 
an  acute  attack  of  intercurrent  disease,  such 
as  erysipelas  of  the  face,  and  even  scarlet 
fever. 

Symptoms. — In  the  early  part  of  the  dis- 
ease there  are  no  symptoms  but  the  glandular 
swelling,  and  this  begins  very  gradually.  In 
most  cases  both  sides  are  involved,  but  as  the 
disease  progresses  the  advanced  changes  are 
usually  confined  to  one  side.  The  enlarge- 
ment is  seldom  continuous;  it  often  increases 
for  a  time  and  then  remains  stationary  or 
even  diminishes,  to  take  a  new  start  from 
the  stimulus  of  some  fresh  infection  of  the 
mucous  membrane  with  which  the  glands  are 
associated,  such  as  an  attack  of  measles  or 
influenza,  or  simply  from  a  deterioration 
in  the  patient's  general  health.  During  ex- 
acerbations, the  glands  may  be  painful  and 
tender,  and  show  the  usual  signs  of  local  in- 
flammation. 

The  whole  course  of  the  disease  varies  from  several  months  to  as 
many  years.  Treves  gives  three  and  a  half  years  as  the  average  dura- 
tion when  suppuration  occurs.  The  glands  first  affected  are  usually 
those  situated  near  the  bifurcation  of  the  common  carotid  artery.  Such 
tumours  usually  make  their  appearance  just  in  front  of  the  sterno-mas- 


FiG.  163. — Posterior  Cer- 
vical Chain  of  Tuber- 
culous Lymph  Nodes. 
The  upper  one  showed 
giant  cells  and  extensive 
cheesy  degeneration;  one 
at  the  middle  showed 
early  tuberculous  changes 
— cell  infiltration,  giant 
cells,  and  a  small  area  of 
cheesy  degeneration;  the 
lowest  node  showed  one 
small  tubercle  with  a 
cheesy  centre.  Child  two 
and  a  half  years  old. 
(Dowd.) 


844  DISEASES  OF  THE  LYMPH  NODES. 

toid  muscle — sometimes  behind  it — and  at  the  level  of  the  upper  border 
of  the  larynx  or  the  hyoid  bone.  In  the  more  rapid  cases  tlie  tumours 
usually  attain  a  considerable  size  in  three  or  four  months,  sometimes  in 
half  that  time.  The  usual  size  reached  is  from  that  of  an  almond  to  an 
English  walnut.  At  first  the  tumours  are  movable  and  preserve  their 
distinct  outline;  later  they  become  adherent,  first  to  the  deeper  tissues 
and  to  each  other,  finally  to  the  skin,  and  there  is  formed  an  irregular 
nodular  mass  in  which  it  is  sometimes  difficult  to  make  out  the  individ- 
ual glands.  As  the  process  approaches  the  surface  there  are  small  spots 
of  softening;  then  there  is  distinct  fluctuation;  the  skin  becomes  discol- 
oured and  finally  gives  way,  and  there  is  a  discharge  of  thick,  curdy  pus, 
which  may  continue  for  an  indefinite  time,  until  the  whole  of  the  broken- 
down  gland  has  been  thrown  off.  This  course  is  repeated  with  each  suc- 
cessive gland  which  breaks  down.  In  cases  progressing  more  slowly  the 
glands  become  adherent  chiefly  to  one  another,  and  suppuration  is  less 
frequent. 

In  what  proportion  of  tuberculous  lymph  nodes  suppuration  occurs, 
it  is  difficult  to  say.  Like  other  tuberculous  lesions  in  the  body,  this  one 
is  more  frequent  tiian  was  once  supposed ;  and  in  the  past  most  of  tliose 
which  did  not  break  down  Mere  not  classed  as  tuberculous.  It  is  prob- 
able that  of  the  cases  allowed  to  run  their  course  about  one-half  terminate 
in  suppuration.  Two  forms  of  suppuration  occur  in  connection  with 
tuberculous  glands — one  an  abscess  of  tiie  gland  proper,  the  other  outside 
of  and  usually  over  it.  In  a  typical  case  of  the  first  variety,  the  gland 
is  distinctly  outlined  and  often  superficial,  there  is  very  little  inflam- 
mation, the  spot  of  softening  and  fluctuation  is  small,  and  the  pus  dis- 
charged is  always  curdy.  In  the  second  variety  the  abscess  is  preceded 
by  a  more  diffuse  swelling,  and  the  outline  of  the  gland  may  not  be  made 
out;  the  signs  of  inflanmiation  are  more  marked,  the  area  of  fluctuation 
is  larger,  and  the  pus  is  more  like  that  of  any  ordinary  abscess.  Often 
the  two  varieties  are  combined  ;  as  when  a  gland  beneath  the  deep  fascia 
breaks  down  and  there  is  formed  directly  over  it  an  abscess  in  the  cellular 
tissue,  which  communicates  through  a  narrow  opening  with  the  gland 
beneath.  In  such  cases  the  sinus  continues  open  for  a  very  long  time, 
until  the  whole  of  the  gland  has  been  discharged.  If  healing  occurs  be- 
fore this,  the  cicatrix  soon  breaks  down. 

Where  abscesses  are  allowed  to  open  spontaneously,  large,  irregular, 
and  usually  very  intractable  ulcers  form.  The  skin  is  undermined  for 
a  considerable  distance,  and  it  has  an  unhealthy  appearance.  Such  ulcers 
sometimes  continue  for  many  months  in  spite  of  all  treatment,  partic- 
ularly if  the  patient's  general  health  is  poor.  The  scars  left  after  them 
are  large  and  unsightly,  and  sometimes  positively  deforming  (Fig.  164). 
Their  appearance  is  quite  characteristic.  They  often  have  many  tabs  of 
skin  attached  to  them;  they  may  form  prominent  ridges  which  undergo 


TUBERCULOUS  ADENITIS. 


845 


contraction  like  those  after  burns;  they  are  of  a  purplish-red  colour,  and 
adherent  to  the  deeper  tissues.     They  are  often  sensitive  and  painful. 
As     time     passes      they 
atrophy  and  become  less 
conspicuous,  though  they 
remain  throughout  life. 

The  general  health  of 
children  with  tuberculous 
glands  may  be  much  or 
little  affected,  and  not  a 
few  remain  in  good  con- 
dition throughout  the 
whole  course  of  the  dis- 
ease, particularly  when 
suppuration  does  not  oc- 
cur, but  sometimes  even 
when  it  is  protracted. 

Prognosis.  —  Tubercu- 
losis of  the  external 
lymph  nodes  is  seldom 
if  ever  the  direct  cause 
of  death;  although  the 
course  is  often  very  pro- 
tracted, ultimate  recov- 
ery can  usually  be  pre- 
dicted. As  previously 
stated,    it    is    surprising 

that  this  process  is  so  frequently  the  only  tuberculous  lesion  in  the 
body.  Treves  states  that  the  percentage  of  those  who  die  from  gen- 
eral tuberculosis  is  so  small  that  this  danger  is  not  to  l)e  considered 
an  argument  for  operation.  Poore  reports  that  of  58  cases  treated  by 
operation,  only  2  were  known  to  have  died  from  tuberculosis.  Dowd 
has  collected  reports  of  309  cases  treated  by  removal  more  or  less  com- 
plete, whose  histories  were  followed  for  several  years  after  operation. 
Of  these,  203,  or  65.4  per  cent,  were  apparently  cured;  57,  or  18.4  per 
cent,  were  living,  though  suffering  from  either  local  or  general  tuber- 
culosis; 50,  or  16.2  per  cent,  died  of  tuberculosis.  These  statistics  surely 
do  not  support  the  hopeful  views  of  the  writers  first  quoted,  but  they  are, 
I  think,  more  in  accord  with  general  experience. 

Diagnosis. — The  diagnostic  features  of  tuberculous  glands  are  the 
age  of  the  patient — usually  from  tliree  to  ten  years — the  site  of  the  pri- 
mary swelling,  the  indolent  course,  the  trifling  original  cause,  and  the 
disposition  to  slow  caseation,  softening,  and  abscess.  The  tuberculin 
reaction  i§  of  great  assistance.     The  cases  of  simple  hyperplasia  are 


Fig.  164. — Cicatrices  Following  a  Neglected  Case 
OF  Tuberculous  Adenitis,  in  a  Girl  Seven  Years 
Old.  There  is  also  a  tuberculous  patch  upon  the 
skin  of  the  cheek  in  a  very  frequent  location. 


846  DISEASES  OF  THE  LYMPH  NODES. 

usually  in  children  under  three  years,  their  progress  is  much  more  rapid, 
there  is  often  some  definite  cause,  and  in  most  cases  they  nearly  or  quite 
disappear  in  the  course  of  three  or  four  months.  They  suppurate,  if  at 
all,  during  the  first  month.  Syphilitic  disease  is  to  be  recognised  mainly 
by  discovering  the  evidence  of  syphilis  elsewhere,  and  by  the  effect  of 
treatment.  In  Hodgkin's  disease,  glandular  groups  in  other  parts  of 
the  body  are  involved  simultaneously  or  in  rapid  succession.  There  are 
no  signs  of  inflammation  or  caseation ;  and  the  swellings  are  accompanied 
by  very  marked  and  definite  constitutional  symptoms — anaemia,  emacia- 
tion, and  general  prostration.  Malignant  growths  are  very  rare;  they 
increase  rapidly,  often  attaining  a  great  size  in  a  few  months. 

Treatment. — The  general  treatment  of  tuberculous  glands  is  to  put 
the  child  under  the  very  best  surroundings  possible.  The  seaside  has  a 
great  reputation  for  such  cases,  and  no  doubt  the  majority  do  very  well 
there;  but  some  are  benefited  even  more  by  a  dry,  mountain  climate. 
At  all  events,  a  child  from  the  city  should  be  sent  into  the  country 
whenever  this  is  possible.  Internally  the  only  remedies  which  have  any 
special  virtues  are  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron.  The 
latter  should  be  given  in  full  doses,  i.  e.,  twenty  or  thirty  drops,  three 
times  a  day,  to  a  child  of  six  years.  Arsenic  and  iron  are  useful  as  gen- 
eral tonics.  Local  applications  are  of  little  value  and  most  of  them  posi- 
tively harmful ;  painting  with  iodine  and  poulticing  should  be  discarded 
altogether.    The  parts  should  be  rubbed  or  handled  as  little  as  possible. 

It  is  important  in  every  case  to  remove  from  the  nose  and  throat  all 
sources  of  local  irritation.  Hypertrophied  tonsils  and  adenoid  tissue  of 
the  pharynx  should  receive  attention,  also  any  pathological  conditions  in 
the  nose,  such  as  hypertrophy  of  the  turbinated  bodies,  and  chronic  otitis, 
chronic  conjunctivitis,  carious  teeth  or  ulcers  in  the  mouth.  All  these, 
if  they  de  no  more,  keep  up  a  constant  glandular  irritation,  and  produce 
conditions  which  are  most  favourable  for  the  activity  of  the  tubercle 
bacillus. 

Operative  Measures. — These  are  indicated  if,  after  two  or  tiiree 
months  of  constitutional  treatment,  the  glands  affected  continue  to  in- 
crease in  size  and  number,  or  if  softening  occurs.  The  advantages  of 
operation  over  leaving  the  case  to  Nature  are,  that  it  leaves  a  clean  scar 
instead  of  a  large,  irregular  one;  that  it  shortens  the  disease  and  pre- 
vents the  long,  tedious  suppuration  of  cases  left  to  themselves;  that  it 
is  a  radical  measure;  and  that  it  avoids  the  danger  of  general  infection 
by  removing  the  tuberculous  focus. 

The  best  results  follow  operation  when  it  is  done  early  before  the  skin 
is  involved  or  the  glands  have  softened  or  have  formed  extensive  adhe- 
sions to  the  great  vessels  and  neighbouring  structures;  also  where  a 
chain  of  glands  is  involved  and  where  the  inflammatory  process  is  slow 
or  indolent.    If  performed  early  a  thorough  operation  by  a  good  surgeon 


HODGKIN'S   DISEASE.  847 

in  the  majority  of  cases  will  result  in  a  |H"riiianent  cure.  However,  the 
operation  is  not  contraindicated  in  cases  which  have  gone  on  to  a  later 
stage,  although  the  results  may  not  he  (]uite  so  satisfactory. 

Glandular  abscesses  should  in  all  cases  be  o])ei!ed  as  soon  as  pus 
forms,  to  prevent  the  extensive  undermining  of  the  skin,  which  is  so 
likely  to  occur.  The  opening  should  be  a  small  one,  and  all  squeezing  of 
the  gland  or  surrounding  tissues  avoided. 


HODGKIN'S   DISEASE. 

(Pseudo-Leukcemia.) 

This  is  a  rare  disease  in  which  there  is  a  general  hyperplasia  of  the 
lympliatic  glands  throughout  tlie  body,  witli  growths  of  lymphoid  tissue 
in  the  spleen,  liver,  and  other  internal  organs.  It  is  accompanied  by 
marked  ana?mia,  is  progressive  in  its  course,  and  usually  terminates 
fatally.  The  cause  is  unknown.  It  is  much  more  common  in  males  than 
in  females.     Its  occurrence  in  childhood  is  exceedingly  rare. 

The  chief  lesion  is  in  the  lymph  nodes  which  become  greatly  en- 
larged, and  besides  new  ones  develop  during  the  course  of  the  disease. 
The  spleen  is  usually,  the  liver  less  frequently,  involved  and  somewhat 
enlarged  by  the  formation  of  lymphomatous  masses  which  may  also 
infiltrate  almost  any  tissue  of  the  body.  Microsco])icany,  the  early 
changes  in  the  glands  consist  in  an  increase  in  the  lymphoid  tissue. 
Later  there  is  proliferation  of  the  endothelioid  cells,  the  formation  of 
giant  cells,  and  an  overgrowth  of  connective  tissue.  The  eosinophile 
cells  are  frequently  present  in  the  tissues  in  great  numbers.  Any  of  the 
external  ©r  internal  groups  of  lymph  glands  may  be  affected,  and  in 
severe  cases  the  disease  may  involve  almost  every  chain  of  glands  in  the 
body.  Of  the  external  groups,  the  cervical  and  the  axillary  are  usually 
most  affected;  of  the  internal  groups,  those  of  the  mediastinum  and  the 
retro-peritoneal  region. 

The  disease  develops  very  gradually,  often  insidiously.  The  external 
glandular  swellings  are  usually  the  first  noticed,  but  sometimes  it  is 
the  ansemia  which  first  attracts  attention;  occasionally  it  is  the  local 
symptoms  resulting  from  the  pressure  of  internal  glands,  which  may 
give  rise  to  oedema,  pain,  cough,  or  dyspnoea.  The  progress  is  generally 
slow  but  steady,  and  the  glands  may  reach  an  immense  size.  The  blood 
changes  are  inconstant.  As  a  rule,  there  is  a  relative  increase  in  the 
lymphocytes,  while  the  total  number  of  wdiite  cells  is  generally  less  than 
normal,  although  sometimes  increased. 

Treatment  is  very  unsatisfactory.  Arsenic  in  full  doses  appears  to 
benefit  some  patients.  The  use  of  the  X-ray  has  produced  striking, 
though  in  most  cases  only  temporary  improvenient  in  the  external  glands. 


848  DISEASES  OF  THE  SPLEEN. 

CHAPTER    III. 

DISEASES  OF   THE  SPLEEN. 

Weight. — From    140   observations   made   at  the   New  York   Infant 
Asylum  the  following  were  the  weights  recorded  at  the  different  ages: 

Weight  of  the  Spleen  in  Infancy  and  Early  Childhood. 


Age. 


Birth 

Three  months .  . 
Twelve  months. 

Two  years 

Three  years  . .  . . 


Ounces. 

Grammes. 

H 

7.7 

y^ 

15.5 

% 

23.2 

W4, 

38.5 

VA 

46.4 

Position  and  Methods  of  Examination. — The  normal  position  of  the 
spleen  is  close  against  the  diaphragm,  its  external  surface  being  opposite 
the  ninth,  tenth,  and  eleventh  ribs.  Its  anterior  border  comes  as  far 
forward  as  the  middle  axillary  line,  its  posterior  border  being  usually 
near  the  vertebral  column.  In  infancy  it  is  practically  impossible  to 
outline  the  spleen  by  percussion,  unless  it  is  enlarged.  During  full  in- 
spiration the  spleen  is  often  depressed  enough  to  be  felt  at  the  free  border 
of  the  ribs,  but  at  other  times  it  can  not  be  felt  unless  it  is  enlarged  or 
pushed  downward  by  some  pathological  condition  in  the  chest.  Nor- 
mally, the  long  axis  of  the  spleen  is  nearly  parallel  with  the  ribs,  but 
when  the  organ  is  much  enlarged,  its  axis  corresponds  nearly  with  a  line 
drawn  from  the  axillary  line  at  the  border  of  the  ribs  to  the  middle  of 
Poupart's  ligament. 

The  thin  abdominal  walls  of  young  cliildren  render  palpation  of  the 
spleen  much  easier  than  in  adults;  and  this  is  a  much  more  satisfactory 
method  of  examination  than  is  percussion.  For  satisfactory  palpation 
it  is  necessary  that  the  abdominal  walls  should  not  be  tense.  The  child 
should  lie  upon  his  back  with  the  thighs  flexed  and  the  skin,  of  course, 
bared.  The  physician,  always  having  taken  the  trouble  to  warm  his 
hands,  should  stand  upon  the  left  side  of  the  patient  and  make  pressure 
with  the  tips  of  the  fingers,  which  are  semi-flexed.  The  pressure  should 
be  at  first  light,  and  gradually  increased,  the  fingers  being  then  held 
stationary  during  two  or  three  respiratory  movements.  Under  ordinary 
conditions  the  spleen  can  easily  be  felt  when  it  is  sufficiently  enlarged 
to  be  of  any  diagnostic  importance. 

When  moderately  enlarged,  the  lower  border  of  the  spleen  is  an  inch 
or  so  below  the  free  border  of  the  ribs;  when  greatly  enlarged,  it  forms 
a  tumour  which  may  nearly  fill  the  left  half  of  the  abdomen.    A  tumour 


ENLARGEMENT  OF  THE  SPLEEN.  849 

in  the  left  hypocliondriae  region  is  recognised  to  he  the  spleen,  hy  the 
fact  tliat  it  is  freely  movable  laterally  and  at  its  lower  border  or  ex- 
tremity, while  it  is  attached  above;  also  its  inner  border  can  usually 
be  felt  to  be  thin  and  sharp,  and  marked  al)out  its  middle  by  quite  a 
deep  notch. 

ENLARGEMENT   OF  THE   SPLEEN. 

In  Acute  Disease.— The  spleen  is  most  frequently  and  most  constantly 
enlarged  in  malarial  and  typhoid  fevers,  but  it  is  occasionally  so  in  all 
the  acute  infectious  diseases. 

In  most  of  these  cases  the  enlargement  is  chiefly  from  congestion,  but 
there  may  be  acute  hyperplasia  and  an  increase  in  size  of  the  Malpighian 
bodies.  It  may  contain  small  haemorrhages,  and  in  extremely  rare  cases 
the  spleen  may  rupture.  It  is  generally  dark-coloured,  soft,  and  some- 
what friable.  In  the  cases  which  recover,  the  splenic  swelling  subsides 
with  the  original  disease. 

In  Chronic  Disease. — Like  the  lymph  nodes,  the  spleen  is  niuch  more 
often  enlarged  in  children,  particularly  young  children,  than  in  adults. 
Enlargement  is  seen  at  times  in  almost  all  the  chronic  diseases  of  early 
life;  but  it  occurs  most  frequently  in  rickets,  syphilis,  malaria,  tuber- 
culosis, the  blood  diseases,  and  in  amyloid  degeneration.  Besides,  it  may 
be  the  seat  of  a  primary  growth,  either  benign  or  malignant. 

Rickets. — The  splenic  enlargement  which  accompanies  rickets  is  gen- 
erally seen  during  the  first  year ;  at  this  period  it  is  very  frequent.  The 
swelling  is  usually  moderate,  but  occasionally  it  is  so  great  that  the 
lower  border  is  three  or  four  inches  below  the  ribs. 

Syphifts. — Enlargement  of  the  spleen  is  one  of  the  most  constant 
lesions  of  hereditary  syphilis.  It  is  present  with  great  uniformity  in 
children  born  with  syphilitic  lesions,  and  very  frequently  during  the 
active  period  of  the  disease  in  early  infancy.  It  is  seen  at  a  later  period 
during  infancy  or  childhood,  associated  with  other  late  symptoms. 

Malaria. — The  swelling  in  cases  of  chronic  malaria  may  be  very  great. 
The  liver  is  not  so  often  enlarged  as  in  syphilis. 

Tuberculosis. — It  is  rare  to  find  anything  more  than  a  moderate 
swelling  of  the  spleen  in  tuberculosis.  In  the  most  acute  cases  this 
may  be  due  to  the  fever  and  general  infection;  in  those  which  are  less 
rapid,  it  depends  either  upon  tuberculous  deposits  or  passive  congestion 
from  venous  obstruction. 

The  Blood  Diseases. — Marked  enlargement  of  the  spleen  is  found  in 
many  cases  of  simple  anaemia  accompanied  by  moderate  leucocytosis. 
The  spleen  is  constantly  swollen,  and  usually  greatly  so,  in  the  pseudo- 
leukaemic  anaemia  of  infants,  in  leukaemia,  and  in  Hodgkin's  disease. 
In  the  last  two  diseases  the  liver  is  also  enlarged,  but  to  a  much  less 
degree  than  the  spleen ;  in  the  others  it  is  but  slightly  changed. 
55 


850  DISEASES  OF  THE  BONES  AND   JOINTS. 

Amyloid  Degeneration. — The  spleen  is  constantly  involved  in  amyloid 
disease,  and  the  enlargement  of  this  organ,  as  well  as  that  of  the  liver, 
may  be  very  great. 

Cardiac  Disease. — In  all  forms  of  cardiac  disease,  and  in  other  con- 
ditions in  which  there  is  obstruction  to  the  systemic  venous  circulation, 
the  spleen  is  enlarged.  It  is  seen  in  congenital  as  well  as  in  acquired 
cases.  The  liver  is  usually  enlarged,  and  there  may  also  be  dropsy  of 
the  feet. 

New-growths,  Tumours,  etc. — It  is  seldom  in  early  life  that  the 
spleen  is  the  seat  of  new-growths;  these  are  usually  varieties  of  sarcoma, 
but  carcinoma  has  also  been  reported. 

Primary  Spleno-megaly. — The  rare  cases  of  immense  primary  en- 
largement of  the  spleen  have  been  variously  interpreted.  By  some 
writers  the  condition  has  been  regarded  as  Ij^mphoma.  Bovaird  '  has  re- 
ported two  cases  in  children,  sisters,  one  of  which  was  carefully  studied 
microscopically,  and  the  conclusions  reached  that  the  process  was  an 
endothelial  hyperplasia.  The  condition  was  first  described  by  Gaucher. 
Clinically  the  disease  is  characterised  by  a  slowly  progressing  enlarge- 
ment of  the  spleen,  wliich  begins  in  early  childhood  and  may  continue 
for  from  five  to  twenty  years ;  the  size  attained  is  very  great,  it  often 
nearl}^  filling  the  abdomen.  In  one  of  Bovaird's  cases  the  weight  was 
twelve  and  a  half  pounds.  The  other  symptoms  are  a  simple  anaemia, 
inflammation  of  the  gums  with  haemorrhages  from  the  nose,  gums,  and 
sometimes  beneath  the  skin,  and  finally  secondary  s3^mptoms  due  to  the 
abdominal  tumour.  The  course  is  very  chronic,  and  thus  far  no  known 
treatment  has  been  of  any  avail. 


CHAPTER    IV. 
DISEASES  OF   THE  BONES  AND  JOINTS. 

ACUTE   ARTHRITIS   OF   INFANTS. 

The  terms  acute  purulent  synovitis,  acute  epiphysitis,  pycemia  of 
hone,  and  acute  osteomyelitis,  have  all  been  applied  to  this  condition. 
The  disease  is  really  a  form  of  pyaemia.  The  causes  and  lesions  may 
differ  considerably  in  the  different  cases,  but  clinically  they  all  have  cer- 
tain features  in  common,  viz.,  an  acute  joint  inflammation  with  sup- 
puration. 

The  acute  arthritis  of  infants  is  essentially  a  disease  of  the  first  year, 
and  is  much  more  frequently  seen  in  the  first  six  months.  The  inflam- 
mation may  begin  in  the  joint,  at  the  epiphyseal  junction,  or  in  the 

^  American  Journal  of  the  Medical  Sciences,  October,  1900. 


ACUTE  ARTHRITIS  OF   INFANTS.  851 

medullary  (tanal ;  but,  however  it  may  start,  tlie  joint  is  soon  invaded. 
The  nature  of  the  arthritis  varies  somewhat  with  tiie  exciting  cause. 
When  it  is  due  to  the  gonococeus,  it  is  usually  confined  to  the  joint;  there 
is  in  most  cases  a  superficial  inflammation  involving  the  synovial  mem- 
brane, but  rarely  leading  to  destructive  changes  in  the  cartilage,  liga- 
ments, or  bone.  When  it  is  due  to  the  streptococcus  or  staphylococcus, 
it  may  begin  elsewhere  than  in  the  joint,  which,  however,  is  usually  soon 
involved,  and  complete  disorganisaticm  may  follow.  It  may  also  result 
in  a  diffuse  osteomyelitis,  in  a  subperiosteal  abi-cess,  or  a  sepnration  of  the 
epiphysis.  As  a  late  result  there  may  be  a  pathological  dislocation  or  a 
"  flail  joint  ";  less  frequently  there  is  ankylosis. 

Etiology. — The  cause  of  acute  arthritis  in  infants  is  the  entrance 
of  pyogenic  organisms  into  the  circulation.  In  my  experience  the  or- 
ganism most  frequently  found  is  the  gonococeus ;  next  to  this  the  strep- 
tococcus and  staphylococcus;  occasionally  the  pneumococcus,  and  very 
rarely  the  influenza  bacillus.  In  most  cases  occurring  during  the  first 
two  months  of  life,  the  portal  of  entry  is  probably  the  umbilical  cord. 
Less  frequently  infection  takes  place  through  the  skin,  conjunctiva, 
genital  tract,  or  the  mouth.  In  the  cases  developing  later  it  is  often 
difficult  to  determine  the  point  of  entry,  especially  when  the  cause  is  the 
gonococeus.  During  the  last  few  years  26  cases  of  acute  gonococeus 
arthritis  have  been  observed  in  the  Babies'  Hospital,  only  2  of  which, 
occurring  during  the  first  month,  could  be  classed  as  infections  of  the 
newly  born.  The  cases  were  observed  during  a  h()S[)ital  e})i(leinic  of 
gonococeus  vaginitis,  and  yet  19  were  in  nude  children,  in  no  one  of 
whom  was 'there  any  genital  lesion,  and  in  only  one  was  there  conjunc- 
tivitis. Of  the  7  cases  occurring  in  girls,  only  2  had  vaginitis.  The 
portal  of  entry  in  these  cases  could  not  be  definitely  determined. 

Symptoms. — General  symptoms  often  precede  the  local  ones.  In  the 
most  acute  cases  the  temperature  is  "high  and  widely  fluctuating,  accom- 
panied by  other  symptoms  of  a  severe  infection.  The  earliest  local 
symptoms  are  pain  and  tenderness,  soon  followed  by  swelling,  which  may 
develop  quite  rapidly  in  a  single  joint,  or  in  several  joints  simultane- 
ously. In  those  superficially  situated  there  is  redness  of  the  skin,  and 
fluctuation  may  be  evident  in  three  or  four  days.  In  cases  coming  on 
more  gradually  the  temperature  may  be  only  from  100°  to  102°  F.,  and 
suppuration  may  not  occur  for  two  or  three  weeks.  In  the  most  severe 
cases  the  progress  is  rapid,  one  joint  after  another  being  involved,  with 
general  symptoms  of  pyaemia,  and  death  may  occur  in  a  week  or  ten  days, 
usually  from  some  visceral  inflammation,  pneumonia,  pericarditis,  or 
meningitis.  This  very  severe  course  is  less  frequent  than  the  more  pro- 
tracted one  where  symptoms  last  from  two  to  four  weeks.  Unless  the 
pus  is  evacuated,  extensive  burrowing  may  take  place. 

In  Townsend's  collection  of  73  cases,  the  joints  were  involved  in  the 


852  DISEASES  OF  THE   BONES  AND  JOINTS. 

following  order:  Hip,  in  38;  knee,  in  27;  shoulder,  in  12;  wrist,  in  5; 
ankle,  in  4;  elbow,  in  4;  small  joints,  in  4.  In  three-fourths  of  these 
cases  only  a  single  joint  was  affected.  In  my  own  26  gonococcus  cases, 
the  localisation  was  as  follows :  Finger  or  metacarpus,  in  20 ;  ankle,  in 
18;  knee,  in  17;  wrist,  in  12;  toe  or  metatarsus,  in  10;  shoulder,  in  9; 
elbow,  in  5 ;  temporo-maxillary,  in  1 ;  hip,  in  1.  The  average  number  of 
joints  involved  was  4  or  5,  the  largest  number  being  8.  The  tendency  of 
the  gonococcus  infections  to  involve  the  small  joints  is  striking. 

Diagnosis. — When  several  joints  are  involved,  the  disease  is  often 
mistaken  for  rheumatism,  which,  however,  at  this  age  is  so  rare  that 
it  may  be  ignored.  Syphilitic  epi])hysitis  resembles  it  in  the  localised  ten- 
derness and  disability;  but  the  rapid  swelling  and  the  severe  constitu- 
tional symptoms  are  lacking. 

Treatment. — Cold  applications  or  wet  dressings  may  be  useful  in 
relieving  the  symptoms.  In  some  cases,  most  frequently  when  the  cause 
is  the  gonococcus,  the  inflammation  subsides  without  suppuration.  In 
infections  due  to  other  organisms,  suppuration  almost' invariably  occurs 
and  early  free  incision  should  be  practised,  followed  by  fixation  of  the 
joint.  The  results  depend  in  no  small  degree  upon  the  promptness  with 
which  the  pus  is  evacuated.  In  the  gonococcus  cases  there  may  be  com- 
plete recovery.    In  most  of  the  others  the  functions  are  impaired. 

TUBERCULOUS  DISEASE   OF  THE   BONES   AND  JOINTS. 

The  chronic  forms  of  tuberculous  bone  disease,  on  account  of  their 
insidious  onset  and  the  frequency  with  which  they  simulate  other  dis- 
eases, more  frequently  fall,  in  the  early  stage  at  least,  into  the  hands  of 
the  physician  than  into  those  of  the  general  or  orthopaedic  surgeon.  All 
that  will  be  attempted  in  this  chapter  will  be  to  outline  in  a  general 
way  the  most  important  forms — viz.,  disease  of  the  vertebrae,  hip,  and 
knee — dwelling  particularly  upon  the  early  symptoms  and  diagnosis. 
For  their  fuller  discussion,  particularly  as  to  the  details  of  treatment, 
the  reader  is  referred  to  text-books  on  general  or  orthopaedic  surgery. 
The  causes  are  the  same,  and  the  lesions  are  very  similar  in  all  forms, 
and  will  therefore  be  considered  together. 

Etiology. — The  age  at  which  tuberculosis  of  the  bones  most  fre- 
quently begins,  is  from  the  third  to  the  eiglith  year,  it  being  compara- 
tively rare  before  the  end  of  the  second  year.  The  sexes  are  affected 
with  about  equal  frequency.  Tuberculous  bone  disease  may  occur  in  a 
child  who  has  previously  been  in  apparent  health,  but  more  often  in  one 
who  has  been  reduced  by  some  previous  illness,  especially  the  infectious 
diseases;  of  these,  it  most  frequently,  follows  measles  and  whooping- 
cough.  Of  sixteen  cases  investigated  by  Park,  the  bacillus  was  of  the 
human  type  in  every  instance. 


TUBERCULOUS   DISEASE.  853 

A  family  history  of  tul)erculosis  is  present  in  a  large  number,  but 
by  no  means  in  a  majority,  of  the  cases.  Like  tuberculosis  of  the  cer- 
vical glands,  it  is  rarely  preceded  by  other  tuberculous  processes,  al- 
though it  may  be  followed  by  them.  It  usually  appears  as  an  example 
of  primary  infection ;  but  it  seems  very  improbable  that  such  should 
actually  be  the  case.  It  is  more  likely  that  there  has  previously  been  a 
latent  focus  of  tuberculosis  elsewhere  in  the  body.  In  many  cases  dis- 
ease of  the  bronchial  glands  has  been  demonstrated  by  autopsy.  Infec- 
tion from  these  or  from  other  tuberculous  lymph  glands  is  the  most 
probable  explanation  of  the  origin  of  infection  in  cases  of  bone  disease. 

Traumatism  is  often  an  exciting  cause,  and  it  may  determine  the 
site  of  the  disease. 

Lesions. — The  tuberculous  joint  diseases  of  childhood  are,  as  a  rule, 
secondary  to  disease  of  the  bones.  Hip-joint  disease  usually  begins  in 
the  head  of  the  femur,  and  knee-joint  disease  in  one  of  the  condyles;^ 
ankle-joint  disease  in  the  lower  epiphysis  of  the  tibia,  etc. 

The  frequency  with  which  disease  is  seen  in  the  different  locations  is 
shown  by  the  following  table,  which  gives  the  number  of  cases  of  each 
form  applying  for  treatment  at  the  Hospital  for  Ruptured  and  Crip- 
pled, New  York,  during  ten  years : 

Spine 2,145  cases,  or  37 . 5  per  cent. 

Hip 1,937  "  "34.0"  " 

Knee 1,222  "  "21.5"  " 

Ankle  or  tarsus 255  "  "      4.5"  " 

Elbow 71  "  "      1.2    "  " 

Wrist 50  "  "      0.9    "  " 

Shoulder 24  "  "      0.4    "  " 

Total 5,704  100.0 

The  character  of  the  bone  disease  upon  which  chronic  joint  disease 
depends  is  generally  a  primary  ostitis,  which  affects  the  articular  ex- 
tremities of  the  long  bones,  usually  beginning  near  the  epiphyseal  line; 
in  the  short  bones  "it  is  a  central  ostitis.  The  stages  in  the  process  are, 
first,  congestion,  swelling,  and  cell  infiltration,  followed  by  caseation, 
and  frequently  by  softening  and  suppuration.  In  the  early  stage,  the 
bone  is  slightly  enlarged,  and  on  section  one  or  more  yellowish  foci  of 
disease  are  seen.  The  disease  may  be  arrested  in  this  stage,  encapsula- 
tion of  the  infiammatory  products  taking  place ;  or  it  may  continue  until 
there  is  a  more  or  less  extensive  breaking  down  or  disintegration  of  the 
affected  bone.  As  the  disease  extends  there  are  involved  the  periosteum, 
the  articular  cartilage,  and  finally  the  joint  itself.  Abscess  may  form  in 
the  joint  or  in  the  soft  parts  surrounding  the  bone.  The  process  is  quite 
analogous  to  tuberculous  disease  of  the  lung.  As  the  disease  advances 
ligamentous  attachments  are  loosened,  and  displacement  of  the  parts 


854  DISEASES  OF  THE   BONES  AND   JOINTS. 

occurs  with  the  production  of  deformity,  due  partly  to  muscular  con- 
traction and  partly  to  the  weight  of  the  body.  The  inflammatory 
process,  with  its  resulting  disintegration,  generally  goes  on  to  a  certain 
point,  where  it  is  arrested.  Gradually  the  broken-down  bone  substance 
is  separated  and  thrown  off  in  small  particles  in  the  discharge,  and  a 
reparative  process  begins,  with  the  formation  of  healthy  bone.  Where 
joint  structures  have  been  destroyed,  cure  takes  place  by  bony  ankylosis. 
Sometimes  the  disease  finds  its  way  to  the  surface  without  involving  the 
joint;  at  other  times  the  disease  may  be  arrested,  and  its  products  be- 
come encapsulated  within  the  bone.  Inflammation  of  the  joint  may 
occur  by  a  gradual  extension  of  the  inflammatory  process,  or  by  a  sud- 
den perforation  of  the  articular  lamella.  As  a  result  of  extensive  dis- 
ease, all  the  joint  structures  may  be  affected — the  synovial  membrane, 
ligaments,  articular  cartilages,  and  the  cellular  tissue  surrounding  the 
"joint.  The  process  of  disintegration  and  that  of  repair  are  both  very 
chronic  and  measured  by  months  or  years.  The  entire  course  of  the 
disease  is  from  one  to  ten  years,  three  years  being  about  the  average  dura- 
tion. In  the  great  proportion  of  cases  but  one  joint  is  involved,  although 
it  is  not  infrequent  in  hospitals  to  see  two,  three,  and  sometimes  four  of 
the  large  joints  affected  in  the  same  patient. 

Secondary  Lesions. — Abscesses  form  in  a  considerable  proportion  of 
the  cases,  and  often  burrow  a  long  distance  before  they  reach  the  surface. 
Amyloid  degeneration  of  the  liver,  spleen,  and  kidney,  and  sometimes  of 
the  intestines,  occurs  as  the  result  of  the  prolonged  suppuration,  chiefly 
in  connection  with  disease  of  the  hip  or  spine,  occasionally  with  that  of 
the  knee.  General  or  localised  tuberculosis,  particularly  tuberculous 
meningitis,  may  develop  at  any  time  and  prove  fatal. 

Caries  of  the  Spine — Pott's  Disease. 

This  consists  in  a  tuberculous  inflammation  of  the  bodies  of  the  ver- 
tebrae, usually  beginning  in  the  central  portion  and  extending  to  the 
periosteum,  ligaments,  cartilages,  and,  in  fact,  to  all  the  contiguous 
structures.  Secondarily  it  involves  the  membranes  of  the  cord,  the 
roots  of  the  spinal  nerves,  and  even  the  cord  itself.  The  number  of  ver- 
tebrae usually  affected  is  from  two  to  five.  The  gross  appearance  of  the 
lesion  in  a  well-marked  case  is  shown  in  the  accompanying  cut  (Fig. 
165).  After  the  bodies  of  the  vertebrae  have  become  softened  and  par- 
tially broken  down  by  disease,  the  pressure  from  the  superincumbent 
weight  of  the  body  causes  them  to  fall  together  and  produces  a  back- 
ward displacement  of  the  spinous  processes,  giving  rise  to  the  deformity 
known  as  kyphosis,  which  in  its  extreme  form  is  popularly  known  as 
"  hunchback." 

Any  part  of  the  vertebral  column  may  be  affected ;  but  the  disease 
is  most  frequent  in  the  dorsal  region,  as  shown  by  the  following  statistics 


CARIES  OF  THE  SPINE. 


855 


from  the  Hospital  for  Ruptured  and  Crippled:  Of  2,143  cases,  73.5 
per  cent  affected  the  dorsal  region,  15.3  per  cent  the  lumbar  region, 
and  12.2  per  cent  the  cervical  region. 

Symptoms. — The  onset  is  gradual,  often 
insidious,  and  the  early  symptoms  are  fre- 
quently overlooked  or  misinterpreted.  The 
case  may  go  on  for  weeks  or  even  montlis 
before  the  true  nature  of  the  disease  is  rec- 
ognised, which  is  often  not  until  deformity 
has  occurred.  In  nearly  all  cases,  however, 
the  early  symptoms  are  sufficiently  char- 
acteristic to  enable  a  careful  observer  to  make 
a  diagnosis  before  the  stage  of  deformity. 

The  most  constant  early  symptoms  are : 
(1)  Pains  caused  by  the  irritation  of  the 
nerve  roots  and  referred  to  various  parts  of 
the  body,  following  the  distribution  of  the 
spinal  nerves;  (2)  rigidity  of  the  spine  from 
muscular  spasm,  this  being  an  attempt  to 
prevent  motion  at  the  seat  of  disease;  and 
(3)  the  assumption  of  various  postures  cal- 
culated to  relieve  pressure  upon  tlie  diseased 
vertebral  bodies.  Sometimes  the  first  symp- 
toms are  those  of  pressure-paralysis;  at  oth- 
ers they  are  the  local  signs  of  abscess.  In 
addition  to  the  local  symptoms  mentioned, 
there  is  usually  disturbed  sleep,  often  ac- 
companied by  moaning. 

Cervical  Disease. — The  pains  are  often  felt  above  the  point  of  dis- 
ease, frequently  in  the  form  of  occipital  neuralgia;  sometimes  they  are 
referred  to  the  front  or  the  side  of  the  neck.  They  may  be  so  frequent 
and  so  severe  that  tlie  face  assumes  a  constant  expression  of  anxiety  or 
distress.  In  other  cases  pain  is  excited  only  by  an  attempt  at  movement. 
The  muscular  spasm  most  frequently  takes  the  form  of  slight  torticollis, 
sometimes  of  slight  opisthotonus;  sometimes  there  is  sin)ply  a  fixation 
of  the  head  by  a  tonic  spasm  of  all  the  muscles  of  the  neck;  both  active 
and  passive  motion  is  resisted,  and  any  movement  may  be  so  painful 
that  the  child  involuntarily  steadies  his  head  with  his  hands.  These 
symptoms  come  on  gradually  and  are  persistent.  Sometimes  they  are 
overlooked,  and  the  first  thing  to  attract  attention  is  a  progressive  weak- 
ness in  the  lower  extremities,  which  prx)ves  to  be  the  beginning  of  par- 
aplegia. Occasionally  the  first  marked  symptoms  are  those  due  to  the 
formation  of  a  retro-pharyngeal  or  a  retro-cesophageal  abscess. 

The  deformity  from  cervical  disease  develops  much  later  than  when 


Fig.  165. — Pott's  Disease  of 
THE  Upper  Dorsal  Region. 
A  vertical  section  of  the 
.spine,  showing  disintegration 
of  the  bodies  of  the  vertebrae 
and  encroachment  upon  the 
spinal  canal.  (From  a  pa- 
tient dying  in  the  Hospital 
for  Ruptured  and  Crippled.) 


856  DISEASES  OF  THE   BONES  AND  JOINTS. 

the  disease  is  located  elsewhere.  Usually  the  neck  ap})ears  broadened  or 
thickened  in  a  nearly  uniform  way,  and  often  the  head  seems  to  have 
settled  downward  upon  the  slioulders.  In  the  lower  cervical  region  a 
kyphosis  is  not  infrequent;  but  in  tlie  middle  and  iipper  regions  there  is 
more  often  an  anterior  prominence,  which  may  l)e  felt  in  the  posterior 
wall  of  the  pharynx. 

'Dorsal  Disease. — The  referred  pains  are  now  below  the  seat  of  dis- 
ease, and  take  the  form  of  intercostal  neuralgia  or  pain  in  the  epigas- 
trium or  the  abdomen.  They  are  often  ascribed  to  cold,  malaria,  indi- 
gestion, or  worms.  There  is  a  disposition  to  assume  the  prone  position 
while  sleeping,  and  also  to  lean  across  a  chair  or  the  lap  of  the  nurse. > 
The  child  walks  carefully,  holding  the  spine  erect  and  very  stiffly,  and 
exhibits  great  caution  in  getting  into  or  cut  of  bed,  or  in  rising  from  a 
recumbent  position.  In  the  beginning  there  may  be  a  slight  lordosis,  or 
forward  curve  at  the  seat  of  disease,  instead  of  the  usual  ky])hosis  or 
backward  projection,  but  the  latter  soon  takes  its  place,  and  with  it  is 
seen  the  compensatory  lordosis  in  the  lumbar  region. 

Lumbar  Disease. — The  first  symptoms  here  are  often  ])ain  and  lame- 
ness, referred  to  one  of  the  lower  extremities.  This  frequently  leads  to 
the  suspicion  that  the  hip  is  the  seat  of  disease.  In  addition  to  the 
lameness  there  may  be  a  tilting  of  the  pelvis  to  one  side,  and  sometimes 
quite  a  distinct  lateral  curvature  of  the  spine.  Referred  pains  are  not 
so  frequent  nor  so  severe  as  when  the  upper  part  of  the  spine  is  affected ; 
they  may  be  felt  in  the  groin,  in  the  loin,  in  the  thigh,  in  the  buttock,  or 
in  the  hypogastrium.  The  gait  and  attitude  are  very  characteristic: 
Throwing  the  shoulders  well  back,  the  patient  walks  stiffly,  with  short 
steps,  holding  the  spine  with  the  greatest  care.  He  rises  from  the  floor 
awkwardly  and  with  difficulty.  Deformity  is  not  usually  so  early  or  so 
marked  as  when  the  disease  is  dorsal,  and  often  before  it  is  visible  there 
are  symptoms  due  to  the  formation  of  psoas  abscess — lameness,  flexion 
of  one  thigh,  and  a  tumour  deep  in  the  iliac  fossa  or  at  the  upper  and 
inner  asi3ect  of  the  thigh;  in  both  locations  it  has  often  been  mistaken 
for  hernia. 

Physical  Examination. — Whenever  any  of  the  above  symptoms  are 
present,  the  child  should  be  stripped  and  submitted  to  a  thorough  ex- 
amination, the  purpose  of  which  should  be  to  determine,  first,  the 
existence  of  any  deformity;  secondly,  the  mobility  of  the  spine;  thirdly, 
the  presence  of  any  secondary  lesions,  such  as  abscesses  or  paralysis. 
The  mobility  of  the  spine  is  best  determined  by  studying  the  attitude, 
gait,  and  posture  of  the  child,  and  the  manner  of  stooping  or  rising 
from  the  floor.  The  gait  has  already  been  described  with  the  symptoms 
of  lumbar  disease.  As  it  has  been  aptly  put,  "  the  child  walks  with  his 
legs,  but  not  with  his  back."  In  stooping,  the  same  disinclination  to  l)end 
or  move  the  spine  is  seen.     It  is  often  impossible  to  induce  the  child  to 


CARIES  OF  THE  SPINE.  857 

stoop  at  all,  and  when  he  does  so,  to  pick  up  some  ol)ject,  there  is  acute 
flexion  at  the  knee  and  hip,  l)ut  as  little  bending  of  tJie  spine  as  pos- 
sible. ]n  rising  from  the  recumbent  position  the  same  thing  is  seen. 
The  posture  and  attitude  of  the  child  will  be  modified  l)y  the  position 
of  the  disease,  and  somewhat  by  the  activity  of  the  process  at  the  time; 
however,  by  comparing  the  movements  referred  to  with  those  of  a 
healthy  child,  the  great  difference  will  at  once  be  apparent.  If  the 
symptoms  point  to  cervical  disease,  a  digital  exploration  of  the  pharynx 
for  deformity  or  abscess  should  be  made,  and  the  extremities  should 
be  examined  for  paralysis.  If  the  disease  is  in  the  lumbar  region, 
deep  palpation  of  the  iliac  fossa  should  be  made  to  discover  a  psoas 
abscess,  and  the  passive  movements  of  the  thigh  should  be  carefully 
tested  to  determine  whether  there  is  any  resistance  to  extreme  exten- 
sion, this  often  being  present  before  the  psoas  tumour.  No  matter  how 
clearly  the  lameness  may  be  at  the  hip,  it  should  be  remembered  that 
this  often  results  from  disease  of  the  lumbar  spine.  If  the  thigh  is  flexed 
and  freely  movable  except  in  extension,  the  symptoms  are  probably  the 
result  of  psoas  irritation,  for  in  hip-joint  disease  the  other  movements 
of  the  joint  are  also  resisted. 

The  deformity  of  Pott's  disease  is  often  s})oken  of  as  "  angular  "  cur- 
vature of  the  spine.  While  this  is  a  true  descri})tion  of  the  disease  at 
an  advanced  stage,  there  is  often  in  the  early  stage  only  a  general  curve. 
Later  a  slight  knuckle  is  seen  from  the  unnatural  projection  of  a  single 
spinous  process.  This  deformity  may  increase  and  finally  involve  five  or 
six  vertebrae.  It  is  usually  greatest  in  the  upper  dorsal  region.  A  slight 
prominence,  which  does  not  disappear  on  suspending  the  patient,  is  al- 
ways suspicious. 

Tenderness  upon  pressure  over  the  spinous  processes  and  increased 
sensitiveness  to  heat  and  cold  are  rarely  present.  Pain  may  sometimes 
be  produced  by  downward  pressure  upon  the  head  or  shoidders  in  the 
axis  of  the  spine.  This  symptom  is  not  necessary  for  diagnosis,  and  the 
attempt  to  elicit  it  is  strongly  condemned  by  Gibney,  who  has  seen  seri- 
ous harm  follow  such  a  test. 

Course  of  the  Disease. — Caries  of  the  spine  is  a  very  chronic  disease, 
its  course  being  measured  by  months  or  years,  but  marked,  as  in  all 
chronic  diseases,  by  periods  of  remission  and  exacerbation.  An  exacer- 
bation may  follow  traumatism,  and  is  often  accompanied  by  the  forma- 
tion of  an  abscess.  After  the  disease  has  lasted  from  one  to  three  years, 
the  destructive  inflammation  usually  ceases  and  repair  begins,  a  cure 
being  finally  effected  by  a  process  of  consolidation  of  the  fragments 
of  the  diseased  vertebrae,  and  the  production  of  ankylosis.  Eelapses 
are  easily  excited  by  traumatism,  by  improper  treatment,  or  by  dis- 
continuing the  use  of  mechanical  supports  l)efore  the  disease  is  ar- 
rested. 


858  DISEASES  OF  THE  BONES  AND  JOINTS. 

Abscesses. — The  frequency  with  which  abscesses  occur  depends  some- 
what upon  the  treatment.  Townsend  states  that  of  380  cases,  abscess 
was  present  in  twenty  per  cent.  They  are  rarely  seen  earlier  than  three 
or  four  months  from  the  beginning  of  symptoms,  and  usually  belong  to 
the  second  year  of  the  disease.  They  sometimes  form  with  acute  symp- 
toms, but  more  frequently  they  appear  as  typical  cold  abscesses.  Those 
connected  with  cervical  disease  are  retro-pharyngeal  or  retro-cesophageal, 
or  they  may  open  externally,  usually  just  above  the  clavicle,  in  front  of 
the  sterno-mastoid  muscle.  Those  with  disease  of  the  lower  cervical 
and  upper  dorsal  vertebrae  are  apt  to  burrow  along  the  spine,  appearing 
in  the  lumbar  region;  rarely  they  may  rupture  into  the  oesophagus  or 
the  pleural  cavity.  Those  with  disease  of  the  lower  dorsal  or  lumbar 
vertebrae  may  open  just  above  the  iliac  crest  posteriorly,  or  burrow  an- 
teriorly between  the  abdominal  muscles,  but  the  usual  course  is  for  them 
to  follow  the  psoas  muscle,  appearing  in  the  groin  just  above  Poupart's 
ligament  or  at  the  uj^per  and  inner  aspect  of  the  thigh. 

Paralysis  occurs  in  about  one-half  the  cases  in  which  the  disease  af- 
fects the  lower  cervical  and  ujjper  dorsal  vertebra,  ])ut  it  is  rare  when 
the  disease  is  below  the  middle  dorsal  region  (see  Compression  Myelitis). 

Prognosis. — -The  actual  mortality  of  Pott's  disease  is  difficult  to  state, 
so  many  of  the  consequences  of  the  disease  being  remote  and  not  fully 
appreciated  until  adult  life  is  reached.  The  general  mortality  from  all 
causes  is  from  ten  to  twenty  per  cent.  The  causes  of  death  are  exliaus- 
tion  from  prolonged  suppuration,  amyloid  degeneration,  myelitis,  gen- 
eral tuberculosis,  and  tuberculous  meningitis.  Sudden  death  occasion- 
ally occurs  from  pressure  upon  the  cord  in  the  upper  cervical  region, 
or  from  the  pressure  effects  of  abscesses  in  the  posterior  pharynx  or  in 
the  posterior  mediastinum. 

The  prognosis  as  to  the  amount  of  permanent  deformity  will  depend 
upon  the  seat  of  the  disease,  the  time  at  which  treatment  is  begun,  and 
upon  the  thoroughness  with  which  it  is  carried  out.  The  best  results  as 
to  deformit}'  are  obtained  when  tlie  disease  is  below  the  middle  dorsal 
region.  With  improved  methods  of  treatment  begun  early,  a  large 
number  of  these  patients  recover  with  an  insignificant  amount  of  de- 
formity, and  some  with  none  whatever. 

Diagnosis. — Tlie  spinal  deformity  resulting  from  Pott's  disease  may 
be  confounded  with  rachitic  kyphosis  or  with  rotary  lateral  curvature. 
Pachitic  curvatures  are  usually  seen  in  children  under  eighteen  months 
of  age,  a  time  when  Pott's  disease  is  rare ;  there  are  other  signs  of  rickets 
present,  and  instead  of  rigidity  there  is  usually  undue  mobility  of  the 
spine.  What  is  true  of  rickets  may  be  said  of  all  curvatures  depending 
\ipon  malnutrition.  Potary  lateral  curvature  is  seen  alx)ut  puberty, 
rarely  in  young  children  except  in  connection  with  rickets.  A  slight 
lateral  deviation  of  the  spine,  sometimes  seen  in  the  early  stages  of  caries. 


HIP-JOINT   DISEASE.  859 

may  resemble  a  case  of  inc-i])ient  rotary  curvature.  The  latter  is  not 
attended  by  pain  or  rigidity,  and  is  most  frequent  in  young  girls  from 
eleven  to  fourteen  years  of  age. 

Other  abscesses  may  be  mistaken  for  those  dependent  upon  vertebral 
caries.  This  difficulty  is  likely  to  exist  in  the  eases  attended  by  very 
little  spinal  deformity.  Tliese  abscesses  are  most  frequently  in  the  iliac 
fossa  or  in  the  lumbar  region,  and  may  l)e  due  to  perinepliritis  or  ap- 
pendicitis. The  latter  are  more  acute  tlian  tliose  depending  upon  bone 
disease  and  usually  accompanied  by  fever.  Tunumrs  of  tlie  vertebrae  or 
of  the  spinal  cord  may  give  rise  to  symptoms  almost  identical  witli  those 
resulting  from  compression  myelitis  due  to  Pott's  disease,  but  both  of 
these  are  extremely  rare. 

Treatment. — The  treatment  of  Pott's  disease  is  both  general  and 
local,  and  neither  should  be  neglected.  Tlie  constitutional  treatment 
should  be  similar  to  that  employed  in  otlier  forms  of  tuberculosis. 

The  indications  for  local  treatment  are  to  put  the  diseased  parts  at 
rest,  by  immobilising  the  spine  and  removing  tlie  superincund)ent  weight 
of  the  body.  With  the  great  advances  made  in  orthopaedic  surgery  it  is 
no  longer  necessary  to  confine  these  patients  in  bed,  as  was  formerly 
practised,  to  secure  this  result.  It  ma}'  be  accomplished  either  by  plaster- 
of-Paris,  or  some  other  form  of  jacket,  or  a  properly  fitting  steel  brace. 
A  head-support  should  be  attached  to  all  forms  of  apparatus,  if  the 
disease  is  above  the  middle  dorsal  region.  The  closest  attention  to  de- 
tails and  much  experience  in  the  use  of  apparatus  are  required  to  secure 
the  best  results.  In  perhaps  no  class  of  cases  have  the  beneficial  results 
of  modern  scientific  treatment  been  more  apparent  than  in  those  of 
Pott's  disease.  For  the  details  in  regard  to  the  mechanical  treatment 
and  the  different  forms  of  apparatus,  the  reader  is  referred  to  works  on 
general  or  orthopaedic  surgery. 

Articular  Ostitis  of  the  Hip — Hip-Joint  Disease. 

In  early  childhood  this  generally  begins  as  a  chronic  ostitis  in  the 
head  of  the  femur,  starting  near  the  epiphyseal  line.  Exceptionally, 
and  oftener  in  older  children,  it  begins  in  the  acetabulum.  The  path- 
ological process,  as  well  as  the  clinical  history,  is  generally  described  as 
consisting  of  three  stages.  In  the  first  stage — that  of  ostitis — the  lesions 
are  limited  to  the  bone;  in  the  second  stage — that  of  arthritis — all  the 
joint  structures  are  involved,  and  in  this  stage  suppuration  usually 
occurs;  in  the  third  stage  there  is  breaking  down  and  absorption  of 
the  head  and  sometimes  of  the  neck  of  the  femur,  which,  with  destruc- 
tion "of  the  ligaments,  leads  to  marked  displacement  of  the  parts  from 
muscular  contraction.  The  disease  may  be  arrested  in  the  first  or  in 
the  second  stage,  or  it  may  continue  through  all  three  stages. 


860  DISEASES  OF  THE  BONES  AND   JOINTS. 

Symptoms. — Clinically,  the  usual  duration  of  the  first  stage  is  tliree 
or  four  months ;  it  may  last  only  for  a  few  weeks,  it  may  extend  over  two 
or  three  years,  and  the  disease  may  be  arrested  in  this  stage.  The  onset 
is  usually  very  gradual,  and  the  symptoms  are  often  considered  of  trivial 
importance  until  they  have  continued  for  some  weeks.  Generally  the 
first  thing  noticed  is  slight  lameness,  due  to  stiffness  of  the  joint.  In 
tlie  beginning  this  may  be  seen  only  in  the  morning,  wearing  off  during 
the  day.  It  may  be  accompanied  by  some  tenderness  about  the  hip  and 
a  disinclination  to  walk.  A  little  later  the  child  complains  of  pain, 
which  is  most  frequently  referred  to  the  front  of  the  knee  or  the  inner 
aspect  of  the  thigh,  but  only  in  rare  cases  to  the  hip  itself.  This  is  slight 
at  first,  but  gradually  increases  in  frequency  and  severity,  and  soon  there 
are  added  the  "  starting  pains "  at  night,  which  are  one  of  the  most 
characteristic  features  of  early  hip  disease.  These  pains  are  produced  by 
a  sudden  spasm  of  the  muscles  during  sleep.  The  child  often  cries  out 
sharply  without  waking,  sometimes  wakes  with  a  cry;  this  is  often  re- 
peated several  times  during  the  night.  Soon  restlessness  and  fretfulness 
during  the  day  are  present.  The  lameness,  which  at  first  was  slight  and 
occasional,  or  noticed  only  in  the  morning,  comes  to  be  a  constant  symp- 
tom, and  week  by  week  increases  in  esverity.  The  evolution  of  these 
symptoms  may  take  only  a  few  weeks,  but  sometimes  they  come  and  go 
in  the  most  inexplicable  manner  during  a  period  of  several  months,  or 
even  one  to  two  years,  before  they  are  fully  developed. 

Every  child  with  a  suspicious  lameness,  or  with  pains  like  those  men- 
tioned, should  be  stripped  and  submitted  to  a  thorougli  examination. 
The  first  points  to  be  observed  on  inspection  relate  to  the  general  con- 
tour of  the  hip;  every  prominence  and  depression  should  be  carefully 
noted.  Then  the  attitude  and  gait  should  be  studied;  and  finally  all 
the  functions  of  the  joint  should  be  carefully  tested,  and  the  limbs 
measured,  to  determine  the  existence  of  shortening  or  atrophy.  At  every 
step  a  comparison  should  be  made  with  the  sound  limb.  The  contour 
of  the  hip  is  changed  quite  uniformly;  there  is  broadening  and  flatten- 
ing of  the  whole  gluteal  region ;  the  trochanter  is  unnaturally  promi- 
nent; the  gluteal  fold  is  shortened,  and  often  single  instead  of  double. 
There  is  no  characteristic  position  of  the  limb  in  this  stage.  There  is 
atrophy  of  the  thigli  and  often  of  the  calf.  In  Fig.  166  is  shown  the 
appearance  of  a  typical  case  in  the  full  development  of  the  first  stage. 
In  walking,  the  child  favours  the  diseased  side,  throwing  the  weight  as 
much  as  possible  upon  the  sound  limb;  but  all  these  symptoms  are  of 
much  less  importance  for  diagnosis  than  is  an  examination  of  the  func- 
tions of  the  joint. 

For  this  purpose  the  child  should  be  placed  upon  a  table  upon  his 
back,  and  the  various  movements  of  the  hip — abduction,  adduction, 
flexion,   extension,   and   rotation — should   be   executed,   first   with   the 


HIP-JOINT  DISEASE. 


861 


sound  limb  and  tlien  with  the  suspected  one,  the  two  being  carefully 
compared  at  every  point  to  determine  the  degree  of  motion  allowed.  It 
is  not  necessary  that  force  should  be  employed  or  pain  inflicted.  If  the 
symptoms  have  existed  for  some  weeks,  there 
is  generally  a  limitation  of  motion  at  the  hip 
in  all  directions,  but  first  usually  in  abduc- 
tion, rotation,  or  extension.  In  more  advanced 
cases,  no  motion  whatever  may  be  permitted 
at  the  joint,  the  pelvis  tilting  with  the  slightest 
movement  of  the  femur.  This  fixation  of  tlie 
hip  is  due  to  tonic  muscular  spasm.  Crowd- 
ing the  articular  surfaces  together,  by  pres- 
sure upon  tiie  heel  or  trochanter,  produces  pain, 
which  is  usually  referred  to  the  joint.  This 
test  should  be  carefully  made,  lest  injury  be 
inflicted.  Gibney  cautions  against  examina- 
tions under  ether,  since  in  this  way  serious 
injury  may  be  done  unconsciously. 

Second  Stage. — This  has  been  called  the 
stage  of  arthritis.  Its  existence  may  be  as- 
sumed when  the  limb  takes  the  position  of 
marked  permanent  deformity,  which  is  due 
at  this  period  to  muscular  action,  not  to  de- 
structive- bone  changes.  The  transition  from 
the  first  toi/  the  second  stage  is  in  most  cases 
a  gradual  one,  and  the  line  between  the  two 
can  not  be  sharply  drawn;  sometimes,  how- 
ever, it  is  rapid,  and  marked  by  a  sharp  ex- 
acerbation of  all  the  symptoms.  This  may 
indicate  a  sudden  perforation  of  the  joint  and 
the  rapid  development  of  suppurative  arthritis. 
Such  is  the  usual  result  when  an  abscess  which 
has  been  slowly  forming  in  the  bone  opens  into 
the   joint;   or   acute  joint   inflammation   may 

be  lighted  up  without  so  evident  a  cause.  Sometimes  the  pus  reaches 
the  surface  below  the  capsular  ligament,  and  the  joint  remains  intact. 
An  acute  exacerbation  is  indicated  by  increased  pain,  excessive  tender- 
ness about  the  hip,  often  by  inability  to  walk,  or  even  to  bear  any  weight 
upon  the  limb,  and  frequently  by  fever.  The  position  assumed  by  the 
limb  is  now  fairly  characteristic.  The  foot  is  generally  everted,  the 
thigh  slightly  flexed  and  rotated  outward,  and  the  limb  apparently 
lengthened.  There  may  be  infiltration  anywhere  about  the  hip,  due  to 
the  formation  of  an  abscess.  The  muscular  spasm  is  so  great  that  the 
joint  is  locked — no  motion  whatever  being  allowed.    Abscesses  may  form 


Fig.  166. — Hip-joint  Dis- 
ease, AT  THE  End  of  the 
First  Stage.  Showing 
muscular  atrophy,  promi- 
nence of  the  trochanter, 
flattening  of  the  gluteal 
region,  and  a  single  gluteal 
fold. 


862  DISEASES  OF  THE   BONES  AND  JOINTS. 

at  any  point  about  the  hip;  they  are  especially  frequent  at  the  upper 
and  outer  aspect  of  the  thigh,  and  may  burrow  long  distances  before 
reaching  the  surface.  The  duration  of  tlie  second  stage  also  is  indefinite, 
but  it  usually  lasts  from  a  few  months  to  a  year,  or  the  disease  may  be 
arrested  in  this  stage. 

Third  Stage. — There  is  now  marked  deformity,  which  is  the  result  of 
muscular  contraction  after  absorption  of  the  head  and  sometimes  the 
neck  of  the  femur,  and  destruction  of  the  ligaments.  The  position  of 
the  limb  is  a  very  constant  one,  and  rescm})les  that  present  in  dislocation 
upon  the  dorsum  of  the  ilium.  There  is  shortening  of  from  one  to  four 
inches;  the  thigh  is  strongly  flexed,  adducted,  and  rotated  inward,  and 
the  foot  is  inverted;  the  trochanter  lies  against  the  outer  surface  of  the 
ilium,  and  is  above  Nelaton's  line.  In  this  position  the  joint  may  be- 
come ankylosed.  The  displacement  usually  comes  on  gradually,  but  it  is 
sometimes  so  sudden  as  to  be  mistaken  for  a  true  dislocation,  although 
the  latter  is  exceedingly  rare  in  the  course  of  hip  disease. 

There  is  now  marked  atrophy  of  all  the  muscles  of  the  limb,  and  the 
thigh  may  be  two  or  three  inches  smaller  than  its  fellow.  No  motion  at 
all  is  usually  allowed  at  the  hip,  but  this  is  compensated  for  to  some 
degree  by  the  exaggerated  mobility  of  the  lumbar  spine.  Tlie  spinal 
curvature — lordosis — is  very  marked  both  upon  standing  and  walk- 
ing. The  duration  of  this  stage  may  be  several  years.  From  time  to 
time  exacerbations  occur,  often  excited  by  falls,  and  accompanied  by  the 
formation  of  new  abscesses.  In  protracted  cases,  all  the  soft  parts  about 
the  hip  may  be  seamed  with  cicatrices  from  old  sinuses.  After  the  dis- 
ease has  gone  on  to  the  third  stage,  cure  can  take  place  only  by  ankylosis. 

Diagnosis. — The  important  point  in  the  early  diagnosis  of  ostitis  of 
the  hip,  is  the  gradual  evolution  of  the  symptoms,  the  most  characteristic 
of  which  are  lameness,  "  starting  pains  "  at  night,  and  impairment  of 
all  the  functions  of  the  joint.  Mistakes  in  diagnosis  most  frequently 
arise  from  a  failure  to  obtain  a  careful  history,  and  from  relying  too 
much  upon  the  symptoms  of  lameness  and  deformity.  The  essentially 
chronic  character  of  the  disease  should  constantly  be  borne  in  mind. 
In  the  vast  majority  of  cases,  with  a  careful  history  and  a  thorough  ex- 
amination, there  can  be  but  little  doubt  as  to  the  diagnosis  except  at  the 
very  outset.  The  proportion  of  obscure  and  irregular  cases  to  those 
following  the  regular  course  is  small. 

In  the  early  stage,  hip-joint  disease  may  be  confounded  with  a  strain 
of  the  joint,  with  muscular  rheumatism,  poliomyelitis,  periostitis  of  the 
shaft  of  the  femur,  phlegmonous  inflammation  in  the  neighbourhood  of 
the  joint,  or  with  caries  of  the  lumbar  spine.  In  the  second  stage  there 
is  even  less  difficulty  in  diagnosis,  although  abscesses  resulting  from 
perinephritis  or  appendicitis  have  been  mistaken  for  those  arising  from 
hip  disease.    In  the  third  stage,  a  mistake  is  almost  impossible. 


KNEE-JOINT  DISEASE.  863 

Prognosis. — This  is  to  be  considered  both  with  reference  to  life  and 
limb.  The  records  of  the  Hospital  for  Kuptured  and  Crippled  show  the 
mortality  of  hospital  patients  with  hip  disease  to  be  nearly  twenty-five 
per  cent.  This  includes  deaths  directly  or  indirectly  traceable  to  the 
disease.  The  causes  are  nearly  the  same  as  in  caries  of  the  spine — ex- 
haustion from  prolonged  suppuration,  amyloid  degeneration,  and  general 
tuberculosis  or  tuberculous  meningitis. 

Under  the  most  favourable  conditions,  the  disease  may  be  arrested  in 
the  first  stage,  and  recovery  occur  without  lameness  or  any  noticeable 
impairment  of  the  joint  functions.  This  result,  however,  is  not  often 
obtained,  because  the  disease  is  usually  well  advanced'  before  it  is  recog- 
nised, or  because  of  the  difficulty  in  the  way  of  carrying  out  all  the  details 
of  treatment  in  the  best  possible  manner.  If  the  disease  has  advanced 
to  the  second  stage  and  suppuration  has  occurred,  there  always  results 
some  impairment  of  the  joint  functions ;  usually  there  are  decided  lame- 
ness and  marJced  muscular  atrophy,  but  very  little  shortening  or  de- 
formity, provided  the  limb  has  been  kept  in  the  proper  position.  If  the 
disease  has  advanced  to  the  third  stage,  there  are  always  marked  short- 
ening, deformity,  and  lameness. 

Treatment. — The  indications  for  constitutional  treatment  are  the 
same  as  in  caries  of  the  spine.  The  purpose  of  local  treatment  is  to 
secure  constant  and  complete  rest  for  the  diseased  parts,  and  to  prevent 
deformity.  ]?est  is  secured  by  overcoming  the  muscular  spasm  by  means 
of  extension,  by  immobilising  the  joint,  and  by  transferring  the  weight 
of  the  bodyj  in  walking,  from  the  hip  to  the  perinseum.  All  these  indi- 
cations are  now  met,  while  the  patient  is  up  and  about,  by  the  use  of 
the  most  approved  apparatus.  The  general  opinion  of  orthopaedic  sur- 
geons at  the  present  day  is  against  excision,  except  in  cases  where,  in 
spite  of  treatment  by  apparatus,  the  disease  has  advanced  to  the  third 
stage,  and  in  cases  where  life  is  threatened  from  prolonged  suppuration 
and  exhaustion. 

Articniar  Ostitis'  of  the  Knee — Knee-Joint  Disease — ^Y]Lite  Swelling. 

Ostitis  of  the  knee  usually  begins  in  one  of  the  condyles  of  the  femur, 
the  inner  much  oftener  than  the  outer  one;  less  frequently  it  begins  in 
the  head  of  the  tibia.  The  pathological  process  is  very  much  like  that 
at  the  hip.  There  is  in  the  first  stage  a  central  ostitis  accompanied  by 
infiltration  and  expansion  of  the  part  of  the  bone  affected.  The  disease 
may  remain  limited  to  the  bone,  the  inflammatory  products  becoming 
encapsulated,  or  softening  and  breaking  down  may  occur,  with  the  for- 
mation of  an  abscess.  Gradually  the  process  extends  outward,  and  the 
periosteum  and  the  soft  parts  are  involved.  The  disease  may  invade  the 
joint  itself  in  a  destructive  inflammation,  or  pus  may  escape  externally 
without  seriously  involving  the  joint  structures.     The  degree  to  which 


864  DISEASES  OF  THE  BONES   AND  JOTNTS. 

the  joint  is  involved  varies  much  in  different  cases;  there  may  be  only 
a  simple  synovitis,  a  suppurative  arthritis,  or  a  destruction  of  the  car- 
tilages and  articular  ends  of  the  bones,  synovial  membrane,  and  liga- 
mente,  so  that  in  the  advanced  stage  alL  traces  of  a  joint  structure 
are  lost. 

If  the  process  remains  limited  to  the  bone,  recovery  may  take  place 
with  very  little  impairment  of  the  joint  functions.  If  supjmration  in 
the  joint  has  taken  place,  there  will  be  more  or  less  stiffness  and  fibrous 
or  bony  ankylosis.  When  there  is  destruction  of  the  ligaments  and  ar- 
ticular ends  of  the  bones,  the  limb  assumes  a  characteristic  position — 
the  joint  is  flexed,  the  tibia  is  displaced  backward  and  rotated  outward, 
and  there  is  marked  over-riding  of  the  femur.  Bony  ankylosis  in  this 
position  is  often  seen. 

Sjrmptoms. — The  earliest  symptoms  of  disease  at  the  knee  are  usually 
a  slight  stiffness  of  the  joint,  with  a  disposition  to  flexion  and  slight 
lameness.  At  first  these  symptoms  are  noticed  only  occasionally;  finally 
they  become  constant  and  there  is  pain,  which  is  usually  referred  to  the 
knee.  In  some  cases  there  are  "  starting  pains  "  at  night,  although  these 
are  less  constant  and  less  severe  than  in  hip  disease.  Swelling  is  noticed 
early,  as  the  diseased  parts  are  superficial.  At  first  this  is  chiefly  of  the 
bone  itself;  the  condyle,  usually  the  inner  one,  is  enlarged  and  elon- 
gated, often  to  a  marked  degree,  before  there  is  any  infiltration  of, the 
soft  parts.  Later  there  is  a  general  fusiform  swelling,  involving  the 
entire  joint  and  effacing  all  the  normal  outlines.  Some  tenderness  upon 
pressure  over  the  bone  affected  is  present  quite  early,  and  there  may  be 
atrophy  of  the  muscles  of  the  thigh  and  calf.  The  knee  is  flexed  and 
slightly  rotated  outward,  the  position  which  secures  the  most  complete 
relaxation  of  the  joint  structures.  In  some  cases  there  is  seen  the  char- 
acteristic swelling  due  to  distention  of  the  synovial  membrane.  Abscesses 
may  form  anywhere  about  the  joint;  very  frequently  they  burrow  be- 
neath the  tendon  of  the  quadriceps  extensor  as  far  as  the  middle  of  the 
thigh.  Gradually  the  deformity  increases  until  the  leg  may  be  flexed  at 
a  right  angle,  and  rotated  outward  over  an  arc  of  twenty  or  thirty 
degrees. 

The  course  of  the  disease  resembles  that  of  ostitis  of  the  hip  and  the 
spine.  During  periods  of  remission  pain  and  tenderness  often  subside 
for  several  months  so  completely  as  to  lead  to  the  supposition  that  the 
disease  has  been  arrested.  An  exacerbation  is  often  excited  by  a  fall  or 
a  strain  of  the  joint,  or  it  may  follow  an  attack  of  acute  illness.  The 
disease  may  then  progress  rapidly  and  abscess  after  abscess  form,  with 
extensive  destruction  of  all  the  joint  structures  and  the  production  of 
permanent  deformity. 

Prognosis. — The  danger  to  life  is  considerably  less  than  in  disease  of 
the  hip  or  spine.    Death,  however,  results  from  the  same  causes — exhaus- 


TUBERCULOUS   OSTEO-MYELITIS.  865 

tion,  amyloid  degeneration,  and  general  tuberculosis  or  tuberculous 
meningitis. 

With  an  early  diagnosis  and  proper  treatment  the  disease  may,  in  a 
considerable  proportion  of  cases,  remain  limited  to  the  bone,  and  the 
resulting  lameness  and  deformity  be  very  sliglit ;  but  otherwise  a  certain 
amount  of  lameness  results  from  the  stiffness  of  tffe  joint.  This  may  be 
due  either  to  fibrous  thickening  or  to  bony  ankylosis.  Nearly  all  pa- 
tients are  able  to  walk  without  crutches,  and  if  proper  treatment  has  been 
carried  out  there  is  neither  marked  shortening  nor  deformity,  although 
there  is  always  great  muscular  atrophy. 

Diagnosis. — The  important  symptoms  for  diagnosis,  are  the  gradual 
onset,  the  early  swelling  which  is  due  to  enlargement  of  the  bone,  and 
the  constant  lameness  and  deformity.  The  disease  may  be  confounded 
with  rheumatism,  with  .synovitis,  and  even  with  scurvy.  In  all  these 
cases  the  resemblance  exists  only  during  the  period  of  exacerbation.  A 
careful  history,  liowever,  M'ill  usually  clear  uj)  the  diagnosis. 

Treatment. — The  general  treatment  is  the  same  as  in  other  forms  of 
joint  disease.  The  indications  for  local  treatment  are  the  same  as  in 
hip  disease — viz.,  to  immobilise  the  affected  limb  and  prevent  deform- 
ity. This  is  accomplished  by  a  form  of  apparatus  which  transfers 
the  weight  of  the  body  from  the  joint  to  the  perinaeum,  and  which  over- 
comes the  muscular  spasm  which  produces  flexion  and  inward  rotation 
of  the  joint.  As  in  hip  disease,  the  results  with  mechanical  and  con- 
stitutional treatment  are  decidedly  better  than  from  early  operative 
measures;  put  late  operations  are  indicated  under  the  same  conditions. 

Tuherculous  Osteo-Myelith. 

This  disease  is  rarely  seen  except  in  the  short  tubular  bones,  most 
frequently  those  of  the  hand  and  fingers.  From  this  fact  it  is  often 
called  scrofulous  or  tuberculous  dactylitis.  It  is  described  by  many 
writers  under  the  name  of  spina  ventosa.  linger  gives  the  following 
figures  showing  the  frequency  with  which  the  different  bones  were  af- 
fected :  Fingers  in  43,  toes  in  3,  metacarpus  in  41,  metatarsus  in  14, 
radius  in  2,  ulna  in  2,  tibia  in  3,  jaw  in  3.  The  first  phalanx  of  the  index 
finger  is  the  bone  which  is  most  frequently  the  seat  of  disease.  In  the 
majority  of  cases  the  process  is  confined  to  a  single  bone,  although  it  is 
not  rare  to  see  five  or  six  affected.  In  such  cases  the  disease  is  seldom 
symmetrical.  The  process  is  a  chronic  infiammation,  beginning  in  the 
centre  of  the  bone  with  the  deposit  of  tuberculous  material.  The  swell- 
ing which  follows  causes  an  expansion  of  the  bone  and  thinning  of  the 
shaft,  until  a  mere  shell  may  remain.  The  later  changes  are  inflamma- 
tion of  the  periosteum  and  the  soft  parts,  the  formation  of  abscesses  and 
sinuses,  necrosis,  the  exfoliation  of  sequestra,  etc.  The  entire  disease 
lasts  from  one  to  three  years,  and  causes  in  most  cases  marked  deformity. 
56 


866  DISEASES  OF  THE   BONES   AND   JOINTS. 

Tuberculous  dactylitis  is  essentially  a  disease  of  early  childhood,  be- 
ing seen  most  frequently  during  the  second  and  third  years.  In  a  con- 
siderable proportion  of  the  cases  there  is  a  family  history  of  tuberculosis. 
The  disease  frequently  appears  to  be  the  only  tuberculous  lesion  in 
the  body,  but  tuberculosis  of  the  hip,  knee,  ankle,  or  spine  may  be 
associated. 

Symptoms. — Tuberculous  dactylitis  usually  begins  as  a  painless  en- 
largement of  one  of  the  phalanges,  most  frequently  the  first  one  of  the 
index  finger.     It  mav  be  two  or  three  months  before  it  is  of  sufficient 


Fig.  167. — Tuberculous  Dactylitis  of  the  First  Phalanx  of  itrn  Inukx  Finueb. 

size  to  attract  much  attention.  Exceptionally  the  inflammation  is  a  more 
active  one,  and  is  accompanied  by  both  pain  and  tenderness.  The  swell- 
ing is  quite  characteristic:  it  is  smooth,  hard,  uniform,  and  generally 
spindle-shaped,  involving  the  entire  phalanx  of  the  affected  finger.  The 
appearance  of  a  severe  typical  case  is  shown  in  Fig.  167.  Later  there  is 
discolouration  of  the  skin,  and  usually  there  is  su])puration.  The  abscess 
generally  opens  at  the  side  of  the  finger,  and  a  curdy  pus  is  evacuated. 
If  the  opening  is  enlarged  by  an  incision  there  is  found  a  cavity  partly 
filled  with  caseous  matter,  and  dead  bone  is  felt,  and  perhaps  a  loose 
sequestrum.  The  cavity  is  surrounded  by  a  thin  shell  of  new  bone,  which 
is  formed  from  the  periosteum.  If  no  operation  is  done  the  discharge 
continues  for  weeks  or  months,  other  abscesses  often  form,  and  finally 
several  small  sequestra  are  exfoliated — sometimes  a  single  large  one, 
which  is  the  shell  of  the  diseased  phalanx  almost  entire. 

In  some  cases  the  disease  is  arrested  before  necrosis  occurs,  but  in  the 
majority  this  is  not  so.     After  the  wounds  have  all  healed  the  finger 


SYPHILITIC  DISEASES  OF  THE  BONES.  867 

remains  shortened,  deformed,  and  often  useless.  In  some  cases  the  dis- 
organisation is  so  extensive  that  amputation  is  necessary. 

Diagnosis. — The  recognition  of  dactylitis  is  usually  easy,  hut  as  symp- 
toms almost  identical  may  be  seen  in  a  syphilitic  intiammation,  it  is 
often  difficult  to  tell  with  which  of  the  two  forms  one  has  to  deal.  The 
tuberculous  form  is  very  much  more  frequent;  it  may  occur  in  a  patient 
with  tuberculous  antecedents,  or  it  may  be  associated  with  other  tuber- 
culous lesions.  Syphilitic  cases  are  distinguished  by  the  fact  that  tbe 
lesion  is  more  frequently  multiple,  that  it  is  often  symmetrical,  and  that 
other  manifestations  of  syphilis  are  generally  present.  The  Wassermann 
and  the  tuberculin  tests  give  definite  information  in  nearly  all  cases. 

Treatment. — Painting  with  iodine  and  like  measures  are  useless. 
The  diseased  part  should  be  kept  at  rest — if  a  finger,  by  the  application 
of  a  splint.  Every  means  should  be  taken  to  build  up  the  patient's  gen- 
eral health,  as  this  is  the  most  effective  way  to  influence  the  local  process. 
The  general  verdict  of  surgeons  is  against  early  excision  as  a  means  of 
arresting  the  disease.  Abscesses  should  be  opened  early  and  freely,  all 
diseased  bone  removed,  the  finger  kept  in  proper  position,  and  the  wound 
treated  according  to  general  surgical  principles.  Under  almost  any 
treatment  the  disease  is  a  protracted  one,  and  rarely  lasts  less  than  a  year. 

SYPHILITIC  DISEASES  OF  THE  BONES. 

The  bone  lesions  of  hereditary  syphilis  are  not  infrequent,  but  were 
long  unrecognised.  They  may  be  divided  into  two  groups — those  occur- 
ring with  the  early  symptoms,  and  those  which  belong  to  the  late  mani- 
festations of  the  disease. 

Acute  Epiphysitis. 

This  is  the  most  frequent  variety  of  bone  disease  in  early  hereditary 
syphilis.  It  may  begin  even  in  intra-uterine  life,  and  it  forms  one  of 
the  most  characteristic  lesions  of  the  disease.  To  some  degree  it  is 
almost  invariably  present  in  syphilitic  foetuses  and  in  syphilitic  infants 
who  are  still-born. 

In  the  early  stage,  there  is  an  increase  in  the  cartilage  cells  and  often 
increased  calcification.  Later,  a  line  of  softening  forms  at  the  epiphyseal 
junction,  which  may  cause  loosening  of  the  cartilages  and  ultimately 
complete  separation  of  the  epiphysis  from  the  shaft,  by  the  formation  of 
granulation  tissue  between  them.  In  cases  receiving  proper  treatment,  re- 
covery may  take  place  with  good  union,  perfect  function,  and  without  any 
deformity.  In  other  cases  degenerative  changes  continue,  and  infection 
with  pyogenic  germs  may  be  added.  The  large  joints  are  usually  affected, 
and  the  lesions  are  frequently  symmetrical.  Acute  suppurative  arthritis 
may  occur  independently  of  changes  at  the  epiphysis ;  but  even  when  these 


868 


DISEASES  OF  THE   BONES   AND  JOINTS. 


are  seen  in  syphilitic  infants  tiiey  are  to  be  regarded  as  oi"  pya^nnie  rather 
than  of  syphilitic  origin.  Secondary  to  the  changes  at  the  epiphysis, 
there  is  periostitis.     Periostitis  of  the  shaft  is  rare  in  early  infancy. 

The  bones  most  frequently  the  seat  of  acute  epiphysitis  are  the  hu- 
merus, radius,  and  ulna,  although  any  of  the  long  bones  may  be  affected. 
Symptoms. — The  early  symptoms  are  usually  quite  acute,  and  appear 
during  the  first  six  weeks  of  life;  they  may  precede  any  other  mani- 
festations of  syphilis.     In  some  cases 
there  is  first  noticed  an  inability  on 
tiie   part   of   the   child   to   move   the 
limb,  which  may  easily  be  mistaken 
for   paralysis.      It   is,   in   fact,   often 
described  as  "  syphilitic  pseudo-paral- 
ysis."    The  limb  lies  perfectly  mo- 
tionless, and  any  attempt  at  passive 
movement  causes  evident  pain.    There 
is  tenderness  on  pressure,  and  soon 
swelling    is    seen,    both    being    most 
marked   at   the  epiphyseal   line.      If 
the  bone  affected  is  superficially  sit- 
uated, as  the  lower  epiphysis  of  the 
humerus,  radius,  or  tibia,  swelling  is 
very  apparent,  while  it  may  be  scarce- 
ly perceptible  at  the  upper  epiphysis 
of    the    humerus.      The    swelling    is 
usually  cylindrical  and  moderate  in 
degree,  being  limited  to  the  extremity 
of  the  bone.     Separation  of  the  epi- 
physis may  take  place,  so  that  crepi- 
tation is  obtained  by  moving  the  limb. 
With  this  there  is  sometimes  suppuration.     The  llontgen  ray  shows  in 
many  instances  an   increase   in  calcification  at  the  epiphysis  with   an 
irregular  serrated  outline  (Fig.  168)  known  as  Gyon's  line. 

In  the  milder  cases,  or  those  which  have  been  subjected  to  active 
treatment,  both  the  swelling  and  the  tenderness  subside  rapidly  without 
suppuration ;  and  even  though  the  epiphysis  has  separated  from  the  shaft, 
it  speedily  unites.  When  pseudo-paralysis  has  been  the  chief  symptom, 
very  rapid  improvement  occurs  under  treatment,  and  usually  there  is  com- 
plete recovery  of  function  in  two  or  three  weeks.  If  the  disease  extends  to 
the  joint,  or  if  osteo-myelitis  develops,  the  case  is  almost  certainly  fatal. 
Diagnosis. — This  is  usually  easy,  from  the  age  of  the  patient — gener- 
ally under  three  months — the  early  prominence  of  pain  and  apparent 
loss  of  power,  with  the  later  appearance  of  swelling  and  signs  of  inflam- 
mation at  the  epiphyseal  junction.     In  all  these  respects  the  disease 


Fig.  168  — Hereditaky  Syphilis. 
Showing  Gyon's  line,  A.  Infant  two 
months  old. 


SYPHILITIC   OSTEO-PERIOSTITIS. 


869 


closely  resembles  scurvy ;  but  the  latter  is  rare  before  the  eighth  or  tenth 
month;  there  is  usually  a  history  of  the  long-continued  use  of  some  pro- 
prietary infant  food,  and  it  is  cured  l)y  dietetic  treatment  alone.  In 
case  of  doubt  the  Wassermann  test  may  be  used. 

The  apparent  loss  of  power  may  lead  to  the  diagnosis  of  birth  palsy, 
especially  of  the  upper-arm  type.  The  presence  of  acute  pain  and  ten- 
derness, the  absence  of  the  characteristic  deformity,  and  the  prompt 
recovery  under  constitutional  treatment,  usually  make  the  distinction 
between  the  two  conditions  an  easy  one. 

Treatment. — This  is  the  same  as  in  all  early  syphilitic  manifestations, 
for  which  see  the  article  on  Syphilis.  Locally,  the  part  requires  in  the 
early  stage  only  protection  and  rest.  Should  suppuration  occur  in  the 
neighbouring  joint,  or  should  osteo-myelitis  develop,  these  conditions 
should  be  treated  surgically,  as  they  are  when  due  to  other  causes. 

Chronic  Osteo-Periustitis. 

This  is  the  usual  form  of  bone  disease  which  is  seen  in  late  hereditary 
syphilis,  and  it  is  one  of  the  most  frequent  and   most  characteristic 


Fig.  169. — Syphilitic  Periostitis  of  the  Fibula.     Infant  three  months  old. 
Same  patient  as  Figs.  173-176.     Right  side  affected;  left  side  normal. 

lesions  of  that  stage  of  the  disease.  It  is  occasionally  seen  in  early  in- 
fancy, and  usually  affects  the  long  bones.  The  lesions  are  multiple,  and 
at  this  age  principally  periosteal.  The  Eontgen  ray  picture  shows  a 
fusiform    swelling   chiefly    due    to    periosteal    thickening    (Fig.    169). 


870 


DISEASES  OF  THE   BONES   AND   JOINTS. 


Clironic  ostoo-periostitis  is  more  frequent  after  the  tliird  year,  and  most 
of  the  oases  occur  between  tlie  fifth  and  fourteentli  years.  The  most 
frequent  seat  of  disease  is  the  tibia,  and  next  to  this  the  bones  of  the 
forearm  and  tlie  cranium.  The  following  is  the  frequency  with  which 
the  different  bones  were  affected  in  the  series  of  cases  re])orted  by  Four- 
nier:  tibia  in  !>1  cases,  ulna  in  22,  radius  in  15,  cranium  in  10,  humerus 
in  12,  all  others  in  37.  The  process  may  result  either  in  a  diffuse  or  a 
localised  hyj)eri)lasia  of  bone  or  in  necrosis. 

The  typical  changes  are  seen  in  the  tibia.  The  shaft  of  the  bone  is 
principally  or  solely  affected.  There  is  often  produced  a  very  charac- 
teristic deformity,  consisting  of  a  forward  curve  of  the  anterior  border 
of  the  tibia,  which  has  been  compared  to  a  sabre  blade  (Fig.  170,  171). 


FiQ.  170. — Syphilitic  OsTEO-PERiosTiris  of  the  Tibia.  Left  tiUa  greatly  enlarged; 
13^  inches  longer  than  the  right,  and  leg  2  inches  larger  in  circumference;  sabre-like 
anterior  border.     Right  tibia  normal;  lesion  of  long  standing.     Patient  13  y(^ar.s  old. 


In  some  cases  the  bone  is  bent  inward  at  its  lower  third,  resembling 
somewhat  a  rachitic  curvature.  Sometimes  the  entire  shaft  of  the 
bone  is  affected,  and  it  may  be  greatly  enlarged.  At  other  times  the 
swelling  is  chiefly  near  the  epiphysis,  where  large  bosses  may  form  of 
sufficient  size  to  interfere  with  the  functions  of  the  joint.  Instead 
of  affecting  the  bone  uniformly,  the  disease  often  affects  only  certain 


SYPHILITIC  OSTEO-PERIOSTITIS. 


871 


parts,  leading  to  tlie  formation  of  largo  nodes  which  are  more  likely  to 
be  followed  by  necrosis  than  are  the  other  lesions.  In  most  of  the  cases 
the  process  is  purely  a  hyperplastic  one,  leaving  the  bone  permanently 
enlarged  and  the  limb  often   lengtiiened.     Less  freijuently,  there  occur 


Fig.  171. — Syphilitic  Osteo-periostitis  of  the  Left  Tibia. 
Similar  lesion  to  that  shown  in  Fig.  170;  patient  8  years  old.     The  right  tibia  is  normal. 


gummatous  deposits  in  or  beneath  the  periosteum,  which  may  soften, 
suppurate,  and  lead  to  superficial  necrosis,  with  the  formation  of  sinuses 
that  remain  open  until  the  sequestrum  is  exfoliated.  Syphilitic  deposits 
sometimes  take  place  in  the  interior  of  the  bones,  generally  near  the 
articular  ends  (Fig.  171)  ;  these  may  soften  and  break  down  with  ab- 
scesses, sinuses,  etc.,  very  much  after  the  manner  of  a  •  tuberculous  in- 
flammation (Fig.  172). 

The  lesions  of  the  other  long  bones  are  essentially  the  same  as  of 
the  tibia.     They  are  nearly  always  symmetrical  and  often  multiple.    In 


872 


DISEASES  OF  THE   BONES  AND  JOINTS. 


a  case  under  my  observation  in  a  boy  of  four  years,  tbe  disease  in- 
volved both  tibiae,  both  radii,  the  right  ulna,  the  left  metatarsus,  and  the 
metacarpal  bone  of  the  left  thumb.     The  course  of  syphilitic  osteo-peri- 


FiG.  172. — Syphilitic  Bone  Lesions  in  a  Boy  Four  Years  Old.  The  lower  end  of  the 
radius  of  both  arms  is  enlarged  as  a  result  probably  of  former  epiphysitis;  there  are 
sinuses  leading  to  dead  bone  over  the  metacarpal  bone  of  the  right  thumb,  and  over 
the  upper  extremity  of  the  left  ulna.     The  last  two  are  recent  lesions. 


ostitis  is  very  chronic,  and  some  permanent  deformity  is  the  rule,  unless 
cases  come  very  early  under  treatment. 

When  affecting  the  bones  of  the  cranium  the  disease  usually  takes  the 
form  of  a  gummatous  periostitis,  which  leads  to  the  formation  of  large 
nodes.  These  may  remain  as  permanent  deformities,  or  they  may  break 
down  and  suppurate,  with  necrosis  of  one  or  both  tables  of  the  skull. 
This  may  be  followed  by  inflammation  of  the  dura,  the  pia,  and  even 
of  the  brain  itself. 

Symptoms. — When  the  long  bones  are  affected,  the  symptoms  are 
pain,  tenderness,  and  deformity.  These  come  on  very  gradually,  and 
often  the  deformity  is  noticed  before  either  pain  or  tenderness  is  suffi- 
ciently marked  to  attract  attention.  The  pain  is  regularly  worse  at 
night,  and  often  felt  only  at  that  time;  it  may  be  mild  and  occasional, 
or  so  severe  as  virtually  to  prevent  sleep.  There  is  tenderness  on  pres- 
sure over  the  bones  affected,  the  acuteness  of  which  will  depend  upon 
the  activity  of  the  process.  When  suppuration  occurs,  it  comes  very 
slowly,  and  never  with  symptoms  of  acute  inflammation.  Sinuses  usu- 
ally continue  to  discharge  until  a  sequestrum  is  exfoliated.     The  course 


SYPHILITIC   DACTYLITIS.  873 

of  the  disease  is  very  tedious,  and  the  wiioh^  duration  is  usually  several 
years. 

When  the  cranium  is  affected,  there  are  seen  irregular  nodes,  espe- 
cially upon  the  frontal  and  parietal  bones.  They  are  from  one  to  two 
inches  in  diameter,  and  project  from  one-eighth  to  one-fourth  of  an  inch 
above  the  general  outline  of  the  skull.  There  may  be  pain,  tenderness, 
softening,  suppuration,  and  necrosis,  as  in  the  long  bones. 

Diagnosis. — It  is  rare  that  disease  of  the  bones  of  the  cranium  is  due 
in  childhood  to  any  other  cause  than  syphilis,  and  this  disease  may  usu- 
ally be  assumed  to  exist  if  traumatism  can  be  excluded.  The  bosses 
upon  the  cranium  in  rickets  are  always  large,  smooth,  and  regular  in 
position,  and  belong  to  infancy. 

Syphilitic  disease  of  the  long  bones  is  recognised  by  the  nocturnal 
pain,  the  tenderness  and  peculiar  deformity,  and  by  the  association  of 
other  late  manifestations  of  syphilis — i.  e.,  the  peculiar  notched  teeth, 
the  interstitial  keratitis,  the  enlarged  epitrochlear  glands,  etc.  Tuber- 
culous disease  generally  affects  the  articular  ends  of  the  bones ;  syphilis 
nearly  always  the  shaft.  The  diffuse  hyperplasia  of  the  tibia  and  the 
sabre-like  deformity  of  its  anterior  border  are  rarely,  if  ever,  due  to  any 
other  cause  than  syphilis. 

The  deformities  of  the  long  bones  have  in  some  cases  a  certain  resem- 
blance to  those  due  to  rickets,  but  the  two  conditions  can  hardly  be  con- 
fused if  a  careful  examination  is  made. 

Treatment. — The  constitutional  treatment  of  these  lesions  is  the  same 
as  that  of  the  other  late  manifestations  of  syphilis;  for  details  see  the 
chapter  on  Syphilis.  Surgical  treatment  is  required  in  cases  which  ter- 
minate in  necrosis,  whether  of  the  cranium  or  the  extremities.  They 
are  to  be  managed  like  the  same  conditions  in  adults. 

Syphilitic  Dactylitis. 

This  belongs  to  a  somewhat  earlier  period  of  syphilis  than  the  dis- 
ease just  described,  and  is  usually  seen  in  infants.  It  is  not  a  frequent 
manifestation  of  syphilis,  and  as  compared  with  tuberculous  dactylitis  it 
is  much  less  common  and  occurs  at  an  earlier  age.  It  was  first  fully  de- 
scribed by  Taylor  (New  York).  The  symptoms  closely  resemble  the  tu- 
berculous form.  It  may  begin  as  a  periostitis,  but  more  frequently  as  an 
osteo-myelitis.  Like  the  tuberculous  form,  it  may  go  on  to  suppuration 
and  necrosis.  According  to  Taylor,  dactylitis  is  more  often  single  than 
multiple,  but  in  my  own  cases  several  phalanges  have  generally  been  in- 
volved, and  the  lesions  have  often  been  symmetrical.  In  one  case,  the 
first  phalanx  of  every  finger  of  both  hands  was  affected.  The  Eontgen 
ray  pictures  show  that  the  metacarpal  bones  are  also  involved  in  many 
cases  (Figs.  175  and  176). 

The  symptoms  and  course  of  syphilitic  dactylitis  are  essentially  the 


874 


DISEASES  OF  THE   BONES  AND  JOINTS. 


same  as  in  the  tuberculous  form.  Tlie  differential  diagnosis  is  considered 
with  the  latter  disease.  The  prognosis  is  much  the  same  in  the  two  vari- 
eties, with  the  exception  that  in  the  early  stage  the  syphilitic  eases  may 


Fig.  173.  I'lu.  174. 

Figs.  173,  174. — Syphilitic  Dactylitis.  On  right  hand  first  phalanges  of  forefinger  and 
little  finger  affected ;  on  left  hand  first  phalanx  of  thumb  and  second  phalanx  of  second 
finger. 

often  he  arrested  by  constitutional  treatment.  This  is  the  same  as  in 
other  late  lesions  of  S3rphilis.  The  same  local  treatment  should  be  em- 
ployed as  in  the  tuberculous  cases. 


Fig.  175.  Fig.  176. 

Figs.  175,  176. — Rontgen  Ray  of  Same  Hands.  Note  that  besides  the  bones  shown 
in  the  other  pictures,  two  metacarpal  bones  (C,  D)  are  affected  in  the  left  hand  and 
the  lower  end  of  the  radius  {G)  in  the  right  hand. 


CONGENITAL   ICHTHYOSIS.  875 

chapim^:k  V. 

DISEASES   OF   THE   SKIN. 

The  skin  at  birth  is  covered  witli  a  wliitisli  sel)aceous  secretion,  tlie 
vernix  caseosa.  The  skin  itself  is  of  a  deep  pur])lis]i  colour,  which 
changes  to  a  bright  red  over  tlie  face  and  trunk  in  a  few  minutes,  with 
the  establishment  of  normal  respiration,  and  in  a  few  liours  the  whole 
body  has  the  same  tint.  Tliis  excessive  redness  slowly  fades  during  the 
first  montli,  at  the  end  of  which  time  the  skin  has  assumed  the  pale  ])ink 
)f  infancy.  On  the  third  or  fourth  day  there  may  be  seen  the  first  signs 
of  icterus ;  this  generally  fades  by  the  end  of  the  second  week. 

The  epidermis  w^hich  is  present  at  birth  soon  loosens  and  is  thrown 
off.  This  normal  desquamation  usually  begins  upon  the  fourtli  or  fifth 
day,  and  is  completed  in  ten  days  or  two  weeks.  If  the  skin  is  fre- 
quently oiled  and  properly  bathed,'  desquamation  is  scarcely  noticeable 
unless  a  close  examination  is  made.  In  some  infants,  especially  those 
who  are  delicate  and  cachectic,  it  is  very  much  more  marked,  and  closely 
resembles  that  seen  in  scarlet  fever.  Ritter  has  described  an  exfoliative 
dermatitis  of  the  newly  born,  appearing  generally  during  the  second 
and  third  weeks,  a  condition  which  is  regarded  by  Kaposi  as  simply  an 
exaggeration  of  the  normal  physiological  desquamation.  This  process 
may  be  mistaken  for  that  due  to  hereditary  syphilis;  the  latter,  however, 
is  rarel}^  general,  appears  later,  and  is  much  more  prolonged. 

Perspiration  is  rarely  present  before  the  end  of  the  fourth  month, 
and  is  then  seen  only  upon  the  forehead.  In  healthy  infants  it  is 
scarcely  noticeable  during  the  first  year.  Copious  perspiration  is  most 
frequently  a  symptom  of  rickets;  less  marked  perspiration  may  occur 
with  any  general  weakness  or  during  acute  illness. 

CONGENITAL   ICHTHYOSIS. 

Congenital,  or  more  properly  foetal,  ichthyosis,  sometimes  known  also 
as  diffuse  keratoma,  is  a  rare  disease,  characterised  by  the  formation,  usu- 
ally all  over  the  body,  of  a  thick,  horny  epidermis  resembling  parchment. 
This  is  divided  by  fissures  or  shallow  furrows  into  irregular  patches; 
sometimes  these  are  two  or  three  inches  wide,  at  others  as  small  as  a  pin's 
head.  The  disease  begins  in  the  early  months  of  foetal  life,  and  is  an 
abnormality  in  the  development  of  the  skin,  there  being  an  excessive  pro- 
liferation of  the  layers  of  the  epidermis. 

Symptoms. — In  the  gravest  form  of  the  disease  the  child  often  lives 
but  a  few  hours,  and  rarely  more  than  a  week.  The  openings  of  the 
nostrils  and  the  ears  may  be  occluded  by  the  excessive  production  of 
epithelial  cells.    The  eyes  are  in  a  condition  of  ectropion,  and  there  are 


876 


DISEASES  OF  THE  SKIN. 


often  deformities  of  the  mouth  and  other  orifices  due  to  the  contractions 
of  the  skin.  The  nails  and  hair  are  usually  imperfectly  developed.  The 
body  seems  incased  in  a  liard,  horny  covering,  and  looks  as  if  it  had  been 
varnished  or  covered  with  collodion.  The  skin  cracks  or  splits  and  the 
edges  curl  up,  an  appearance  which  has  been  aptly  compared  to  the  skin 
of  a  boiled  potato. 

In  the  milder  form,  the  duration  of  life  is  indefinite,  depending  upon 
the  degree  of  development  of  the  disease;  but  even  in  such  cases  there 
are  frequently  seen  the  deformities  at  the  orifices  of  the  body,  and  there 
may  also  be  a  continued  exfoliation  of  the  epidermis  in  large  irregular 


Fig.  177. — Congenital  Ichthyosis  in  a  Child  Ten  Months  Old.  The  large  scaly 
patches  are  well  shown  on  the  lower  part  of  the  right  chest  and  abdomen,  and  the 
constricting  bands  upon  the  legs.     (From  a  photograph  by  Dr.  Cabot.) 

patches.  After  this  has  separated,  the  skin  beneath  appears  red  and 
moist,  but  gradually  becomes  dry,  hard,  and  shining,  slowly  contracting 
until  it  splits  in  various  directions.  In  a  case  recently  under  observation 
in  the  Babies'  Hospital,  a  picture  of  which  is  shown  in  the  accompanying 
illustration  (Fig.  177),  it  was  stated  by  the  mother  that  during  the  first 
ten. months  of  life  complete  exfoliation  of  the  skin  had  occurred  in  the 
course  of  every  two  or  three  months. 

The  outlook  is  bad  in  all  cases;  in  most  of  the  severe  forms  death 
occurs  in  infancy,  but  in  some  of  the  milder  ones,  life  may  be  prolonged 
throughout  childhood.  The  "alligator  boy"  of  the  "Dime  Museum" 
is  an  example  of  thig  class. 


MILIARIA.  877 

Treatment. — The  indications  are  to  keep  the  skin  moist  and  soft  by 
the  use  of  oils,  continuous  baths,  etc.,  and  to  prevent  infection  by  perfect 
cleanliness.  Although  a  certain  amount  of  improvement  usually  follows 
these  measures,  a  cure  is  not  to  be  expected. 


MILIARIA. 

The  term  miliaria  is  applied  to  an  obstruction  of  the  sweat  glands, 
which  ma}^  occur  either  with  or  without  inflammation.  The  non-inflam- 
matory form  is  known  as  sudamina,  the  inflammator}^  forms  as  miliaria 
rubra,  miliaria  vesiculosa,  and  miliaria  papulosa. 

Sndamina. — In  this  form  there  is  no  inflammation.  The  sweat  ducts, 
according  to  Crocker,  are  blocked  by  an  accumulation  of  epithelial  cells 
while  no  perspiration  is  going  on;  and  when  the  process  is  restored  the 
fluid,  being  unable  to  escape,  accumulates  in  the  form  of  tiny  vesicles. 
These  appear  like  small  pearly  bodies  very  closely  set,  and  disappear  in 
the  course  of  a  few  days  by  a^bsorption.  Fresh  crops  may  appear  from 
time  to  time.  Sudamina  may  be  seen  in  any  of  the  continued  fevers  or 
exhausting  diseases.     It  requires  no  treatment. 

Miliaria  Rubra. — This  condition,  also  known  as  red  gum,  strophulus, 
etc.,  is  a  sweat  rash,  usually  seen  in  young  infants  as  the  result  of  ex- 
cessive clothing.  It  is  most  frequently  observed  upon  the  cheeks  and 
neck,  often  upon  the  side  of  the  face  upon  which  the  infant  sleeps,  or  the 
side  held  agajnst  the  mother's  body  while  nursing,  if  this  is  done  upon 
only  one  breast.  The  eruption  consists  of  scattered  red  papules,  some- 
times with  tiny  vesicles.  Miliaria  rubra  is  an  inflammation  about  the 
sweat  glands,  the  result  of  which  is  a  retention  of  their  secretion.  There 
is  generally  little  or  no  itching.  The  treatment  consists  in  the  removal 
of  the  cause,  and  the  application  of  some  absorbent  powder,  such  as 
boric  acid  and  starch. 

Miliaria  Papulosa  {Lichen  Tropicus,  Prickly  Heat,  etc.). — This  is  the 
most  common  and  most  important  variety  of  miliaria.  There  is  in  this 
disease  an  obstruction  of  the  sweat  glands  by  inflammatory  products. 
The  lesion  consists  in  the  formation  of  bright-red  papules,  which  are 
very  closely  set,  the  summits  of  some  of  them  being  surmounted  by  tiny 
vesicles,  and  here  and  there  in  severe  cases  even  small  pustules  may  be 
seen.  If  not  interfered  with  by  scratching,  the  vesicles  dry  up  without 
rupture,  and  are  followed  by  a  slight  desquamation.  Where  there  is  much 
scratching,  an  eczematous  condition  may  result.  Miliaria  papulosa  comes 
out  with  great  rapidity,  especially  upon  the  neck,  forehead,  back,  and 
chest.  It  is  accompanied  by  an  almost  intolerable  itching  and  stinging 
sensation.  Over  other  parts  of  the  body  profuse  perspiration  occurs. 
The  disease  is  produced  by  very  hot  weather  and  excessive  clothing. 
Although  the  duration  of  a  single  attack  is  but  two  or  three  days,  in 


878  DISEASES  OF  THE  SKIN. 

susceptible  patients  it  may  keep  recurring  for  weeks,  being  exceedingly 
intractable.  Where  there  is  much  scratching  the  resulting  eczema  is 
very  troublesome.    It  is  not  infrequently  followed  by  furunculosis. 

The  diagnosis  of  miliaria  rubra  and  miliaria  papulosa  is  usually  easy. 
They  are  distinguished  from  eczema  by  the  suddenness  with  which  they 
appear,  by  the  associated  sweating  of  other  parts  of  the  body,  by  the 
transitory  character  of  the  eruption,  and  by  the  fact  that  the  rash  never 
occurs  in  circumscribed  patches.  Prickly  heat  sometimes  resembles  the 
rash  of  scarlet  fever,  but  the  fact  that  the  tiny  papules  are  in  some  places 
crowned  by  vesicles  and  that  constitutional  symptoms  are  absent,  usually 
make  the  distinction  an  easy  one. 

Treatment. — Prickly  heat  is  to  be  prevented  by  light  clothing,  fre- 
quent bathing,  and  the  plentiful  use  of  a  good  toilet  powder,  such  as 
boric  acid  and  starch.  The  skin  should  be  protected  against  the  irrita- 
tion of  flannel  undergarments  by  the  interposition  of  silk  or  linen.  When 
the  inflammation  is  at  its  height,  relief  is  obtained  by  the  application  of 
a  calamine  and  zinc  lotion,  or  by  a  dilute  solution  of  the  acetate  of  lead ; 
carbolic  acid  may  be  added  to  either,  where  the  itching  is  intense.  In 
some  cases  powders  are  preferable  to  lotions.  One  of  the  best  is  the 
stearate  or  the  oxide  of  zinc,  twelve  parts;  bismuth,  three  parts;  pow- 
dered camphor,  one  part ;  or  equal  parts  of  starch  and  boric  acid  may  be 
used,  or  simply  rice  flour.  All  of  these  must  be  very  freely  applied. 
The  diet  should  be  light  and  fluid,  and  if  milk  is  the  food  it  should  be 
considerably  diluted. 

SEBORRHCEA. 

Seborrhcea  is  considered  by  dermatologists  generally,  as  a  functional 
disease  of  the  sebaceous  glands;  although  Unna  regards  all  such  cases 
as  inflammatory,  and  classes  them  as  seborrhceic  eczema,  which  is  of  para- 
sitic origin.  The  disease  may  affect  almost  any  part  of  the  body,  and 
children  of  any  age,  but  the  most  frequent  form  is  that  which  is  seen 
upon  the  scalp  in  young  infants.  This  is  the  most  important  variety, 
and  the  only  one  which  will  be  here  considered. 

Seborrhcea  of  the  scalp  is  characterised  by  the  formation  upon  the 
vertex,  of  dirty-yellow  crusts,  which  are  soft,  greasy,  and  friable.  They 
are  composed  of  epithelial  cells,  fat-globules,  and  granular  masses,  to 
which  is  always  added  dirt.  In  neglected  cases  the  hairy  scalp  is  nearly 
covered  by  a  dense  crust,  which  may  be  as  thick  as  heavy  pasteboard. 
If  the  crusts  are  removed  the  underlying  scalp  may  be  found  perfectly 
healthy,  but  more  frequently,  in  cases  of  long  standing,  it  is  eczematous. 
The  eczema  is  set  up  by  the  decomposition  of  the  exudation,  or  by  the 
efforts  to  remove  the  crusts  by  such  means  as  the  fine-toothed  comb, 
commonly  employed  in  domestic  practice.  There  is  little  tendency  to 
spontaneous  improvement  or  recovery,  and  the  condition  often  lasts  for 


ECZEMA.  879 

months.      Every   seborrhea   sliould    l)e   treated,    for    when    nej^^lected    it 
furnishes  a  favourable  soil  for  the  developiiient  of  (^ezeiiui. 

Treatment. — Only  local  measures  are  required.  Tlie  crusts  are  first 
to  be  softened  with  oil,  and  then  removed  by  wasliing  tliorougldy  with 
warm  water  and  soap,  after  which  an  ointment  of  resorcin  (resorcin,  gr. 
x;  ungt.  aquae  rossa,  3j)  or  sulphur  (precipitated  sulphur,  .")_];  lanoline, 
3j)  should  be  applied.  The  oil  and  soap  and  water  are  re])eated  every 
few  days,  or  as  often  as  tlie  crusts  form.  In  the  meantime  the  scalp  is 
kept  covered  with  the  ointment. 

ECZEMA. 

Eczema  may  be  defined  as  a  catarrhal  inflammation  of  the  skin.  It 
is  the  most  frequent  and  altogether  the  most  important  disease  of  the 
skin  in  early  life.  The  scope  of  the  present  work  permits  only  a  dis- 
cussion of  sucli  features  and  varieties  as  are  peculiar  to  infants  and 
young  children.  The  eczema  of  older  children  does  not  differ  in  any 
essential  points  from  that  of  adults. 

Etiology.— The  conditions  in  infancy  which  predispose  to  eczema  are, 
first,  that  the  skin  is  extremely  delicate,  and  hence  more  easily  affected 
by  external  irritants  and  micro-organisms;  secondly,  its  more  intense 
glandular  activity.  While  all  children  are  susceptible,  there  are  certain 
ones  in  whom  the  susceptibility  is  very  marked,  and  in  them  the  slightest 
amount  of  external  irritation,  or  the  most  ti'ivial  disturbance  of  diges- 
tion may  produce  a  severe  eruption.  ^Ye  can  not  connect  eczema  with 
any  single  diathetic  condition;  but  it  is  much  more  often  seen  in  chil- 
dren with  so-called  gouty  antecedents  than  in  others.  Such  children 
are  often  in  later  life  the  subjects  of  asthma.  Eczema  of  the  face  is 
common  in  fat,  healthy-looking  infants,  both  in  those  who  are  nursing 
and  in  those  who  are  artificially  fed.  It  rarely  occiirs  in  poorly  nour- 
ished children. 

The  exciting  causes  of  eczema  may  be  external  or  internal.  Of  the 
former  the  most  important  are  heat,  cold  dry  air,  and  winds — as  in  the 
familiar  chapping  of  the  face — the  use  of  hard  water  or  of  strong  soaps 
in  bathing.  The  disease  may  be  due  to  the  irritation  of  clothing,  to 
want  of  cleanliness,  or  to  irritating  discharges  from  nmcous  surfaces,  as 
in  the  eczema  of  the  upper  lip,  thighs,  or  buttocks.  It  accompanies  most 
of  the  parasitic  skin  diseases,  particularly  pediculosis,  scabies,  and  ring- 
worm. 

What  part  is  played  by  micro-organisms  in  the  etiology  of  eczema  has 
not  yet  been  fully  determined.  As  a  primary  factor  they  do  not  seem 
to  be  of  the  first  importance.  Secondary  infection,  however,  occurs  in 
most  cases,  and  this  is  important  in  keeping  up  the  disease. 

The  internal  causes  of  eczema  are  chiefly  associated  with  deficient 
elimination  from  the  kidneys  and  bowels,  and  digestive  disturbances.    It 


880  DISE.\SES  OF  THE  SKIN. 

often  accompanies  chronic  constipation,  especially  when  this  is  due  to 
an  excess  of  fat  in  the  food.  Eczema  is  also  seen  where  the  urine  is 
scanty  and  concentrated  because  children  partake  too  largely  of  solid 
food.    The  latter  is  true  both  in  the  first  and  second  years. 

Eczema  may  be  produced  by  any  form  of  digestive  disturbance,  but 
it  is  especially  frequent  in  the  intestiiial  indigestion  which  results  from 
overfeeding,  or  the  too  early  or  excessive  use  of  farinaceous  food,  or  from 
breast-milk  in  which  the  percentage  of  fat  is  very  high.  Of  farinaceous 
articles,  the  two  which  are  most  often  to  be  blamed  are  potato  and  oat- 
meal. Although  eczematous  patients  usually  appear  to  be  well  nour- 
ished, it  is  rare  that  some  symptoms  of  indigestion  are  not  present. 

Eczema  is  often  due  to  some  form  of  reflex  irritation.  Such  are  the 
cases  which  accompany  dentition,  and  the  rare  ones  due  to  genital  irrita- 
tion. By  many  writers  the  eczema  caused  by  disorders  of  the  stomach 
or  intestines  is  regarded  as  reflex.  The  stronger  the  predisposition,  the 
more  trivial  is  the  reflex  irritation  Te(|uired  to  induce  an  eni])tion. 

Simple  Chronic  Eczema — Eczema  Rubrum. — This  is  the  most  frequent 
form  of  eczema  occurring  in  infants  and  young  cliildren,  and  is  uf^ually 
seen  upon  the  face.  It  affects  by  preference  tlie  clieeks,  forehead,  and 
scalp,  not  infrequently  the  ears  and  neck,  and  may  occur  upon  any  part 
of  the  body.  Upon  the  trunk  and  extremities  the  eruption  is  usually  in 
patches,  but  in  rare  cases  may  cover  nearly  the  entire  body.  The  disease 
generally  begins  upon  the  cheeks  w- ith  the  formation  of  small  red  papules ; 
later  these  coalesce,  and  there  is  a  moist,  red  surface  exniding  serum  or 
sero-pus.  The  secretion  dries  and  forms  thick,  gummy  crusts,  which 
may  be  so  hard  as  to  form  a  mask  for  the  face.  From  the  scratching 
caused  by  the  almost  intolerable  itching,  the  surface  bleeds  freely,  and 
the  dried  blood  gives  to  the  crusts  a  dirty-brown  colour  and  adds  to  the 
distressing  appearance.  The  skin  is  often  much  swollen.  After  the 
removal  of  tiie  crusts  there  is  seen,  in  acute  cases,  a  red,  inflamed,  gran- 
ular surface,  discharging  pus  or  serum  and  bleeding  readily.  When  the 
process  is  less  active,  there  is  redness,  thickening,  induration,  and  scali- 
ness  of  the  skin,  and  marked  itching.  In  the  same  case  these  stages 
may  alternate,  exacerbations  occurring  whenever  the  exciting  cause  ?S 
particularly  active.  From  the  cheeks  the  disease  spreads  to  the  forehead, 
ears,  and  scalp,  and  here  similar  lesions  are  seen.  Upon  the  trunk  and 
extremities  thick  crusts  rarely  form,  but  the  skin  is  red,  thick,  and  scaly. 
The  parts  most  often  affected  are  the  forearms,  chest,  elbows,  knees, 
abdomen,  and  back ;  occasionally  the  eruption  is  general.  Eczema  of  the 
occipital  region  of  the  scalp  is  usually  due  to  pediculosis. 

Swelling  of  the  lymph  nodes  in  the  neighbourhood  of  the  eruption 
is  a  constant  feature  of  eczema  of  the  face  and  scalp;  these  may  reach 
the  size  of  a  chestnut  or  walnut,  and  occasionally  they  may  su])purate. 
Intense  itching  is  a  characteristic  feature  of  all  cases  of  eczema  of  the  face 


ECZEMA.  881 

or  scalp.  While  most  children  with  eczema  are  well  nourished  in  the 
beginning,  and  some  remain  so  during  a  prolonged  attack,  tlie  general 
health  of  many  is  undermined.  The  itching  and  discomfort  cause  con- 
stant irritability,  loss  of  sleep  and  other  nervous  symptoms  which  some- 
times seriously  impair  the  child's  nutrition. 

The  effects  of  very  extensive  eczema  resemble  in  some  particulars 
those  of  burns  of  the  second  degree.  There  may  be  fever,  delirium,  other 
nervous  symptoms  and  even  a  fatal  termination.  Four  cases  have  been 
seen  recently  in  the  Babies'  Hospital  with  a  generalised  eczema  in  which 
there  developed,  without  evident  cause,  exceedingly  high  temperature, 
in  two  cases  reaching  109°  F.,  accompanied  by  symptoms  of  a  most 
profound  intoxication.  Two  of  the  four  cases  ended  fatally;  one  child 
in  whom  the  temperature  reached  109°  F.  recovered.  In  two  of  the 
patients  a  marked  degree  of  acetonuria  was  present.  No  satisfactory 
explanation  of  these  severe  intoxications  has  yet  been  offered. 

There  are  some  patients  in  whom  an  alternation  of  eczema  and  attacks 
of  bronchitis  with  asthma  may  occur.  During  the  eczema,  the  pulmonary 
symptoms  are  entirely  wanting;  but  when  the  eczema  is  relieved  the  pul- 
monary s3Tnptoms  rapidly  develop.  This  is  often  seen  in  patients  of  the 
so-called  gouty  diathesis.  In  a  few  patients  an  alternation  of  eczema 
and  diarrhoea  is  observed. 

Eczema  of  the  face  is  very  chronic,  easily  improved,  but  cured  only 
with  great  difficulty.  There  is  a  strong  tendency  to  relapse,  brought  on 
by  neglect  rff  local  treatment  or  by  any  digestive  disturbance. 

The  predisposition  to  eczema  often  ceases  with  the  second  year ;  those 
who  have  suffered  from  it  almost  constantly  during  infancy  may  be  free 
from  it  during  the  remainder  of  childhood.  This  is  in  part  to  be  ex- 
plained by  the  loss  of  fat  in  consequence  of  more  active  exercise  and  a 
diet  which  is  more  largely  nitrogenous.  Where  the  disease  continues 
through  the  third  and  fourth  years,  the  associated  infantile  condition — 
obesity — is  not  infrequently  present. 

Pustular  Eczema  of  the  Scalp. — This  condition,  often  called  "  simple 
impetigo,"  is  less  frequently  seen  in  infants  than  in  children  from  two 
to  five  years  old.  There  are  usually  present  from  half  a  dozen  to  fifty 
greenish-yellow  crusts,  matting  the  hair,  usually  discrete,  but  sometimes 
coalescing  to  form  a  mask  over  half  the  scalp.  There  is  very  little  itch- 
ing, in  some  cases  none  at  all.  The  lymph  glands  are  invariably  en- 
larged. There  is  frequently  continued  auto-infection,  and  in  this  way 
the  disease  may  be  prolonged  indefinitely.  It  is  possible,  too,  that  infec- 
tion may  spread  to  other  children. 

Intertrigo. — This  term  is  rather  indiscriminately  applied  to  any  erup- 
tion which  develops  upon  two  moist  surfaces,  which  are  in  contact.  It 
is  often  regarded  as  a  form  of  eczema.  There  may  be  a  simple  erythema 
or  an  eczema  resulting  from  traumatism  or  the  decomposition  of  secre- 
57 


882  DISEASES  OF  THE   SKIN. 

tions.  Intertrigo  is  seen  in  the.  folds  of  the  groin,  between  the  scrotum 
and  the  thighs,  between  the  buttocks,  about  the  anus,  in  the  axilla?,  in 
the  neck,  or  behind  the  ears.  Its  essential  causes  are  moisture,  friction, 
want  of  cleanliness,  and  sometimes  infection.  The  disease  is  generally 
seen  in  its  worst  form  about  the  thighs,  genitals,  and  buttocks;  it  some- 
times covers  the  sacrum  and  extends  down  to  the  middle  of  the  thighs. 
There  is  an  intense  uniform  redness,  and  in  some  cases  the  epidermis  is 
denuded  over  large  areas,  and  the  surface  is  moist.  There  is  no  thick 
crusting  and  little  or  no  itching.  Intertrigo  is  usually  easy  to  control 
except  in  very  poorly  nourished  or  marantic  children,  among  whom  it  is 
especially  frequent. 

Diagnosis  of  Eczema. — This  is  usually  quite  an  easy  matter.  In  the 
majority  of  cases,  the  disease  affects  the  face  or  the  scalp,  and  its  appear- 
ances are  typical.  Eczema  of  the  body  or  extremities  may  be  confounded 
with  scabies  or  syphilis,  and  occasionally  with  other  forms  of  skin  dis- 
ease. Scabies  resembles  eczema  in  its  intense  itching  and  multiform 
lesions;  but  in  the  former,  one  may  often  find  evidences  of  its  presence 
in  other  members  of  the  family;  the  parts  most  frequently  affected  are 
the  flexures  of  the  wrists,  the  elbows,  the  skin  between  the  fingers,  the 
margins  of  the  axillae,  the  lower  part  of  the  abdomen  and  back,  and,  in 
boys,  the  penis;  and  by  careful  examination  with  a  lens  some  of  the 
characteristic  burrows  are  certain  to  be  discovered. 

Syphilis  is  likely  to  be  confounded  with  papular  eczema  of  the  but- 
tocks. The  latter  affects  the  parts  near  the  anus,  and  the  irritation  may 
lead  to  the  development  of  spots  closely  resembling  mucous  patches.  The 
local  appearances  may  at  times  be  indistinguishable  from  syphilis,  and 
the  diagnosis  is  to  be  made  only  by  the  other  symptoms  present.  In 
syphilis  the  characteristic  eruption  is  seen  usually  upon  the  face,  hands, 
legs,  and  sometimes  the  palms  and  soles;  there  is  no  itching  and  very 
little  evidence  of  inflammation;  the  eruption  is  copper-coloured,  and 
occurs  as  small  circumscribed  spots ;  there  are  usually  present  other  symp- 
toms, such  as  the  coryza,  the  sj'philitic  cachexia,  and  enlargement  of  the 
spleen. 

The  diagnosis  from  pediculosis  and  ring-worm  of  the  scalp,  rarely 
presents  any  difficulties. 

Prognosis. — All  cases  of  chronic  eczema  are  tedious.  There  is  only  a 
slight  tendency  to  spontaneous  improvement,  and  very  little  to  spontane- 
ous recovery  during  early  infancy.  About  the  end  of  the  first  year  the 
disease  disappears  in  many  children;  some  relapse  after  this  time,  but 
others  are  never  again  troubled  with  eczema.  In  a  severe  case  of  gen- 
eral eczema  the  possibility  of  the  development  of  severe  toxic  SAonptoms 
should  not  be  forgotten.  In  a  given  case,  the  prognosis  depends  upon 
the  duration  of  the  disease,  its  severity,  and  very  much  upon  the  co- 
operation of  the  mother  or  nurse.     The  results  obtained  depend  not 


ECZEMA.  883  Jf 

only  upon  the  particular  line  of  treatment  adopted,  but  upon  how  well 
it  is  carried  out.  Usually  it  must  be  continued  for  several  months. 
Eczema  of  the  face  is  especially  intractable  when  occurring  in  children 
suffering  from  chronic  indigestion  and  constipation.  Intertrigo  is  in 
most  cases  easily  cured,  unless  the  patient  is  suffering  from  marasmus. 

Treatment. — A  judicious  combination  of  general  and  local  measures 
is  necessary  for  the  best  results.  One  should  first  seek  to  discover  and 
correct  what  is  wrong  with  the  child's  digestion,  assimilation,  and  elimi- 
nation ;  unless  nutritive  disturbances  can  be  removed,  local  treatment  will 
give  only  temporary  relief.  External  causes  also  must  be  investigated. 
The  local  measures  employed  must  be  chosen  with  reference  to  the  con- 
dition present;  stimulating  applications  should  not  be  ordered  for  an 
acutely  inflamed  skin,  nor  sedative  applications  in  very  chronic  con- 
ditions. 

Diet. — A  thorough  investigation  into  the  food  is  necessary,  not  only 
as  to  its  character,  but  as  to  quantity  and  preparation,  the  manner  and 
frequency  of  feeding,  etc.  If  the  patient  is  a  nursing  infant,  an  exami- 
nation of  the  nurse's  milk  is  indispensable  to  intelligent  treatment.  If 
the  child  is  very  fat  and  well  nourished,  it  is  generally  the  case  that  the 
fat  of  the  milk  is  too  high  and  must  be  reduced  according  to  the  rules 
given  elsewhere,  the  most  important  thing  being  to  exclude  from  the 
nurse's  diet  malt  liquors  and  alcohol  in  all  forms,  and  reduce  the  amount 
of  meat.  The  amount  of  food  should  be  reduced  by  lengthening  the 
period  between  the  nursings,  and  shortening  the  time  which  the  child  is 
allowed  to  remain  at  the  breast  at  one  nursing.  Plain  water,  or  better, 
some  alkaline  water,  should  be  given  freely  between  the  nursings.  In 
children  fed  upon  cow's  milk,  the  trouble  may  be  with  the  sugar,  or 
more  frequently  with  the  fat.  This  should  first  be  reduced  and  if  no 
improvement  occurs  the  sugar  should  also  be  diminished.  In  all  dietetic 
changes  the  general  nutrition  of  the  child  should  be  regarded  as  more 
important  than  the  relief  of  the  eczema. 

During  the  latter  part  of  the  first  and  the  entire  second  year,  the 
usual  error  is  that  of  overfeeding  with  in  most  cases  an  excessive  use 
of  solid  food,  especially  farinaceous  articles.  The  diet  should  then  be 
much  reduced,  and  the  amount  of  farinaceous  food  restricted,  potatoes 
and  oatmeal  being  absolutely  prohibited.  The  diet  which  suits  most 
children  best  is  one  composed  of  milk,  beef  juice,  broth,  fruit,  eggs,  and 
a  little  red  meat,  with  the  addition  in  some  cases  of  rice,  wheat,  or  barley. 
In  severe  and  obstinate  cases,  however,  as  complete  a  change  in  diet  as 
possible  is  sometimes  the  best  prescription.  Any  form  of  indigestion 
which  exists  is  to  be  managed  according  to  the  special  indications  in 
each  case. 

The  diet  of  older  children  needs  to  be  watched  no  less  closely  than 
that  of  infants.    The  general  rules  laid  down  elsewhere  for  feeding  after 


384  DISEASES  OF  THE  SKIN. 

the  second  year  should  be  observed.  The  great  majority  of  cases  do  best 
upon  a  diet  which  is  largely  fluid,  and  composed  of  milk,  buttermilk, 
kumyss  or  matzoon. 

Elimination  by  the  kidneys  should  be  stimulated  by  the  very  free  use 
of  water,  to  which  may  be  added  the  citrate,  or  acetate  of  potassium, 
from  ten  to  twenty  grains  daily. 

Attention  to  the  condition  of  the  bowels  is  of  the  greatest  importance. 
To  overcome  the  tendency  to  constipation  is  in  many  cases  to  cure  the 
eczema.  Suggestions  under  this  head  will  be  found  in  the  chapter  on 
Chronic  Constipation.  The  occasional  use  of  catharsis  by  calomel  every 
week  or  ten  days  is  often  beneficial.  The  best  effects  from  this  are  seen 
in  overfed  children.  It  has  a  favourable  effect  upon  the  kidneys  as  well 
as  upon  the  bowels.  The  bowels  must  not  only  be  opened,  they  must 
be  kept  open  by  the  daily  use,  if  necessary,  of  some  of  the  milder 
laxatives,  such  as  magnesia,  phosphate  of  sodium,  rhubarb,  or  cas- 
cara.  Castor  oil,  given  in  from  half  a  teaspoonful  to  teaspoonful  doses 
every  night  for  two  or  three  weeks  at  a  time,  is  at  times  a  useful 
measure. 

When  the  disease  occurs  in  flabby,  anaemic,  or  poorly  nourislied  chil- 
dren, iron  and  bitter  tonics  are  required,  but  rarely  cod-liver  oil.  In 
other  words,  the  child's  general  condition  should  be  treated  just  as  if 
no  eczema  existed.  Arsenic  is  indicated  in  a  chronic  or  recurring  form 
of  eczema  with  dry,  scaly  eruption.  It  is  in  no  sense  a  specific  remedy, 
but  is  sometimes  of  value. 

The  general  management  of  cases  is  important.  The  skin  must  be 
carefully  protected  by  an  ointment  whenever  the  child  is  in  the  open 
air;  if  the  weather  is  very  cold,  or  there  are  high  winds,  children  with 
active  eczema  should  not  go  out,  but  be  aired  indoors.  Never  should 
an  eczematous  surface  be  washed  with  plain  water,  and  much  less  with 
castile  soap  and  water,  so  frequently  employed  by  the  ignorant.  Where 
washing  is  necessary,  it  may  be  done  with  bran  water,  milk  and  water, 
or  starch  and  water,  to  which  borax  (a  teaspoonful  to  the  quart)  may  be 
added.  The  clothing  should  not  be  so  excessive  as  to  keep  the  child 
constantly  in  a  perspiration.  Napkins  should  not  be  washed  in  strong 
soda  solutions,  nor,  in  case  of  eczema  of  the  buttocks,  should  they  ever 
be  used  a  second  time  after  being  simply  dried. 

In  eczema  of  the  face  it  is  absolutely  necessary  to  prevent  the  child 
from  scratching  the  parts.  The  use  of  a  mask  is  not  always  sufficient, 
nor  the  wearing  of  mittens;  nor  is  the  local  application  of  anti-pruritic 
lotions  or  ointments  invariably  successful.  In  severe  cases  mechanical 
restraint  is  absolutely  indispensable.  The  most  satisfactory  method  is  to 
surround  the  arms  at  the  elbows  by  pasteboard  splints,  and  hold  them  in 
place  by  bandages.  This  allows  free  use  of  the  hands,  but  makes  it 
absolutely  impossible  for  the  child  to  reach  the  face. 


ECZEMA.  885 

Local  Treatment. — Local  treatment  is  always  necessary,  for  not  only 
are  the  causes  sometimes  entirely  external,  but  the  condition  may  persist 
after  the  original  internal  cause  has  been  removed.  There  are  several 
indications  to  be  met  by  local  treatment  at  different  stages  in  the  disease : 
(1)  To  remove  crusts  and  other  inflammatory  products;  (2)  to  allay 
congestion  and  acute  inflammation;  (3)  to  relieve  itching;  (4)  to  pro- 
tect the  delicate  new  skin  which  is  forming;  (5)  to  prevent  infection; 
(6)   to  stimulate  the  skin  in  the  chronic  stages  of  the  disease. 

Preparatory  to  the  use  of  any  application,  the  scales,  crusts,  and  other 
products  of  inflammation  must  be  softened  and  removed  in  order  that 
the  diseased  surface  may  be  reached.  In  most  cases  it  is  sufficient  to 
soften  the  crusts  by  the  use  of  olive  oil  for  twelve  or  twenty-four  hours, 
and  then  remove  them  by  soap  and  warm  water.  If  the  crusts  are  very 
hard  and  thick,  they  can  be  softened  by  a  poultice.  During  the  stage  of 
acute  inflammation  only  sedative  applications  should  be  used.  One  of 
the  best  of  these  is  a  lotion  of  zinc  and  calamine : 

9  Pulv.  calaminae  preparatae 3  ij 

Zinci  oxidi 1  ss. 

Glycerinae §  j 

Liquor  calcis ^  ij 

Aquae  rosae §  viij. 

A  piece  of  muslin  should  be  dipped  in  this  solution,  and  applied  to 
the  affected  part,  being  kept  in  place  by  a  bandage.  If  there  is  much 
itching,  ope  per  cent  of  carbolic  acid  may  be  added. 

Another  plan  of  treatment,  where  there  is  much  secretion,  is  to  keep 
the  surface  covered  with  equal  parts  of  boric  acid  and  starch  or  talcum 
powder.  An  application  which  is  often  successful  in  allaying  the  in- 
tense burning  and  itching  is  black  wash.  This  is  applied  several  times 
a  day  in  full  strength  or  diluted  and  allowed  to  dry  on,  after  which  a 
protective  ointment  is  used. 

A  soothing  application  in  general  eczema  is  one  composed  of  equal 
parts  of  lime-water  and  sweet-almond  oil ;  sometimes  this  may  be  advan- 
tageously followed  by  smearing  the  body  with  a  thick  starch  paste  and 
allowing  it  to  dry  on. 

As  a  simple  protective  ointment,  one  containing  starch,  zinc  oxide, 

or  bismuth,  either  alone  or  in  combination,  may  be  used.    An  excellent 

formula  is  Lassar's  paste: 

9  Acidi  salicylici ' gr.  x 

Zinci  oxidi 3  ij 

Amyli '. 3  ij 

Vaseline I  j. 

Later,  when  the  inflammation  is  less  acute  and  the  itching  severe, 
nothing  is  so  generally  useful  as  a  combination  of  tar  and  zinc,  as  in 
the  following: 


886  DISEASES  OF  THE  SKIN. 

3  Ungt.  picis  liquidae 3  iij 

Zinci  oxidi 3  iss. 

Ungt.  aquse  rosae 3  vi. 

For  more  chronic  cases,  the  amount  of  tar  may  be  increased.  All 
ointments  used  should  be  spread  upon  muslin,  and  kept  in  close  contact 
with  the  inflamed  part  by  means  of  a  bandage  or  mask.  Little  or  noth- 
ing is  accomplished  by  simply  rubbing  the  ointment  upon  the  affected 
part.  Where  it  is  difficult  to  keep  a  mask  applied,  or  in  situations  where 
it  is  impossible  to  use  the  ointment.  Pick's  paste  may  be  tried: 

3  Pulv.  tragacanthse 3  j 

Glycerinae 3  iss. 

Aquse  rosae 1  iv. 

To  this  may  be  added  zinc  oxide,  gr.  xl,  and  carbolic  acid,  gr.  v,  or  tar,  TTL 
X.  A  similar  basis  for  ointments,  made  from  gum  tragacanth  has  been 
suggested  by  Elliot  and  is  known  as  bassorin  paste.  It  may  be  combined 
with  tar,  zinc,  salicylic  acid,  or  resorcin.  An  ointment  containing  five  or 
ten  per  cent  of  calomel  is  often  the  best  application  for  an  eczema  which 
is  not  too  extensive. 

The  methods  of  treatment  above  mentioned  are  especially  applicable 
to  eczema  of  the  face  and  scalp.  For  pustular  eczema  of  the  scalp  the 
best  application  is  the  white  precipitate  ointment,  which  should  be  com- 
bined with  three  or  four  parts  of  vaseline.  This  is  excellent  also  for 
small  eczematous  patches  upon  the  body,  but  it  is  not  to  be  used  over  a 
large  surface. 

In  intertrigo,  the  treatment  should  have  reference  to  the  patholog- 
ical condition  which  is  present.  Cases  of  simple  erythema  usually  yield 
promptly  to  cleanliness  and  the  free  use  of  absorbent  antiseptic  powders, 
such  as  boric  acid  and  starch  in  equal  parts,  or  calomel  two  per  cent  may 
be  used  with  talcum.  If  there  is  an  acute  dermatitis,  the  calamine  and 
zinc  lotion  may  be  used,  and  later  some  protecting  ointment.  When  in- 
fection has  been  added,  lotions  of  resorcin  or  ichthyol,  one-half  or  one 
per  cent  strength,  should  first  be  applied,  and  the  skin  then  covered 
with  one  of  the  powders  mentioned;  both  are  to  be  repeated  as  often 
as  the  parts  are  wet  by  urine  or  soiled  by  faeces.  It  is  important  in  all 
cases  that  the  diseased  surfaces  should  be  kept  separated,  which  is  best 
done  by  boric  acid  and  starch.  All  napkins  should  be  immediately  re- 
moved when  soiled. 

In  cases  of  chronic  eczema,  where  the  skin  remains  thickened,  red, 
scaly,  and  itching,  stimulating  applications  are  to  be  used,  such  as  the 
tincture  of  green  soap  or  stronger  preparations  of  tar  than  those  men- 
tioned.   They  should  be  applied  every  three  or  four  days. 


FURUNCULOSIS.  887 

FURUNCULOSIS. 

A  furuncle,  or  boil,  is  a  circumscribed  inflammation  of  the  subcuta- 
neous cellular  tissue,  usually  beginning  in  a  hair  follicle,  and  usually 
ending  in  suppuration.  When  severe,  it  may  result  in  necrosis  of  the 
follicle,  which  forms  the  "  core,"  or  the  necrotic  process  may  extend  to 
the  surrounding  tissues  for  a  variable  distance.  The  ordinary  boil  need 
not  be  described,  as  it  presents  nothing  peculiar  in  early  life.  The  con- 
dition, however,  which  is  characteristic  of  young  children  is  the  forma- 
tion of  small  ones  in  great  numbers.  It  is  to  this  more  especially  that 
the  term  furunculosis  is  applied.  The  principal  location  of  these  small 
abscesses  is,  in  nearly  all  cases,  the  scalp,  face,  and  shoulders,  although 
they  may  be  found  upon  any  part  of  the  body.  They  are  sometimes 
numbered  by  hundreds,  and  appear  in  crops  for  a  period  of  several 
months.  In  size,  they  usually  vary  from  a  pea  to  an  almond,  and  they 
rarely  contain  a  core.  Infants  are  much  more  often  the  subjects  of  this 
disease  than  are  those  who  have  passed  the  second  year.  In  the  great 
majority  of  cases  the  condition  is  not  serious,  yet,  occurring,  as  it  often 
does,  in  infants  who  are  already  suffering  from  extreme  malnutrition 
or  marasmus,  whose  tissues  possess  but  little  resistance,  the  process  may 
develop  into  a  gangrenous  dermatitis,  which  may  prove  fatal. 

Furunculosis  is  seen  in  children  who  are  in  other  respects  apparently 
healthy,  even  robust;  but  the  majority  are  in  a  more  or  less  debilitated 
condition,  and  often  are  the  subjects  of  digestive  disturbances.  The  dis- 
ease is  quite  frequent  in  syphilitic  infants ;  but  these  simple  abscesses  are 
to  be  sharply  distinguished  from  those  which  result  from  the  breaking 
down  of  gummata  of  the  skin.  Want  of  cleanliness  of  the  skin  is  a 
factor  of  some  importance  in  producing  the  disease.  Furunculosis  may 
be  associated  with  eczema.  The  exciting  cause  in  all  cases,  as  shown  by 
recent  investigations,  is  the  entrance  of  the  staphylococcus  pyogenes 
aureus,  sometimes  with  other  organisms,  into  the  follicles  of  the  skin. 

Treatment. — The  internal  treatment  is  to  be  directed  toward  any  dis- 
turbance of  digestion  or  general  nutrition  which  is  present.  General 
tonics  are  indicated  in  most  cases,  particularly  iron,  arsenic,  and  the  com- 
pound syrup  of  the  hypophosphites.  Bvit  little  reliance  can  be  placed 
upon  drugs  such  as  sulphide  of  calcium,  for  the  purpose  of  arresting 
this  disease.  Striking  benefit,  however,  often  follows  the  internal  use 
of  yeast;  either  brewer's  yeast  or  the  ordinary  commercial  yeast  cake, 
freshly  made,  may  be  given.  The  latter  is  usually  easier  to  obtain.  To 
a  child  of  two  or  three  years  one-fourth  to  one-half  a  yeast  cake  or  about 
half  a  teaspoonful  may  be  administered  daily.  Local  treatment  should 
have  for  its  first  object  thorough  cleanliness  of  the  skin.  This  is  best 
secured  by  frequently  bathing  the  parts  affected  with  a  1  to  5,000  solution 
of  bichloride.     Single  furuncles  may  often  be  aborted  by  touching  them 


888  DISEASES  OF  THE  SKIN. 

with  pure  carbolic  acid  or  the  application  of  Bier's  cups.  In  my  ex- 
perience the  best  plan  of  treating  the  multiple  small  furuncles,  is  to 
delay  incision  until  they  have  pointed,  then  to  incise  and  empty  the 
follicle  completely  by  compression.  After  this  the  part  should  be  cov- 
ered with  simple  collodion.  Where  the  abscesses  are  of  large  size  and 
upon  the  scalp,  it  is  wise  to  make  compression  by  applying  a  snug  band- 
age for  a  day.  When  the  suppuration  is  more  diffuse  and  there  is 
necrosis  of  the  cellular  tissue,  ichthyol,  either  in  the  form  of  an  ointment 
or  lotion  (one  to  five  per  cent  strength)  is  one  of  the  best  applications. 
For  general  funinculosis  or  the  continual  recurrence  of  larger  abscesses 
the  use  of  vaccines  is  altogether  the  most  effective  treatment.  While 
autogenous  vaccines  are  perhaps  preferable,  the  use  of  stock  vaccines  is 
in  most  cases  equally  effective.  Injections  should  be  repeated  every 
three  or  four  days;  beginning  with  fifty  millions,  the  dose  may  be 
increased  to  one  hundred  millions.  The  results  in  most  cases  are  very 
striking. 

GANGRENOUS  DERMATITIS. 

This  is  not  a  frequent  disease,  and  is  seen  almost  exclusively  in  in- 
fancy. It  may  be  primary  or  it  may  follow  other  diseases,  and  hence  has 
been  described  under  many  different  names,  viz.,  varicella  gangrenosa, 
ecthyma  gangrenosa,  pemphigus  gangrenosa,  etc. 

The  lesion  consists  in  small,  discrete  areas  of  inflammation  of  the 
skin,  ending  in  necrosis.  In  the  primary  cases  there  is  usually  first  seen 
a  vesicle,  about  as  large  as  a  pea,  with  a  dusky  areola ;  it  increases  in 
size  and  becomes  a  pustule.  Crusts  form  which  are  quite  adherent,  and 
on  removing  them  a  loss  of  tissue  is  seen.  The  ulcers  usually  have 
sharp  but  not  undermined  edges,  often  presenting  a  "  punched-out "  ap- 
pearance. By  the  coalescence  of  several  small  ones,  ulcers  an  inch  or 
more  in  diameter  are  sometimes  formed. 

The  primary  form  of  gangrenous  dermatitis  occurs  in  wretched, 
poorly-nourished  infants,  and  is  most  often  seen  upon  the  buttocks.  In 
this  location  it  may  be  mistaken  for  syphilis.  The  secondary  form  is 
more  common,  and  usually  follows  varicella,  less  frequently  vaccinia,  or 
impetigo.  In  such  cases  the  lesion  is  usually  seen  upon  the  upper  half 
of  the  body,  especially  upon  the  neck  and  chest.  It  follows  the  ordinary 
lesions  of  varicella  and  continues  usually,  in  spite  of  treatment,  from 
one  to  four  weeks,  in  many  cases  ending  fatally.  The  disease  always 
occurs  in  infants  of  poor  vitality,  often  in  those  suffering  from  maras- 
mus, and  is  seldom  seen  outside  of  institutions.  It  may  be  accompanied 
by  fever,  and  other  severe  constitutional  symptoms. 

For  the  production  of  the  disease,  two  factors  are  necessary :  First, 
the  constitutional  condition  referred  to;  and,  secondly,  the  entrance  of 
pyogenic  germs,  usually  the  streptococcus  pyogenes. 


IMPETIGO  CONTAGIOSA.  889 

Treatment. — Every  means  possible  should  be  employed  to  build  up 
the  general  health  of  the  infant  by  tonics,  fresh  air,  careful  feeding,  etc. 
Locally,  strict  cleanliness  and  antiseptic  applications  are  necessary.  The 
best  application  is  a  solution  of  bichloride  (1  to  5,000),  or  an  ointment 
of  ichthyol  or  white  precipitate. 

IMPETIGO   CONTAGIOSA. 

Impetigo  contagiosa  is  a  disease  characterised  by  the  formation  of 
discrete  vesiculo-pustules,  occurring  most  frequently  upon  the  hands 
and  face.  Cases  are  usually  seen  in  groups  affecting  several  children  in 
one  family  or  institution.  It  may  be  communicated  from  one  person 
to  another,  and  spread  by  auto-inoculation  from  one  part  of  the  body 
to  another. 

One  rarely  has  an  opportunity  to  see  the  disease  until  vesicles  have 
formed.  These  are  usually  from  one-fourth  to  one-half  inch  in  diam- 
eter, and  are  flaccid,  never  distended.  Later,  their  contents  become 
slightly  yellowish;  then  they  rupture  and  dry,  forming  thick  yellow 
crusts,  which  have  the  appearance  of  being  "  stuck  on,"  the  surrounding 
skin  being  quite  healthy.  After  the  crusts  fall  off,  a  small  red  patch 
remains,  which  slowly  fades.  The  true  skin  is  not  involved,  except  in 
poorly  nourished,  cachectic  subjects,  as  a  result  of  continued  local  irrita- 
tion, like  scratching.  Under  such  conditions  ulceration  may  occur. 
Instead  of  thp  small  vesiculo-pustules  described,  bullae  from  one  to  two 
inches  in  diameter  may  form,  filled  first  with  serum,  afterward  with 
sero-pus.  Very  little  inflammation  is  seen  about  these  patches,  and  in 
most  cases  the  intervening  skin  is  normal. 

The  favourite  seat  of  the  eruption  is  the  face,  especially  about  the 
chin,  next  the  hands,  the  neck,  the  feet  and  legs,  the  forearms,  and  the 
scalp;  it  is  rarely  seen  upon  the  abdomen,  and  never  upon  the  back. 
There  may  be  only  half  a  dozen  vesiculo-pustules,  or  from  thirty  to  forty 
may  be  present.  The  smaller  ones  sometimes  coalesce  and  form  others 
of  considerable  size.  Itching  is  never  a  prominent  symptom,  and  in 
most  cases  it  is  absent  altogether. 

The  usual  duration  of  impetigo  contagiosa  is  two  or  three  weeks ;  it, 
however,  runs  no  regular  course,  and  by  continued  auto-inoculation  may 
last  much  longer  than  this. 

The  studies  of  Gilchrist  (Baltimore)  point  to  a  streptococcus  of 
low  virulence  as  the  cause  of  this  disease.  European  investigators, 
however,  have  with  considerable  uniformity  found  the  staphylococ- 
cus pyogenes  aureus  in  the  vesicles.  Impetigo  contagiosa  may  occur 
in  any  child,  but  is  seen  most  frequently  in  one  who  is  poorly  nour- 
ished. 

The  diagnosis  is  not  often  difficult,  and  is  made  by  the  following 


890  DISEASES  OF  THE  SKIN. 

features,  viz.,  the  occurrence  of  several  cases  together,  the  isolated 
vesiculo-pustules  situated  upon  the  face  and  hands,  the  slight  itching, 
and  the  prompt  cure  by  local  measures  only.  The  bullous  form,  how- 
ever, is  frequently  confounded  with  pemphigus;  many  cases  in  which 
the  diagnosis  of  pemphigus  is  made  are  examples  of  impetigo. 

Treatment. — This  is  simple  and  usually  very  effective.  The  crusts 
are  to  be  softened  and  removed  by  thoroughly  washing  the  part  with 
soap  and  water  or  a  bichloride  solution,  after  which  the  white  precipitate 
ointment,  combined  with  three  parts  of  vaseline,  should  be  applied. 

URTICARIA. 

Urticaria  is  a  frequent  disease  in  early  life,  and  presents  some  fea- 
tures, particularly  in  infants  and  young  children,  which  are  quite  dif- 
ferent from  those  seen  in  adults.  This  is  due  to  the  fact  that  papules 
and  vesicles,  and  occasionally  pustules,  are  associated  with  the  wheals. 
As  the  wheals  quickly  subside,  it  frequently  happens  that  the  other 
lesions  mentioned  are  the  only  ones  present.  This  fact  has  given  rise 
to  considerable  confusion  in  names,  and  the  urticaria  of  infancy  has 
been  called  lichen  urticatus,  urticaria  papulosa,  strophulus,  etc.  It  is 
now  pretty  generally  agreed  that  the  clinical  picture,  which  is  a  familiar 
one,  belongs  to  a  single  disease,  and  that  this  is  urticaria. 

The  initial  lesion  is  the  wheal,  but  on  account  of  the  extreme  suscep- 
tibility of  the  skin  in  young  children,  the  process  is  more  intense  than 
in  older  patients,  so  that  it  may  result  in  the  formation  of  an  inflam- 
matory papule  or  a  vesicle.  In  a  few  hours  the  wheals  may  subside,  and 
only  the  papules  or  vesicles  remain,  and  without  a  good  history  the  dis- 
ease may  be  a  very  obscure  one.  The  papules  and  vesicles  occur  with 
greatest  frequency  upon  the  hands  and  feet,  particularly  the  palms  and 
soles.  The  more  severe  form  of  the  disease  in  poorly  nourished  children 
is  sometimes  accompanied  by  a  pustular  eruption,  and  there  may  even 
be  deep  ulceration  (ecthyma).  The  usual  appearance  of  the  eruption  is 
a  number  of  small  inflamed  red  papules  whose  tops  are  covered  with 
crusts,  the  result  of  scratching.  The  eruption  may  be  limited  to  the 
extremities  or  it  may  be  general.  It  is  as  a  rule  more  severe  in  regions 
accessible  to  scratching. 

There  is  usually  severe  itching,  which  leads  to  loss  of  sleep,  and  often 
in  this  way  the  disease  affects  the  general  health  of  the  child.  The  urti- 
caria of  older  children  does  not  differ  essentially  from  the  same  disease 
in  adults.  The  alternation  of  urticaria  and  asthma  is  occasionally  met 
with. 

The  character  of  the  eruption  in  urticaria  and  even  its  distribution 
strongly  suggest  scabies ;  and  unless  one  has  had  an  opportunity  to  witness 
the  development  of  the  lesions,  a  differential  diagnosis  may  be  very  difficult. 


SCABIES.  891 

as  almost  every  lesion,  except  the  wheal,  may  be  identical  in  both  diseases. 
Other  cases  may  resemble  varicella. 

Urticaria  in  early  life  is  most  frequently  the  result  of  some  disturb- 
ance in  the  digestive  tract.  Almost  any  sort  of  derangement  may  pro- 
duce it,  the  exciting  cause  varying  with  the  patient.  Exceptionally,  it 
may  result  from  other  forms  of  irritation,  such  as  dentition  or  intestinal 
worms. 

Treatment. — The  milder  forms  of  urticaria  usually  respond  quickly  to 
treatment;  but  when  it  is  severe  and  has  existed  for  several  weeks,  it  is 
one  of  the  most  troublesome  and  intractable  skin  diseases  of  childhood. 
The  treatment  is  to  be  directed  primarily  toward  the  condition  of  the 
digestive  organs.  Children  should  be  put  upon  a  milk  diet.  The  bowels 
should  be  kept  freely  open  by  calomel,  a  nightly  dose  of  castor  oil,  or  a 
morning  dose  of  magnesia.  If  the  urine  is  excessively  acid  and  scanty, 
alkaline  diuretics  should  be  given.  The  drugs  most  useful  for  the  indi- 
gestion with  which  urticaria  is  associated  are  salicylate  of  soda  and  nitro- 
muriatic  acid,  each  of  which  is  to  be  given  after  meals. 

All  local  causes  of  irritation,  such  as  rough  flannel  underclothing, 
should  be  removed.  The  sleep  may  be  so  much  disturbed  as  to  require 
the  use  of  trional  or  bromide  and  chloral.  Antipyrine  and  atropine  are 
often  useful;  they  may  be  given  separately  or  in  combination,  and  in 
moderately  large  doses. 

The  local  irritation  and  itching  may  be  relieved  by  a  very  dilute 
solution  of  tlve  subacetate  of  lead  or  carbolic  acid,  or  by  a  mixture  of 
vinegar,  or  the  fluid  extract  of  hamamelis,  or  bicarbonate  of  soda,  and 
water.  When  pustules  are  present,  the  white  precipitate  ointment  may 
be  used,  combined  with  four  parts  of  vaseline;  in  the  papular  and 
vesicular  forms,  an  ointment  of  ichthyol,  one  per  cent  strength.  In 
many  cases  the  improvement  in  the  general  health  by  the  use  of  tonics, 
change  of  air,  etc.,  will  accomplish  more  than  any  measures  directed 
especially  to  the  relief  of  the  urticaria. 

SCABIES. 

Scabies  is  a  contagious  disease  due  to  the  burrowing  into  the  skin  of 
the  female  acarus,  with  secondary  lesions  which  result  from  scratching. 

The  burrowing  of  the  acarus  is  usually  where  the  skin  is  thinnest — 
viz.,  between  the  fingers,  on  the  flexor  surfaces  of  the  wrist,  the  axillae, 
and,  in  males,  the  genitals.  It  is  not  seen  upon  the  face,  except  in  in- 
fancy, when  it  may  be  infected  by  contact  with  the  breasts  of  the  mother. 
The  lesion  excited  by  the  acarus  is  usually  a  papule  or  a  vesicle,  some- 
times a  pustule.  In  some  cases  no  evidences  of  inflammation  are  pres- 
ent, but  in  infants  and  young  children  they  may  be  marked — pustular 
eruptions  being  frequent  and  often  extensive,  especially  upon  the  hands 


892  DISEASES  OF  THE  SKIN. 

and  feet.  The  characteristic  burrow  is  from  one-fourth  to  one-half  inch 
in  length,  and  appears  as  a  fine  brown  or  black  line,  at  the  end  of  which 
the  acarus  may  be  discovered  as  a  small  white  speck.  The  burrows  are 
often  difficult  to  find  in  infants.  They  are  generally  to  be  seen  along 
the  ulnar  border  of  the  hand  and  between  the  fingers.  The  intensity  of 
tlie  inflammatory  lesions  varies  greatly  in  different  cases;  in  some  they 
are  very  few,  while  in  others,  particularly  in  delicate,  cachectic,  and 
neglected  children,  they  are  sometimes  very  severe,  so  that  the  skin  of 
the  affected  part  is  nearly  covered  with  pustules.  These  secondary  lesions 
are  due  to  infection  by  the  streptococcus  or  staphylococcus.  A  pustular 
eruption  upon  the  hands  should  always  suggest  scabies.  The  lesions 
which  result  from  scratching  may  be  found  on  any  accessible  portion 
of  the  body.  There  are  usually  at  first  linear,  bloody  marks,  but  after 
a  time  these  may  not  be  visible.  In  little  children  urticaria  is  often 
associated. 

The  diagnosis  of  scabies  is  usually  quite  easy,  as  several  children  in 
a  family  are  likely  to  be  affected,  particularly  if  they  occupy  the  same 
bed.  The  diagnostic  features  of  the  eruption  are  the  presence  of  papules, 
vesicles,  or  pustules,  especially  upon  the  hands,  wrists,  and  genitals.  A 
careful  examination  with  a  lens  will  usually  disclose  some  of  the  char- 
acteristic burrows,  or  even  the  acarus.  In  infancy,  scabies  may  be  easily 
confounded  with  the  vesicular  form  of  urticaria,  unless  the  development 
of  the  lesions  has  been  observed. 

Scabies  may  always  be  cured,  provided  sufficient  precautions  are  taken 
to  prevent  reinfection.  This  necessitates  boiling  or  baking,  not  only  the 
patient's  clothes,  but  all  the  bedding  as  well. 

Treatment. — This  should  always  be  begun  by  a  hot  bath,  in  order  to 
soften  the  epithelial  scales  about  the  burrows.  The  body  should  be  thor- 
oughly scrubbed  with  soap  and  water,  preferably  with  a  nail-brush,  the 
bath  being  continued  for  at  least  half  an  hour.  It  is  well  to  do  this  at 
night.  After  the  bath,  the  body  is  anointed  with  the  parasiticide,  which 
should  be  thoroughly  rubbed  into  the  skin,  clean  clothing  applied,  and 
the  child  put  into  a  perfectly  clean  bed.  In  the  morning  the  ointment 
may  be  washed  off,  but  none  of  the  clothing  previously  worn  should  be 
put  on.  This  treatment  is  to  be  repeated  on  two  or  three  successive 
nights,  and  if  thoroughly  done  it  will  effect  a  cure.  The  ordinary  sul- 
phur ointment  is  too  irritating  for  use  in  little  children,  and  one  of  the 
following  may  be  substituted:  Naphthol,  15  parts;  creta  preparata,  10 
parts;  vaseline,  100  parts  (Kaposi);  or,  precipitated  sulphur,  1  part; 
balsam  of  Peru,  1  part ;  vaseline,  8  parts ;  or  the  simple  balsam  of  Peru 
may  be  applied  without  dilution.  After  the  use  of  the  parasiticide  there 
is  generally  required,  for  a  few  days,  some  soothing  application  like  those 
mentioned  in  the  chapter  upon  Eczema. 


TINEA  TONSURANS— RING-WORM   OF  THE   SCALP.  893 

TINEA  TONSURANS— RING-WORM   OF  THE  SCALP. 

Ring-worm  of  the  scalp  is  a  very  frequent  disease  in  institutions  for 
children,  often  occurring  as  an  epidemic.  According  to  Crocker,  the 
primary  lesion  consists  in  a  red  papule  surrounding  a  hair,  which  soon 
increases  to  a  small  circular  patch;  this  spreads  at  its  outer  margin, 
gradually  increasing  in  size  until  it  is  from  one  to  two  inches  in  diameter, 
but  rarely  larger  than  this.  Sometimes  several  of  the  patches  coalesce. 
These  affected  areas  always  have  rounded  borders,  and  are  sharply  out- 
lined. Here  the  hairs  are  very  brittle,  and  often  broken  off  close  to  the 
scalp,  so  that  the  area  may  appear  to  be  bald.  Where  they  have  not  fallen 
off,  the  hairs  liave  lost  their  lustre.  The  stumps  of  the  broken  hairs  point 
in  all  directions. 

The  fungus  which  produces  the  disease  is  the  trichophyton  tonsurans. 
It  penetrates  the  shaft  of  the  hair,  both  the  spores  and  the  mycelium 
being  seen  under  the  microscope.  The  spores  are  present  in  great  num- 
bers in  the  hair,  but  the  mycelium  is  most  abundant  in  the  scales.  The 
amount  of  inflammation  found  in  the  diseased  areas  varies  much  in  the 
different  cases.  There  may  be  only  a  scaliness  of  the  scalp,  or  a  forma- 
tion of  pustules  in  the  hair  follicles,  the  hairs  loosening  and  falling  out 
in  consequence.  In  young  infants,  where  the  hair  is  scanty  and  thin,  the 
disease  resembles  tinea  circinata — i.  e.,  it  is  superficial,  and  the  hair  fol- 
licles are  often  not  involved.  Children  of  all  ages  are  liable  to  tinea 
tonsurans.  It  flourishes  particularly  in  institutions  and  in  those  children 
who  are  dirty  and  poorly  cared  for. 

The  diagnostic  feature  of  the  disease  is  the  presence  of  scaly  patches, 
with  loss  of  hair.  The  patches  are  usually  circular,  and  by  examination, 
with  a  lens  the  stumps  of  broken  hairs  are  seen  all  over  the  diseased 
area.  By  a  microocopical  examination  the  fungus  is  -discovered.  In 
typical  cases  the  diagnosis  is  easy  if  the  process  is  at  all  advanced,  but 
there  are  many  atypical  forms  and  many  mild  cases  where  the  recogni- 
tion of  the  disease  is  difficult.  The  symptoms  are  often  masked  by  the 
inflammatory  conditions  present.  The  disease  may  be  confounded  with 
seborrhcea;  but  in  the  latter  the  lesion  is  diffuse,  never  sharply  defined; 
there  is  general  thinning  of  hair  over  the  scalp,  and  never  the  stumpy, 
broken  hairs.  Psoriasis  has  points  of  resemblance,  but  it  is  usually  found 
on  other  parts  of  the  body,  especially  the  knees  and  elbows,  and  upon  the 
scalp  the  patches  are  more  numerous  and  smaller.  In  eczema  the  loss  of 
hair  in  circumscribed  patches  is  never  seen,  nor  are  the  broken  stumps. 

Tinea  tonsurans  is  always  curable,  provided  the  patient  can  be  kept 
under  close  surveillance,  and  treatment  thoroughly  carried  out.  There  is 
no  tendency  to  spontaneous  recovery.  In  a  recent  case,  treatment  must 
usually  be  continued  for  one  or  two  months,  and  in  chronic  cases  from 
six  months  to  one  year,  with  the  closest  watchfulness. 


894  DISEASES  OF  THE  SKIN. 

Treatment. — The  great  difficulty  in  treatment  is  to  get  the  parasiticide 
deeply  enough  into  the  scalp  to  reach  the  fungus,  since  this  is  often  at 
the  very  bottom  of  the  hair  follicles.  As  a  first  step,  the  hair  should  be 
cut  short  all  over  the  patch  and  for  at  least  an  inch  beyond  it;  this  is 
necessary  in  order  to  get  at  the  diseased  part  and  to  detect  new  foci  of 
infection  early — if  possible  before  the  fungus  has  extended  deeply  into 
the  follicles.  The  parasiticide  should  be  applied  not  only  upon  but 
around  the  patch,  and  the  entire  scalp  should  be  washed  thoroughly  two 
or  three  times  a  week.  To  prevent  the  disease  spreading,  all  the  scales 
are  to  be  kept  softened  by  the  use  of  carbolic  soap.  The  hair  should  not 
be  brushed,  as  this  tends  to  scatter  the  spores  and  spread  the  disease. 
All  patients,  while  under  treatment,  should  wear  a  cap  of  muslin  or  oiled 
silk,  or  one  lined  with  paper,  in  order  to  prevent  infecting  others.  In 
institutions,  affected  children  should  invariably  be  isolated. 

To  destroy  the  fungus  almost  every  germicide  on  the  list  has  been 
advocated  at  one  time  or  another,  which  proves  that  the  disease  is  a  very 
obstinate  one,  and  that  no  one  application  is  invariably  successful. 
Those  which  have  the  sanction  of  the  widest  use  are  the  tincture  of  iodine, 
the  bichloride,  white  precipitate,  and  oleate  of  mercury,  kerosene,  creo- 
sote, and  croton  oil.  As  a  vehicle  for  ointments,  adeps  lanae  (lanoline) 
is  greatly  to  be  preferred  to  vaseline  or  lard.  Most  of  the  germicides 
mentioned  are  used  in  the  strength  of  one  to  five  per  cent,  according  to 
the  age  of  the  child  and  the  irritability  of  the  scalp.  In  an  epidemic 
of  ring-worm  in  the  New  York  Infant  Asylum  the  following  combination 
of  bichloride  and  kerosene  proved  extremely  satisfactory :  ten  grains  of 
the  bichloride  were  dissolved  in  alcohol,  and  to  this  were  added  two  and 
a  half  ounces  each  of  olive  oil  and  kerosene.  * 

Epilation  is  necessary  in  many  cases  as  an  accessory  to  the  application 
of  germicides,  particularly  in  older  children. 


CHAPTEE   VI. 

DISEASES  OF  THE  EAR. 
ACUTE  OTITIS. 

Otitis  is  a  frequent  affection  during  infancy  and  early  childhood, 
attacks  usually  occurring  in  the  cold  season.  Of  all  the  inflammatory 
conditions  which  may  be  met  with  in  early  life,  there  is  perhaps  none 
which  more  frequently  gives  rise  to  obscure  febrile  symptoms  than  this. 

Etiology. — Acute  otitis  is,  as  a  rule,  a  secondary  disease,  and  is  gen- 
erally preceded  by  some  infectious  process  in  the  rhino-pharynx.  The 
usual  avenue  of  infection  is  through  the  Eustachian  tube. 

The  most  severe  forms  of  otitis  usually  follow  scarlet  fever,  epidemic 


ACUTE  OTITIS.  895 

influenza,  measles,  diphtheria,  or  pneumonia.  The  entrance  of  fluids 
through  the  Eustachian  tube  from  the  nasal  douche  or  nasal  syringing 
may  cause  acute  otitis.  It  sometimes  results  as  an  extension  of  inflam- 
mation from  meningitis,  especially  the  cerebro-spinal  form. 

The  micro-organisms  concerned  in  the  production  of  acute  otitis 
vary  somewhat  with  the  condition  of  which  it  is  a  complication.  In  the 
order  of  frequency  there  are  found  the  staphylococcus  aureus,  the  pneu- 
mococcus,  the  streptococcus,  and  the  influenza  bacillus.  Mixed  infections 
are  very  common.  In  cases  complicating  diphtheria,  the  Klebs-Loeffler 
bacillus  may  be  found  with  any  of  the  forms  mentioned,  or  may  occur 
alone.  In  chronic  cases  any  of  the  pyogenic  organisms  may  be  present, 
and  not  very  infrequently  the  tubercle  bacillus. 

Lesions. — The  ordinary  course  of  events  in  the  pathological  process  is, 
first,  acute  hyperaemia  and  swelling  of  the  mucous  membrane  of  the  rhino- 
pharynx,  which  extends  into  the  Eustachian  tube,  causing  obstruction 
more  or  less  complete.  The  inflammatory  process  may  be  limited  to  the 
tube,  or  it  may  extend  to  the  mucous  membrane  lining  tlie  middle  ear. 

There  are  two  varieties  of  acute  inflammation  of  the  middle  ear :  ( 1 ) 
The  catarrhal  form,  which  usually  accompanies  simple  catarrh  of  the 
rhino-pharynx  or  complicates  measles.  This  is  an  inflammation  of  the 
mucous  membrane  merely,  and  its  products  are  serum  and  mucus  or 
muco-pus.  It  is  not  usually  accompanied  by  great  pain  or  followed  by 
serious  consequences.  It  is  generally  confined  to  the  lower  part  of  the 
tympanic  cavity,  and  is  the  form  most  frequently  seen  in  infants.  (2) 
The  purulent  or  phlegmonous  form,  which  affects  older  children  prin- 
cipally. This  is  a  much  more  serious  infiammation,  and  is  often  ex- 
cited by  the  infectious  catarrh  of  scarlet  fever,  diphtheria,  or  epidemic 
infiuenza.  In  this  variety  micro-organisms  find  their  way  into  the  mid- 
dle ear  in  great  numbers,  and  set  up  an  infiammation  of  a  more  or  less 
virulent  type,  which  may  involve  not  only  the  mucous  membrane  lining 
the  tympanum,  but  also  the  cellular  tissue  in  the  upper  part  of  the  tym- 
panic cavity.  The  lining  membrane  of  the  mastoid  cells  is  involved 
in  many,  if  not  all,  of  the  cases. 

The  catarrhal  form  of  inflammation  frequently  subsides  in  a  few 
days  with  proper  treatment,  the  only  result  being  a  slight  deafness, 
which  is  temporary.  The  phlegmonous  form  causes  a  stoppage  of  the 
Eustachian  tube,  rupture  or  sloughing  of  the  tympanic  membrane,  and 
discharge  of  the  products  of  inflammation,  or  rarely  pus  finds  an  outlet 
by  burrowing  between  the  cartilages.  The  inflammatory  process  may 
extend  to  the  bones,  causing  necrosis  of  the  ossicles  or  the  bony  walls  of 
the  tympanum.  The  remote  results  are  periostitis  and  necrosis  of  the 
petrous  bone,  pachymeningitis,  infectious  thrombosis  of  the  lateral 
sinus,  general  purulent  meningitis,  and  cerebral  abscess.  These  will  be 
considered  under  Complications. 


896 


DISKVSES  OF  THE  EAR. 


Symptoms. — These  are  usually  few  in  number,  but  present  great  varia- 
bility as  regards  their  combination  and  intensity.  The  two  most  con- 
stant symptoms  are  pain  and  fever.  In  a  typical  case  in  an  infant,  there 
is  generally  at  the  beginning  some  discharge  from  the  nose,  slight  con- 
gestion of  the  phar^TLs  and  tonsils,  and  a  temperature  of  100°  to  103°  F. 
There  is  nothing  characteristic  about  this  catarrh.  After  two  or  three 
days  the  objective  sjTnptoms  subside,  but  the  infant  continues  to  be  rest- 
less, worries  much  of  the  time,  wakes  frequently  at  night  with  a  start, 
nurses  poorly,  and  the  temperature  remains  elevated,  usually  from  100° 
to  103°  F.  (Fig.  178).  The  infant  seems  decidedly  ill,  and  yet  no  very 
definite  symptoms  are  present.  Sometimes  there  is  marked  tenderness 
about  the  ear,  and  the  child  refuses  to  lie  upon  the  affected  side,  or  shows 
signs  of  pain  when  the  ear  is  touched.  After  a  week  or  ten  days  spon- 
taneous rupture  of  the  drum  membrane  takes  place,  and  subsidence  of  the 
constitutional  symptoms  follows.  In  some  cases  there  is  seen  only  a  high 
temperature,  ranging  from  101°  to  104°  F.,  which  persists  for  several 


nay 
Hour 

1              2 

3 

1 

5 

6 

7             S 

'J 

10 

11 

12 

13 

It. 

1 

1  i 

105 

101 
103 

-InfI:.eJ 

PJirtit-E 

iT'-Dr.iiuj 

l-liieiseJ 

/ 

i 

f 

\      J. 

1 

I 

V  v'X 

loa 

101 

n 

^— 

— \ 

Hi 

i 

r~^ 

sff-tlr-1 

Jni;,i-£.i 

^ 

i- 

E 

100° 

i= 

—— 

B^ 

rw 

iH^ 

-r+t- 

-j — i- 

-I  yy — ^ — — 

■  :    f 

'     ! 

^ 

T7~ 

RFp- 

\:r/__ 

I— A 

m 

99 

[_J_ 

1     1 

Vl 

Sp 

A_7_ 

\^ 

\1P 

11^ 

/ 

V 

— V — 

^^ 

'"'^ 

98 

;    : 

-^ 

.* 

: 

— f 

1     —  i  1 

1  1  ■■ 

-^ 

1    '    1 

1  i 

1  ;  [ 

-trr 

i  \  1 

,  1  1 

1  1  i 

\  i  i 

.'II 

ill     III 

\  \  1 

1     1     1 

.,1  i.  1 

1  i  i 

!  1  1 

1  1  1 

1  1  1 

1.11 

,.  i  I 

i  i  1 

Fk.  178. — TiafPEKATtmB  Chabt  of  Acute  Onn.s  Followhto  IioxirEWZA,  in  a  Cniuj 

Thbee  Yeabs  Old. 


days  without  outward  evidences  of  pain  or  other  signs  of  inflammation, 
and  the  discharge  is  the  first  sjrmptom  which  leads  the  physician  to  sus- 
pect disease  of  the  ear.  In  other  cases  there  is  marked  dulness,  apathy, 
anorexia,  and  sometimes  nausea  and  vomiting,  but  for  several  days 
no  evidence  of  pain;  the  temperature  may  be  but  little  elevated. 
Thus,  in  most  of  the  attacks  seen  in  infancy,  pain  is  not  very  marked, 
and  it  is  this  which  so  often  leads  to  the  great  obscurity  of  the 
sjTnptoms. 

In  older  children  the  symptoms  are  more  characteristic.  Pain  is 
usually  sharp  and  severe,  and  is  complained  of  early  in  the  attack.  The 
temperature  is  nearly  always  elevated  two  or  three  degrees,  and  occa- 


ACUTE  OTITIS. 


897 


Da; 

Hour 

I 

2 

3 

1 

5 

6      1 

1    1    i 

1    1    1 

!  1  1 

1    1    i 

10J° 
lOt^ 
103° 
102° 
101° 
100° 
99° 

h-E. 

r-fli;u 

_1 

. '• 

'     /    1       '       '       ' 

1    1 

^ 

/    1 

~f~ 

- 

Z 

— 

I 

I 

z 

~~ 

)' 

\ 

~^^r 

^ 

I 

- 

= 

~ 

- 

z 

I 

J 



- 

t 

\ 

1 

1 

, 

_ 

S 

. 

^— 1 

— r— 

— — 

-^ 

- 

^ 

y 

- 

98 

: 

_L 

.,,11 

I  1  1 

„ 

. 

sionally  it  is  103°  or  104°  F.  (Fig.  179),  with  severe  headache,  extreme 
restlessness,  and  even  delirium  or  convulsions,  so  that  meningitis  may  be 
suspected. 

The  inflammation  does  not  neces- 
sarily go  on  to  suppuration  and  rup- 
ture. There  are  even  more  frequently 
seen,  accompanying  ordinary  head-colds 
or  mild  attacks  of  influenza,  cases  in 
which  the  pain  is  quite  severe  for 
twenty-four  or  thirt3'-six  liours,  and 
accompanied  even  by  a  moderate  ele- 
vation of  temperature,  and  yet  which 
rapidly  subside  without  further  symp- 
toms. 

In  infants  suffering  from  malnutri- 
tion or  marasmus,  otitis  often  comes 
on  without  any  objective  symptoms, 
the  first  thing  noticed  being  the  dis- 
charge. 

Of  all  the  symptoms,  fever  is  the 
most  constant,  and  is  present  in  all 
cases  except  those  just  mentioned.  Tlie 
usual  range  of  temperature  is  from 
100°  to  102°  F.;  exceptionally  it  may 
be  from  103°  to  105°  F.  The  course 
of  the  temperature  is  irregular.  After  spontaneous  rupture  or  in- 
cision of  the  drum  membrane  the  temperature  usually  falls,  but 
often  not  immediately.  Pain  is  more  marked  in  older  children  than  in 
infants — first,  because  in  the  latter  the  drum  membrane  is  not  so  firm, 
yields  more  readily,  and  ruptures  earlier;  and,  secondly,  because  the  in- 
flammation is  usually  of  the  catarrhal  and  not  the  phlegmonous  type. 
Tenderness  is  sometimes  elicited  by  pressure,  especially  just  in  front  of 
the  external  auditory  meatus ;  there  may  be  increased  sensitiveness  of  all 
parts  of  the  ear  and  even  of  the  whole  side  of  the  head ;  but  no  reliance 
should  be  placed  upon  the  absence  of  such  symptoms  in  excluding  otitis. 
Children  often  complain  of  noises  in  the  ear.  Cerebral  symptoms  are  in- 
frequent, and  occur  chiefly  in  cases  not  receiving  proper  early  treatment ; 
they  may  indicate  meningeal  congestion,  or,  less  frequently,  localised 
meningitis  or  thrombosis. 

In  secondary  otitis,  especially  when  complicating  severe  scarlet  fever, 
diphtheria,  measles,  or  typhoid  fever,  all  subjective  symptoms  are  fre- 
quently wanting;  unless  the  ears  are  examined  the  disease  may  be  over- 
looked until  rupture  has  taken  place. 

The  local  appearances  in  the  early  stage  are  marked  redness  and  con- 
58 


Fig.  179. — Temperatttre  Chart  op 
Acute  Otitis  Aborted  by  Early 
Paracentesis.  Boy  nine  years  old; 
attack  followed  a  mild  catarrh;  se- 
vere pain  in  both  ears  began  in  after- 
noon of  second  day.  Both  drum 
membranes  found  acutely  congested 
and  bulging;  incision  followed  by 
free  haemorrhage  and  immediate  re- 
lief of  pain.  No  suppuration  oc- 
curred; patient  well  on  fifth  day. 


898  DISEASES  OF  THE  EAR. 

gestion;  later  there  is  distinct  bulging.  If  perforation  has.  taken  place, 
its  site  may  or  may  not  be  visible,  but  its  existence  may  be  assumed  if 
bubbles  of  air  are  seen  deep  in  the  canal,  and  if  much  mucus  or  pus  is 
present,  as  inflammation  of  the  external  canal  seldom  causes  a  discharge. 
The  pus  sometimes  burrows  between  the  cartilages  and  escapes  externally 
behind  or\at  the  side  of  the  ear.  In  the  catarrhal  form  the  discharge  is 
at  first  sero-mucus  and  quite  profuse ;  later  it  is  purulent.  In  the  phleg- 
monous form  it  is  always  purulent,  and  liable  to  a  sudden  arrest  with 
an  increase  in  the  constitutional  symptoms. 

Diagnosis. — Otitis  in  infancy  is  frequently  obscure,  because  tlie  pa- 
tient is  too  young  to  direct  attention  to  the  seat  of  pain,  or  because  the 
pain  is  slight  or  absent.  The  temperature  is  almost  invariably  elevated, 
and  the  usual  problem  presented  is  to  discover  a  cause  for  this  fever. 
The  examination  of  the  ears  with  a  speculum  should  be  done  as  a  matter 
of  routine  in  all  children  with  fever,  especially  those  in  whom  the  cause 
of  the  fever  is  not  perfectly  clear.  Otherwise  many  cases  will  be  over- 
looked. A.  leucocytosis  of  15,000  to  20,000  is  almost  invariably  found. 
Local  t(  derness,  deafness,  or  noises  in  the  ears  are  significant  when 
present,  but  are  often  wanting.  Otitis  is  so  common  a  cause  of  high 
temperature  in  infants  during  the  cold  season,  that  one  should  always 
have  it  in  mind. 

Complications  and  Sequelae. — Eemote  consequences  are  most  likely 
to  be  seen  in  cases  following  scarlet  fever,  probably  because  of  their 
severity,  particularly  when  early  treatment  has  been  neglected. 

Mastoiditis. — This  is  the  most  frequent  complication  of  acute  otitis. 
In  infancy  the  mastoid  process  is  small  and  contains  but  a  single  cavity, 
the  mastoid  antrum,  which  communicates  directly  with  the  vault  of  the 
tympanum.  It  is  probable  that  in  every  severe  case  of  acute  suppurative 
otitis  there  is  some  pus  in  the  antrum.  This  is  usually  discharged  into 
the  middle  ear  after  the  tympanic  membrane  is  incised  or  ruptures  spon- 
taneously. The  principal  cause  of  mastoid  involvement  is  want  of  proper 
early  treatment  in  acute  otitis,  particularly  the  practice  of  allowing  these 
cases  to  take  their  natural  course  instead  of  securing  early  drainage  by 
incision  of  the  drum  membrane. 

The  important  symptoms  of  acute  mastoiditis  are  fever,  mastoid  ten- 
derness, and  swelling.  If  mastoiditis  develops  rapidly  after  acute  otitis 
the  temperature  may  be  high — 103°  to  105°  F.,  and  the  leucocytosis  is 
somewhat  greater;  if  it  develops  gradually  and  appears  late  the  tem- 
perature may  be  scarcely  above  100°  F.  Abrupt  cessation  of  an  ear  dis- 
charge should  always  arouse  suspicion.  It  is  always  difficult  to  de- 
termine the  presence  of  a  slight  amount  of  mastoid  tenderness,  but 
persistent  tenderness  of  one  side  only  is  significant.  It  is  often  most 
marked  close  behind  the  auricle  just  over  the  antrum.  The  early  swell- 
ing is  due  to  oedema ;  later  there  may  be  an  accumulation  of  pus.    Post- 


ACUTE  OTITIS.  899 

auricular  abscess  causes  a  very  cliaracteristic  swelling,  the  ear  standing 
out  from  the  head.  It  is  usually  due  to  spontaneous  rupture  through 
the  outer  bony  wall  just  over  the  antrum ;  it  may  occur  where  there  has 
been  no  discharge  from  the  ear.  It  is  a  frequent  result  of  severe  cases 
of  acute  mastoiditis  not  operated  upon,  especially  in  young  children. 

The  characteristic  otoscopic  appearances  of  acute  mastoiditis  are: 
bulging  of  Shrapnell's  membrane  and  drooping  of  the  upper  posterior 
wall  of  the  external  auditory  canal. 

Meningitis.-j-T his  is  very  rare  in  infants,  but  is  more  common  in 
older  children.  There  may  be  a  localised  pachymeningitis  with  the  for- 
mation of  pus — an  epidural  abscess — or,  less  frequently,  general  purulent 
meningitis.  It  may  be  secondary  to  other  lesions,  such  as  thrombosis  of 
the  lateral  sinus,  or  the  rupture  of  a  cerebral  abscess,  but  is  usually  due 
to  infection  through  the  roof  of  the  tympanum,  or  along  the  internal 
auditory  meatus.  Meningitis  may  occur  either  with  acute  or  chronic 
cases.  Its  symptoms  are  those  of  a  severe  acute  meningitis ;  its  duration 
is  short;  its  termination  almost  invariably  in  death. 

Cerebral  Abscess. — This  is  due  to  a  direct  extension  of  the  infection 
from  the  bone,  veins,  or  dura  mater.  In  about  two-thirds  of  the  cases 
the  abscess  is  in  the  temporo-sphenoidal  lobe.  The  next  most  frequent 
seat  is  the  lateral  lobe  of  the  cerebellum.  Korner  states  that  disease  of 
the  mastoid  and  middle  ear  leads  to  cerebral  abscess,  and  disease  of  the 
labyrinth  to  cerebellar  abscess.  Abscesses  may  be  complicated  by  throm- 
bosis or  by  meningitis.  They  are  often  latent  until  just  before  death, 
which  more  frequently  occurs  from  the  development  of  purulent  menin- 
gitis than  from  any  other  cause.  They  are  rare  except  in  otitis  of  long 
standing. 

Thrombosis  of  the  lateral  sinus  may  be  simple  or  septic.  In  the 
former  there  is  occlusion  of  the  vessel  by  a  fibrinous  clot;  in  the  latter 
there  are  in  addition,  micro-organisms. 

Simple  thrombosis  causes  no  important  symptoms.  Septic  throm- 
bosis is  relatively  infrequent  and  causes  very  marked  and  severe  symp- 
toms. It  follows  operation  upon  the  mastoid,  or  occurs  as  a  complication 
of  mastoiditis  quite  apart  from  operation.  The  temperature  is  usually 
of  a  high  and  widely  fluctuating  type,  and  there  may  also  be  chills.  In 
some  cases  the  constitutional  symptoms,  except  fever,  may  not  at  first  be 
severe,  but  may  suddenly  become  very  grave.  Marked  cerebral  symptoms 
often  develop  rapidly,  and  death  may  follow  in  from  twelve  to  twenty- 
four  hours.  At  autopsy  there  may  be  ^ound  a  soft  broken-down  clot  in 
the  sinus,  which  may  extend  into  the  jugular.  It  may  be  followed  by 
secondary  lesions  of  a  general  pyaemia,  or  by  localised  or  general  menin- 
gitis.    Blood  cultures  usually  give  positive  information. 

The  labyrinth  is  infrequently  involved,  although  cases  are  recorded 
by  Pye,  Phillips,  and  others,  in  which  the  necrosis  and  discharge  of  the 


900  DISEASES  OF  THE  EAR. 

entire  labyrinth  has  occurred  after  scarlet  fever.  In  most  of  these  cases 
the  deafness  was  complete,  and  in  several  vertigo  was  present. 

Facial  paralysis  rarely  occurs  in  the  acute  cases,  but  accompanies  a 
considerable  proportion  of  the  chronic  ones.  It  is  especially  seen  in  the 
tuberculous  variety.  It  is  due  to  an  extension  of  the  inflammatory  proc- 
ess from  the  bone  to  the  seventh  nerve,  where  it  passes  through  the  canal. 
The  symptoms  are  those  of  ordinary  peripheral  facial  palsy. 

Treatment. — Something  may  be  done  in  the  way  of  prophylaxis.  It 
is  of  the  first  importance  to  secure  a  normal  condition  of  the  mucous 
membrane  of  the  naso-pharynx  by  the  removal  of  enlarged  tonsils,  ade- 
noids, etc.  The  occasional  attacks  of  earache  accompanying  these  con- 
ditions are  pretty  sure  to  be  followed  by  more  serious  trouble  unless  they 
are  relieved.  Whether  during  attacks  of  measles  or  scarlet  fever,  much 
can  be  done  to  prevent  otitis,  is  still  a  mooted  question.  Personally  I 
believe  the  risks  of  infection  of  the  middle  ear  when  judicious  nasal 
syringing  is  employed  are  less  than  when  nothing  is  done  to  cleanse 
the  rhino-pharynx. 

The  medical  treatment  of  acute  otitis  aims  at  the  relief  of  pain  and 
arrest  of  the  inflammation.  If  the  case  is  seen  in  the  early  stage  the 
introduction  of  a  few  drops  of  a  solution  of  adrenalin  into  the  nostrils 
and  ears  and  repeated  every  two  or  three  hours,  will  sometimes  abort 
an  attack.  This  may  be  aided  by  free  catharsis  and  the  application  of 
dry  heat  or  frequent  syringing  of  the  ears  with  a  saline  solution  as  hot 
as  can  be  borne.  Neither  oil  nor  laudanum  should  be  dropped  into  the 
ear  as  is  so  often  done  in  domestic  practice;  but  there  is  no  objection 
to  a  few  drops  of  a  four-per-cent  solution  of  cocaine,  or  a  five-per-cent 
solution  of  carbolic  acid,  either  of  which  may  relieve  intense  pain.  If 
the  child  is  not  soon  comfortable,  an  opiate  should  be  given  which  may 
not  only  relieve  pain,  but  may  have  a  favourable  influence  upon  the  in- 
flammation. 

A  continuance  of  pain  in  spite  of  these  measures,  with  an  increas- 
ing temperature,  calls  for  operative  interference.  But  a  more  reliable 
guide  is  the  appearance  of  the  drum  membrane.  If  in  addition  to  these 
symptoms  there  is  mastoid  tenderness  immediate  paracentesis  of  the 
drum  membrane  is  imperative.  An  early  incision  is  usually  followed  by 
a  discharge  of  blood  only;  but  tension  is  relieved,  pain  disappears,  and 
the  inflammation  often  quickly  subsides  without  the  formation  of  pus. 
(See  Fig.  179.)  Much  suffering  is  thereby  avoided;  the  wound  rapidly 
heals,  and  much  less  damage  is  dofte  than  by  allowing  .the  disease  to  go  on 
to  a  spontaneous  rupture.  Later  incision  may  be  required  either  for  the 
relief  of  pain  or  for  the  evacuation  of  pus  to  prevent,  if  possible,  the  dis- 
•ease  from  spreading  to  the  bony  parts.  The  advantages  of  early  paracen- 
tesis in  acute  otitis  can  hardly  be  overstated.  Properly  performed,  it  is 
free  from  risk,  causes  little  or  no  shock,  and  should  be  advised  in  many 


ACUTE   OTITIS.  901 

cases  even  in  which  the  indications  are  not  so  clear  as  those  above  described. 
I  favor  incising  the  drum  membrane  in  cases  of  doul)t  rather  than  wait- 
ing for  more  definite  indications  with  the  attendant  risks  of  delay. 

In  the  secondary  otitis  of  scarlet  fever,  measles,  and  diphtheria,  the 
indications  for  paracentesis  are  usually  to  be  derived  from  the  appear- 
ance of  the  drum  membrane  alone,  other  symptoms  being  absent  or 
masked  by  the  primary  disease. 

After  incision  or  spontaneous  rupture  of  the  drum  membrane  the 
ear  should  be  syringed  every  two  or  three  hours  with  a  warm  solution 
of  bichloride  (1  to  10,000),  or  a  saturated  solution  of  boric  acid,  or 
simply  with  a  sterile  salt  solution.  A  bulb  ear-syringe  of  soft  rubber 
or  a  fountain  syringe  may  be  used. 

In  most  cases  the  discharge  ceases  in  from  one  to  three  weeks ;  should 
it  continue  longer,  some  measures  for  checking  it  may  be  used.  The  use 
of  a  few  drops  of  a  1  to  3,000  solution  of  bichloride  in  sixty-five  per 
cent  alcohol  after  syringing  is  of  some  value.  It  should  be  used  with 
a  medicine  dropper.  When  the  discharge  has  become  foetid,  syringing 
once  a  day  with  a  solution  of  peroxide  of  hydrogen  (1  to  2)  is  often 
useful.  A  persistent  discharge  often  depends  upon  the  fact  that  the 
child's  general  condition  is  poor,  and  improvement  in  this  is  more  im- 
portant than  any  variation  in  local  treatment. 

When  symptoms  pointing  to  acute  mastoiditis  are  present,  early 
free  incision  of  the  drum  membrane  is  indicated,  and  a  mastoid  ice- 
bag  should  be  applied  continuously  for  thirty-six  or  forty-eight  hours.  In 
addition,  in  older  children,  the  artificial  leech  may  be  placed  over  the 
antrum  or  the  mastoid  tip.  With  these  measures  the  inflammation  often 
subsides.  Regarding  operation  upon  the  mastoid,  my  own  belief  is  that 
it  is  now  performed  too  frequently  and  with  insufficient  indications, 
especially  in  infancy  and  early  childhood.  The  operation  is  a  serious 
one,  and  at  this  age  its  immediate  risks  are  considerable.  I  have  per- 
sonally known  of  a  number  of  deaths  directly  connected  with  it,  and  of 
others  occurring  at  a  later  period,  whei-e  the  child  was  worn  out  by  the 
long  after-treatment,  dying  perhaps  from  some  intercurrent  disease  or 
from  exhaustion.  On  the  other  hand,  the  dangers  to  which  patients  are 
exposed  who  are  not  operated  upon  have,  I  think,  been  greatly  exag- 
gerated. In  my  own  experience,  meningitis,  sinus  thrombosis,  and 
cerebral  abscess  do  not  occur  in  anything  like  the  proportion  of  cases 
that  the  surgeons  would  have  us  believe.^ 

While  I  fillly  appreciate  the  value  of  the  operation,  and  am  quite 
sure  that  lives  are  often  saved  by  its  timely  performance,  I  would  in- 

*  The  records  of  the  New  York  Foundling  Hospital,  with  a  resident  population  of 
about  800  infants  and  young  children,  showed  573  cases  of  acute  otitis  in  five  years 
(1900  to  1904  inclusive).  During  this  period  there  were  three  extensive  epidemics  of 
measles  with  a  total  of  1,034  cases;  166  cases  of  scarlet  fever;  578  cases  of  diphtheria; 


902  DISEASES  OF  THE  EAR. 

sist  that  it  be  done  only  with  very  positive  and  clear  indications.  In 
infants,  localised  tenderness  is  difficult  to  determine;  and  fever  after 
acute  otitis  may  be  due  to  many  other  conditions.  In  very  young  pa- 
tients we  should  therefore  insist  upon  other  symptoms  before  deciding 
to  operate.  The  risks  of  waiting  for  clearer  indications  are,  I  believe, 
much  less  than  those  attendant  on  unnecessary  operation.  Often  the 
cause  of  the  temperature  is  found  in  the  lungs ;  and  not  very  infrequently 
a  moderate  pulmonary  congestion  or  bronchitis  becomes  a  pneumonia 
as  a  consequence  of  the  prolonged  anaesthesia  necessary  for  the  operation. 
With  infants  therefore  in  case  of  any  doubt,  as  to  diagnosis  or  the 
progress  of  the  case,  one  should  invariably  decide  against  operation,  or 
at  least  for  postponement.  With  older  children,  however,  conditions 
are  somewhat  different;  diagnosis  is  easier  and  the  operative  risk  much 
less. 

The  treatment  of  chronic  otitis  and  of  the  associated  conditions  is 
largely  surgical,  and  belongs  to  the  specialist;  but  it  is  extremely  im- 
portant that  the  general  practitioner  should  be  familiar  with  their  symp- 
toms, and  realise  the  danger  from  these  neglected  cases,  not  only  to  the 
function  of  hearing,  but  also  to  life  itself.  The  essential  thing  in  treat- 
ment is  that  the  operation  should  be  thorough  enough  to  secure  free 
drainage,  and  to  permit  thorough  cleansing  of  the  parts.  Too  much 
can  not  be  said  against  the  expectant  treatment  of  these  cases,  or  against 
the  practice  of  prolonged  poulticing. 

and  1,505  cases  of  pneumonia.  With  the  573  cases  of  otitis,  acute  mastoiditis  was 
recognised  and  recorded  in  but  17  patients.  It  is  not  improbable  that  other  mastoid 
inflammations  were  overlooked.  In  this  institution,  however,  nearly  every  fatal  case 
comes  to  autopsy,  and  if  an  unrecogmsed  mastoiditis  had  led  to  a  fatal  result  the 
autopsy  records  should  show  it.  In  the  five-year  period,  900  autopsies  were  made. 
There  was  no  instance  recorded  of  abscess  of  the  brain  following  otitis.  There  were 
but  two  examples  of  acute  meningitis  following  otitis  with  mastoiditis;  but  there  were 
14  cases  of  acute  meningitis  secondary  to  other  conditions — pneumonia,  10;  to  peri- 
carditis, 2;  to  empyema,  1;  to  diphtheria,  1.  During  the  p>eriod  mentioned  there 
were  11  mastoid  operations  performed  in  the  hospital,  with  6  recoveries  and  5  deaths, 
all  from  causes  directly  connected  with  the  operation. 

If  mastoiditis  follows  otitis,  complicating  the  acute  infectious  diseases  of  early 
childhood  as  often  as  has  been  claimed,  we  must  admit  that  a  very  large  proportion 
of  the  patients  may  get  well  without  operation. 


SECTION   IX. 
THE  SPECIFIC  INFECTIOUS  DISEASES. 

Accurate  classification  of  the  infectious  diseases  is  at  the  present 
time  impossible,  but  there  are  two  quite  distinct  groups  into  which,  with 
one  or  two  exceptions,  those  here  considered  may  be  placed. 

The  first  group  includes  scarlet  fever,  measles,  rubella,  and  varicella. 
The  nature  of  the  specific  poison  in  each  of  these  is  as  yet  unknown. 
They  are,  strictly  speaking,  contagious;  for  it  is  practically  certain  that 
any  of  them  may  be  contracted  by  proximity  to  a  person  suffering  from 
the  disease,  without  actual  contact.  In  no  one  of  these  diseases  is  the 
poison  given  off  in  a  single  definite  discharge,  and  in  no  one  is  there  a 
characteristic  visceral  lesion.  These  peculiarities,  together  with  the  fact 
that  thus  far  the  poison  of  each  of  these  diseases  has  resisted  all  attempts 
at  isolation,  render  it  not  improbable  that  the  exciting  cause  in  each  is 
some  other  variety  of  micro-organism  rather  than  a  bacterium. 

In  the  second  grou'p  may  be  placed  diphtheria,  pertussis,  influenza, 
tj^hoid  fever,  and  tuberculosis,  in  each  of  which  the  specific  poison  is  a 
known  form  of  bacterium.  Each  of  these  diseases,  except  pertussis  and 
influenza,  is  associated  with  definite  and  characteristic  visceral  lesions. 
The  poison  is  discharged  from  the  body  in  a  certain  well-understood 
manner  from  the  tissues  which  are  affected  by  the  disease,  and  in  no 
other  way. 

Syphilis  and  malaria  have  not  been  included  in  either  of  the  above 
groups.    They  belong  in  a  class  by  themselves. 


CHAPTEE    I. 

SCARLET  FEVER. 

(Scarlatina.) 

ScAELET  FEVER  is  an  acutc,  contagious,  self -limited  disease,  one  attack 
usually  protecting  the  individual  through  life.  The  period  of  incuba- 
tion is  usually  from  two  to  four  days;  that  of  invasion,  from  twelve  to 
twenty-four  hours;  that  of  eruption,  from  four  to  six  days;  that  of 
desquamation,  from  three  to  six  weeks.  The  disease  may  be  communi- 
cated at  any  time  from  the  first  symptom  of  invasion  throughout  des- 

903 


904  THE  SPECIFIC  INFECTIOUS  DISEASES. 

quamation,  and  even  during  the  existence  of  purulent  discharges  from 
the  nose  or  other  mucous  or  serous  membranes.  It  is  usually  ushered 
in  by  Vomiting,  fever,  and  sore  throat,  and  is  characterised  by  an  ery- 
thematous rash  appearing  first  upon  the  neck  and  spreading  rapidly  over 
the  entire  body.  Its  chief  complications  are  otitis,  adenitis,  and  mem- 
branous inflammations  of  the  pharynx,  which  frequently  extend  to  the 
nose,  rarely  to  the  larynx.  The  most  important  sequelse  are  otitis  and 
nephritis.  The  constancy  of  the  throat  infection  in  scarlet  fever  strongly 
points  to  the  pharynx  as  the  point  of  entry  of  the  infection. 

Etiology. — Analogy  leads  to  the  belief  that  scarlet  fever  is  due  to  a 
micro-organism,  but  as  yet  its  nature  has  not  been  discovered.  The 
complications  are  usually  associated  with  the  development  of  a  strepto- 
coccus. Some  have  gone  so  far  as  to  claim  that  a  streptococcus  is  the 
cause  of  the  disease.  From  present  knowledge,  however,  it  appears  rather 
to  play  the  role  of  a  secondary  or  accompanying  infection,  for  the  devel- 
opment of  which  the  mucous  membranes  of  a  person  suffering  from 
scarlet  fever  seem  to  afford  most  favourable  conditions.  To  the  strepto- 
coccus may  be  ascribed  the  membranous  inflammations  of  the  tonsils 
and  pharynx,  the  otitis,  the  inflammation  of  the  lymph  nodes  and  the 
cellular  tissue  of  the  neck,  and  probably  also  the  nephritis,  endocarditis, 
pneumonia,  and  joint  lesions.  In  many  of  the  above  conditions  the 
streptococcus  is  associated  with  other  pyogenic  germs,  and  in  some  cases 
with  the  diphtheria  bacillus.  The  exact  role  played  by  the  strepto- 
cocci and  by  the  virus  of  scarlet  fever  in  these  complications  is  still  a 
matter  of  dispute,  the  probabilities  being  that  some  are  due  to  one  and 
some  to  both  of  these  infective  agents. 

PredisposUion. — The  susceptibility  of  children  to  the  scarlatinal 
poison  is  much  less  than  to  that  of  measles ;  still,  it  is  much  greater  than 
that  of  adults.  Billington  (New  York)  records  observations  made  in 
twenty-six  families  living  in  tenements  where  little  or  no  attempt  at 
isolation  was  made.  In  these  families  there  occurred  forty-three  cases 
of  scarlet  fever ;  but  forty-seven  other  children,  although  unprotected  by 
previous  attacks  and  constantly  exposed,  did  not  contract  the  disease. 

Johannessen  reports  that  of  185  children  under  fifteen  years  who 
were  exposed,  twenty-eight  per  cent  contracted  the  disease;  while  of  314 
adults,  only  five  per  cent  contracted  the  disease.  It  may  be  stated  that, 
approximately,  not  more  than  one-half  of  the  children  exposed  take  the 
disease.  The  susceptibility  is  not  great  in  early  infancy,  but  it  increases 
until  about  the  fifth  year,  after  which  it  steadily  diminishes.  Both  sexes 
are  equally  liable  to  scarlet  fever.  Epidemics  are  more  frequent  in  the 
fall  and  winter  than  in  summer,  and  cases  occurring  in  the  cold  months 
are  apt  to  be  more  severe.  Whitelegge,  in  6,000  cases,  found  the  highest 
mortality  in  the  month  of  October ;  and  in  Caiger's  report  of  1,008  cases 
this  was  also  the  month  showing  the  greatest  mortality. 


SCARLET  FEVER.  905 

Incubation. — Of  113  cases  '  in  whicli  the  period  of  incubation  could 
be  accurately  determined,  it  was  as  follows : 


24  hours  or  less 6  cases. 

2  days 15  " 

3  "     28  " 

4  "     25  " 

5  "     6  " 

6  "     15  " 

7  "     8  " 


8  days  .  .  ., 2  cases. 

9  "     

11     "     

14     "     

21     "     


5 

(( 

1 

case. 

1 

(( 

1 

II 

L3 

cases. 

Thus  in  eighty-seven  per  cent  of  these  it  was  between  two  and  six 
days,  and  in  sixty-six  per  cent  between  two  and  four  days.  Speaking 
generally  if,  after  exposure,  a  week  passes  without  symptoms,  the  chances 
of  infection  are  very  small.  A  short  incubation  is  more  frequently  seen 
in  severe  than  in  mild  cases. 

Mode  of  Infection. — The  chief  source  of  infection  is  the  patient  him- 
self. It  is  somewhat  doubtful  whether  the  poison  of  scarlet  fever  can 
be  conveyed  by  the  breath,  but  it  surely  is  by  discharges  from  the  mucous 
membranes  involved,  probably  by  the  scales  during  desquamation,  and  by 
all  the  excretions  of  the  patient — urine,  faces,  and  perspiration.  Infec- 
tion often  takes  place  from  the  carpets  or  furniture  of  the  sick-room, 
and  from  the  clothing  of  the  patient.  In  a  city,  the  bedclothing,  while 
airing  in  the  window,  has  been  known  to  convey  the  disease  to  an  adjoin- 
ing house.  Instances  are  recorded  of  the  spread  of  scarlet  fever  by  the 
washing  of  infected  with  other  clothing.  Toys  or  books  may  be  carriers 
of  the  disease.  A  bouquet  of  flowers  sent  from  a  sick-room  to  an  insti- 
tution, in  one  instance  proved  a  vehicle  of  infection.  Cats,  dogs,  and 
other  domestic  animals  are  known  to  have  conveyed  the  disease.  Scarlet 
fever  is  sometimes  spread  by  food,  particularly  by  milk. 

The  transmission  of  the  disease  through  a  third  person  is  not  fre- 
quent, but  numerous  instances  of  it  are  on  record.  The  persons  most 
likely  to  carry  it  are  the  nurse  and  the  physician.  Physicians  have  in 
many  cases  carried  scarlatina  to  their  own  children,  but  only  when  there 
had  been  very  direct  contact  with  the  patient,  and  where  the  interval 
before  seeing  the  second  child  was  short.  The  clothing  of  the  nurse 
may  be  almost  as  infectious  as  that  of  the  patient.  The  transmission  of 
the  disease  by  one  who,  although  living  in  the  house,  does  not  come  in 
contact  with  the  patient  is  extremely  improbable.  An  instance  is  re- 
corded in  Allbutt  where  scarlatina  was  transmitted  through  two  healthy 
persons. 

Duration  of  the  Infective  Period. — There  is  no  evidence  to  show  that 
the  disease  is  communicable   during  the  period   of  incubation.     It  is 

'  Part  of  these  are  from  personal  observation,  but  the  great  majority  are  isolated 
cases  scattered  through  medical  literature,  occurring  under  circumstances  which  made 
it  possible  to  determin^he  exact  length  of  the  incubation  period. 


906  THE  SPECIFIC   INFECTIOUS   DISEASES. 

slightly  contagious  from  the  beginning  of  invasion,  before  the  rash 
appears.  Infection  appears  to  be  most  active  at  the  height  of  the  febrile 
period — from  the  third  to  the  fifth  day — ^and,  next  to  this,  during  the 
stage  of  active  desquamation. 

In  simple  cases,  the  average  duration  of  the  contagious  period  may 
be  placed  at  six  weeks,  or  until  desquamation  is  complete.  However, 
physicians  generally  have  been  accustomed  to  place  too  much  stress  upon 
the  danger  from  the  scales,  and  too  little  upon  that  from  the  discharges 
from  the  mucous  membranes.  Early  infection  comes  chiefly  from  the 
throat,  nose,  or  possibly  the  breath.  Late  infection  may  arise  from  a 
purulent  otitis,  rhinitis,  chronic  pharyngitis,  suppurating  glands,  em- 
pyema, and  possibly  also  from  the  urine  in  nephritis.  The  infectious 
nature  of  these  purulent  discharges  has  not  been  sufficiently  recognised. 
It  is  possible  for  them  to  convey  the  disease  during  a  period  of  several 
months.  One  case  is  recorded  in  which  scarlatina  was  communicated 
through  a  purulent  nasal  discharge  after  eleven  weeks ;  another  in  which 
the  opening  of  a  post-scarlatinal  empyema  in  a  surgical  ward  was  fol- 
lowed by  an  outbreak  of  scarlet  fever. 

In  winter  especially,  a  chronic  pharyngeal  catarrh  may  long  contain 
the  germs  of  infection.  Ashby  found,  on  careful  investigation,  that  from 
two  to  four  per  cent  of  patients  discharged  from  a  scarlet-fever  hospital 
subsequently  conveyed  the  disease.  There  is  particular  danger  from  a 
child  who  has  recently  had  the  disease  sleeping  with  other  children.  Line 
records  a  case  in  which  this  was  the  means  of  conveying  the  disease  after 
fourteen  weeks,  and  when  the  patient  had  been  considered  perfectly  well 
for  three  weeks.  It  is  impossible  to  say  that  at  any  specified  time  ab- 
solute safety  exists.  All  patients  before  being  discharged  from  a  hospital 
or  released  from  quarantine  in  private  practice,  should  be  carefully  ex- 
amined as  to  the  condition  of  the  mucous  membranes,  and  quarantine 
continued  as  long  as  catarrhal  inflammations  are  present.  The  poison 
of  scarlatina  clings  more  tenaciously  to  clothing,  upliolstery,  and  apart- 
ments than  that  of  any  other  infectious  disease,  possibly  excepting  tuber- 
culosis. Authentic  cases  are  on  record  in  which  more  than  a  year  had 
elapsed  between  the  first  and  second  cases,  where  the  source  of  infection 
seemed  certam. 

Lesions. — The  only  characteristic  lesions  of  scarlatina  are  those  of 
the  skin  and  the  mucous  membranes  of  the  mouth  and  throat.  The  skin 
is  the  seat  of  an  acute  dermatitis  of  variable  depth  and  intensity.  There 
is  first  acute  hyperemia,  followed  by  an  exudation  of  serum  and  cells  in 
the  corium,  especially  about  the  blood-vessels  and  hair  follicles.  There 
results  a  death  of  the  epidermis  which  is  thrown  off  in  tlie  desquamation. 
The  mucous  membrane  of  the  mouth,  tongue,  and  throat  is  the  seat  of 
a  catarrhal,  membranous,  or  gangrenous  inflammation  which  rarely  in- 
vades the  larynx,  but  very  frequently  the  middle  ear  and  nose.    The  entire 


SCARLET  FEVER  907 

oesophagus  is  often  the  seat  of  an  intense  congestion.  From  the  ear  the 
infection  may  extend  to  the  mastoid  cells,  the  meninges,  or  the  brain, 
and  from  the  nose  to  the  accessory  sinuses,  particularly  the  antrum 
of  Higlimore.  All  the  lymph  nodes  about  the  neck  may  be  involved, 
the  infection  ending  in  cell-hyperplasia,  suppuration,  or  necrosis. 
The  cellular  tissue  of  this  neighbourhood  may  also  become  infiltrated, 
this  being  followed  sometimes  by  suppuration  and  occasionally  by 
gangrene. 

The  most  constant  change  throughout  the  body,  according  to  Pearce, 
is  hyperplasia  of  the  lymphoid  tissue,  which  is  seen  everywhere.  The 
other  lesions  are  degenerations  due  to  the  scarlatinal  poison  alone,  or 
in  conjunction  with  the  various  forms  of  secondary  infection,  or  to 
the  latter  alone.  The  most  important  are :  fatty  degeneration  of  the 
heart;  areas  of  focal  necrosis  in  the  liver;  acute  degeneration  of  the 
kidney  or  acute  diifuse  nephritis;  proliferation  of  the  cells  of  the 
Malpighian  bodies  of  the  spleen;  broncho-pneumonia,  gangrene,  or 
abscess  of  the  lung;  pleurisy,  which  is  often  purulent;  endocarditis, 
pericarditis;  abscesses  in  the  cellular  tissue  and  inflammation  of  the 
joints.  These  visceral  changes  will  be  considered  more  fully  under 
Complications. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  scarlet  fever  is  ab- 
rupt, the  symptoms  at  the  onset  usually  being  directly  in  proportion  to 
the  severity  ,^f  the  attack.  In  the  majority  of  cases  there  is  vomiting, 
a  rapid  rise  in  temperature,  and  soreness  of  the  throat.  Often  the  vomit- 
ing is  repeated ;  it  is  frequently  forcible,  and  without  nausea.  In  severe 
cases  the  rise  in  temperature  is  very  rapid,  to  104°  or  105°  F. ;  in  the 
mildest  cases  it  may  not  be  above  101°  F.  A  child  may  complain  of  sore- 
ness of  the  throat,  or  the  throat  symptoms  may  be  entirely  objective.  In 
most  severe  cases,  there  is  a  uniform  erythematous  blush  covering  the 
pharynx,  tonsils,  and  fauces,  but  on  the  hard  palate  there  are  minute 
red  points.  The  appearance  of  this  is  usually  coincident  with  the  rise 
in  temperature.  Occasionally  membranous  patches  may  be  seen  upon  the 
tonsils  the  first  day,  but  not  generally  before  the  third  or  fourth  day.  In 
mild  cases  the  throat  shows  only  a  very  moderate  congestion.  Severe 
cases  are  sometimes  ushered  in  by  convulsions,  especially  in  very 
young  children.  Diarrhoea  is  not  uncommon  in  summer.  There  is 
general  prostration,  which  is  directly  proportionate  to  the  height  of  the 
fever. 

Eruption. — This  usually  appears  from  twelve  to  thirty-six  hours  after 
the  first  symptoms  of  invasion ;  exceptionally,  not  until  the  third  or  even 
the  fifth  day.  A  later  appearance  than  this  is  somewhat  doubtful,  for 
the  rash  not  infrequently  recedes  and  reappears,  having  been  overlooked 
in  the  first  instance.  In  108  cases  observed  in  the  New  York  Infant 
Asylum,  the  duration  of  the  rash  was  as  follows : 


908  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Two  days  or  less 5  cases. 

Three  to  seven  days 81      " 

Eight  to  eleven  days 16      " 

Over  eleven  days 4      " 

Recurring 2     " 

These  statistics  are  confirmed  by  the  observations  of  most  writers, 
that  the  rash  lasts  from  three  to  seven  days.  The  full  development  of 
the  rash  is  generally  seen  in  from  twelve  to  twenty-four  hours  from  its 
first  appearance,  and  not  infrequently  the  whole  body  is  covered  in  the 
course  of  four  or  five  hours.  Very  rarely  its  extension  is  so  slow  that 
it  is  two  or  three  da3's  before  the  body  is  covered.  Its  first  appearance 
is  almost  invariably  upon  the  neck  and  chest.  In  the  cases  of  moderate 
severity  the  typical  rash  is  seen.  Its  colour  is  red  rather  than  scarlet,  and 
on  close  inspection  it  is  seen  to  be  made  up  of  very  minute  points  upon 
a  reddish  ground  giving  the  appearance  of  a  uniform  blush ;  or  the  back- 
ground may  be  wanting  and  only  the  punctate  eruption  shows.  These 
points  are  the  papillae  of  the  skin  and  hair  follicles.  The  rash  usually 
covers  the  entire  body  except  the  face.  This  may  be  the  seat  of  an 
ordinary  flush.  Even  in  cases  with  intense  eruption  the  central  part  of 
the  face  usually  escapes,  though  elsewhere  the  eruption  may  be  as  bright 
as  upon  the  body.  There  is  often  a  peculiar  pallor  about  the  mouth 
which  is  characteristic.  The  appearance  of  the  eruption  in  dark-skinned 
races  is  much  modified  and  often  difficult  of  recognition.  In  the  negro  the 
palms  and  soles  may  be  the  only  places  where  the  eruption  can  be  distin- 
guished.   Here  may  be  seen  a  bright  red  blush  or  a  fine  papular  eruption. 

Variations  in  the  eruption  are  very  frequent  and  very  puzzling.  They 
occur  especially  in  the  very  mild  and  in  the  most  severe  cases. 

In  the  mild  cases  the  rash  is  not  seen  upon  the  face ;  it  is  often  faint 
upon  the  body,  and  may  be  present  only  upon  certain  parts;  when  the 
rash  is  faint  or  scanty  it  is  usually  most  marked  in  the  groins  and 
axillae,  or  over  the  buttocks  and  back  of  the  thighs;  it  may  last  only 
one  day,  and  sometimes  may  be  so  slight  as  to  escape  notice  altogether. 
It  may  be  absent  in  some  very  mild  cases,  in  certain  others  where  the 
throat  symptoms  are  severe,  and  in  malignant  cases.  In  the  very  severe 
cases  many  irregularities  are  seen,  both  as  to  the  time  of  the  appear- 
ance of  the  eruption  and  its  character.  Sometimes  it  occurs  as  large, 
irregular  patches;  again,  it  is  macular,  closely  resembling  the  rash  of 
measles;  occasionally  it  is  of  a  dark  purplish  colour;  and  very  rarely  it 
is  haemorrhagic.  Not  infrequently  an  eniption  of  fine  vesicles  is  seen, 
especially  on  the  chest,  axillae,  and  abdomen.  It  is  seen  both  in  mild 
and  severe  cases.  This  is  especially  diagnostic.  A  well-developed  bright 
rash  indicates  strong  heart  action,  and  a  sudden  recession  of  the  rash 
is  a  sign  of  heart  failure.  Often  a  rash  which  is  faint  and  doubtful  in 
character  may  be  brought  out  fully  by  a  hot  bath. 


SCARL-ET   FEVER.  909 

With  the  eruption  at  its  height,  there  is  intense  itching  or  burning 
of  the  skin,  and  in  severe  eases  considerable  swelling,  chiefly  noticeable 
upon  the  hands  and  face. 

Desquamation. — Shortly  after  the  rash  has  faded,  about  the  eighth 
day,  there  begins  an  exfoliation  of  the  dead  epidermis,  known  as  des- 
quamation. This  is  even  more  characteristic  of  the  disease  than  is  the 
rash.  It  is  usually  first  seen  upon  the  neck  and  chest,  where  it  appears 
as  fine  flakes.  The  desquamation  of  the  trunk  is  completed  in  from 
one  to  three  weeks.  If  baths  and  inunctions  are  being  used,  it  is  scarcely 
perceptible.  It  continues  longest  where  the  epidermis  is  thickest — viz., 
upon  the  hands  and  feet — and  here  it  lasts  from  four  to  seven  weeks,  and 
not  infrequently  eight  weeks.  The  appearance  of  the  fingers  and  toes 
during  desquamation  is  characteristic.  The  finger  tips  usually  peel  first, 
and  the  new  epidermis  is  pink  and  fresh-looking,  while  that  which  has 
not  yet  separated  is  of  a  dull  gray  colour  and  loosened  at  the  margin. 
Occasionally  the  epidermis  of  a  considerable  part  of  a  finger  may  be 
loosened  at  once,  so  that  a  partial  cast  may  be  thrown  off  like  the  finger 
of  a  glove.  Sometimes  the  patient  comes  under  observation  for  the  first 
time  during  desquamation,  the  history  of  the  early  symptoms  being 
doubtful  or  absent.  Such  desquamation  as  has  been  described,  occurring 
both  upon  the  hands  and  feet,  may  be  regarded  as  conclusive  evidence  of 
scarlet  fever,  no  matter  what  the  history  may  be.  In  rare  instances 
desquamation  may  include  loss  of  the  hair  and  the  nails. 

1.  The  Mild  Cases. — The  symptoms  may  be  so  slight  as  to  be  entirely 
overlooked,  nothing  being  noticed  until  desquamation  occurs.  Usually, 
however,  there  is  a  rather  abrupt  invasion,  with  vomiting  and  a  tempera- 
ture from  100°  to  103°  F.  The  tonsils  and  pharynx  are  congested,  while 
the  palate  shows  a  punctate  redness  somewhat  like  the  cutaneous  erup- 
tion. The  papillae  of  the  tip  and  borders  of  the  tongue  are  enlarged. 
Nearly  always  within  twenty-four  hours  the  rash  makes  its  appearance, 
generally  first  upon  the  neck  and  chest.  Very  often  it  is  not  seen  upon 
the  face,  but  is  abundant  on  the  rest  of  the  body.  The  rash  fades  on 
the  third  or  fourth  day,  and  has  disappeared  by  the  fifth  day.  There  is 
very  little  prostration,  the  child  often  being  with  difficulty  kept  in  bed. 

The  highest  temperature  is  coincident  with  the  full  eruption,  and 
is  usually  seen  during  the  first  thirty-six  hours  of  the  disease.  It  grad- 
ually falls  to  normal  by  the  third  or  fourth  day.  Some  examples  are 
shown  in  Fig.  180.  In  the  mildest  cases  the  temperature  may  never  be 
above  100°  F. 

Desquamation  is  often  faint  over  the  body,  but  is  unmistakable  over 
the  hands  and  feet.  It  begins  about  the  end  of  the  first  week,  always 
being  most  marked  where  the  eruption  has  been  most  intense. 

The  mild  cases  are  usually  uncomplicated,  but  the  possibility  of  otitis 
and  of  late  nephritis  should  .always  be  kept  in  mind,  as  these  may  occur 


910 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


even  with  the  mildest  attacks.  The  diffit'ulties  in  diagnosis  in  mild 
attacks  of  scarlet  fever  are  often  great.  It  should  be  remembered  that 
these  cases  are  just  as  contagious  as  severe  ones,  and  that  from  a  mild 
attack  a  severe  one  is  often  contracted.  It  is  frequently  by  these  mild 
cases  that  this  disease  is  spread  in  schools.  In  dispensaries  I  have  often 
seen  patients  desquamating  from  scarlet  fever,  who  had  been  attending 


TUTT       /        i'       i 

y       /      2-       J     ^ 

3^              /             2. 

J            V           v5- 

BftlR 

io3» : 

: 

;e;;eeeeeeheee 

102* 

1 1  1  1 1 1  [  1 1 1  y\j  I 

:HEHEE=E5EEE;; 

lot" 

UJ 

Ik  ;|:R: 

~         ^v/ 

ulj 

»»•  Z2ZZZZZZSZZ 

,-,     •        Y- 

;^^^ 

rs'-" ':-""""'"" 

-f_    -.      :      .             .      .      A       !             !    .; 

E-'A-z----'-------- 

.»** ±_ 

zL 

Fig.  180. — Mild  Scarlet  Fever.  Three  cases  occurring  successively  in  the  same  family. 
Diagnosis  not  made  until  the  third  case  developed,  at  which  time  the  first  one  was  found 
to  be  desquamating  in  a  typical  manner. 


school  regularly  up  to  the  time  when  they  were  brought  for  treatment 
for  nephritis  or  some  other  disease. 

2.  Cases  of  Moderate  Severity. — The  onset  is  sudden  with  vomiting, 
which  is  usually  repeated,  rarely  with"  convulsions.  The  temperature 
rises  rapidly,  and  by  the  end  of  the  first  twenty-four  hours  has  reached 
104°  or  105°  F.  The  rash  generally  appears  within  the  first  twenty-four 
hours,  and  its  intensity  is  usually  in  direct  proportion  to  the  severity  of 
the  attack.  Appearing  first  upon  the  neck  or  chest,  it  extends  rapidly, 
covering  the  entire  trunk  and  extremities,  often  in  a  few  hours.  It  is 
generally  typical  in  appearance,  being  made  up  of  minute  points,  but  giv- 
ing the  appearance  of  a  uniform  blush,  which  has  been  compared  to  a 
boiled  lobster.  Little  change  takes  place  in  the  rash  for  four  or  five 
days.  After  this  it  fades  quite  rapidly,  and  disappears  by  the  sixth  or 
seventh  day. 

The  throat  resembles  that  of  the  mild  form,  except  that  the  redness 
is  more  intense  and  there  is  slight  swelling  of  the  tonsils,  fauces,  and 
uvula,  and  often  pain  upon  swallowing.  Occasionally  small  yellowish 
patches  are  seen  upon  the  tonsils  by  the  second  or  third  day,  but  these 
can  be  wiped  off  and  are  not  distinctly  membranous.  There  is  iisually 
a  moderate  discharge  of  a  sero-purulent  character  from  the  nose.  The 
lymph  glands  at  the  angle  of  the  jaw  are  swollen  and  quite  tender.  The 
tongue  may  be  coated  in  the  centre  and  show  bright  red  points  at  its 
borders  and  tip,  or  it  may  be  quite  red  and  show  the  prominent  papillae 
everjrwhere — the  "  strawberry  tongue  " ;  while  not  exclusively  seen  in 


SCARLET  FEVER. 


911 


niTE 
ii»i  r. 

/ 

J- 

J 

4 

6' 

~r-' 

y 

^ 

-'.- 

"^ 

=7n 

_ 

_ 

^ 

• 

^ 

- 

_ 

. 

- 

. 

104° 

\ 

\ 

^ 

5 

^ 

: 

E 

z 

J 

^ 

: 

E 

: 

-1 
- 

\ 

\ 

\l 

j 

[ 

E 

: 
: 

^ 

I 

1 

I 

I 

~- 

E 

E 

IDS' 
102' 
lOl" 

|ioo° 

Z 

I 

r 

: 

^ 

= 

\ 

^ 

!! 

^ 

\ 

^ 

\ 

: 

: 

z 

] 

z~ 

: 

: 

z 

I 

z 

- 

; 

z 

- 

: 

= 

I 

= 

z 

z 

r 

p 

E 

z 

z 

: 

z 

5 

□ 

I 

z 

tJ 

z 

z 

i3 

: 

q 

- 

E 

3 

z 

: 

: 

z 

I 

: 

: 

: 

: 

- 

' 

- 

p 

;; 

Z 

; 

; 

; 

\_ 

] 

t 

H 

-- 

z 

- 

; 

J 

- 

- 

^ 

- 

q 

- 

- 

- 

- 

- 

: 

E 

I 

! 

I 

I 

: 

I 

= 

\ 

E 

: 

z 

: 

1 

h 

z 

E 

^ 

E 

? 

^ 

^ 

^ 

\ 

E 

E 

I 

E 

: 

E 

[ 

E 

■  «° 

\ 

^ 

E 

= 

\ 

I 

\ 

= 

\ 

E 

E 

p 

E 

E 

-H 

. 

s 

^ 

E 

: 

s 

i 

E 

\ 

: 

E 

E 

E 

-^ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

^ 

_ 

_ 

^ 



__j 

_ 

_ 

_ 

_ 

_ 

_ 

„ 

,_ 

y 

_ 

_ 

_ 

• 

■" 

J 

■ 

-< 

■ 

■ 

■ 

■ 

■ 

- 

- 

■ 

■ 

■ 

■■ 

- 

" 

■ 

M 

■ 

■ 

■ 

- 

M 

■ 

J 

■ 

■ 

■ 

. 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

^ 

. 

., 

, 

, 

_ 

_ 

. 

_ 

._ 

,^ 

_ 

Fig.  181. — Typical  Temperature  Curve  of  Uncom- 
plicated Scarlet  F'ever  of  Moderate  Severity. 
Girl  three  years  old. 


scarlatina,  this  is  of  considerable  diagnostic   value.     It  is  rarely  seen 
before  the  third  day,  and  may  continue  several  days  or  even  weeks. 

During  the  height  of  the  fever  there  is  restlessness,  thirst,  and  not 
infrequently  slight  delirium.  The  temperature  usually  reaches  the  maxi- 
mum by  the  second  day,  and  falls  gradually,  but  even  in  uncomplicated 
cases  the  fever  often 
lasts  from'  ten  to  four- 
teen days  (Fig.  181). 
The  pulse  in  the  early 
part  of  the  disease  is 
rapid,  its  frequency  be- 
ing usually  out  of  pro- 
portion to  the  lieiglit 
of  tlie  temperature. 
Tliere  is  much  pros- 
tration, frequently  fol- 
lowed by  quite  a  marked 
degree  of  ansemia. 

This  form  of  the  disease  rarely  proves  fatal  apart  from  complications. 
The  complications  seen  most  frequently  in  this  form  of  scarlet  fever  are 
adenitis,  otitis,  and  pneumonia.     Nephritis  is  the  only  common  sequel. 

3.  The  Severe  Cases. — The  severe  type  of  scarlet  fever  usually  de- 
clares itself  ^rom  the  beginning.  The  incubation  is  short,  and  the  full 
rash  may  be  seen  within  a  few  hours  after  the  initial  symptoms.  It  is 
usually  intense  and  covers  the  entire  body,  even  including  the  face.  In 
other  cases  the  eruption  is  delayed,  often  scanty,  and  may  disappear  in 
a  few  hours.  The  disease  assumes  one  of  two  fairly  distinct  types;  one 
is  characterised  by  the  severity  of  the  general  toxaemia,  the  other  by  the 
predominance  of  the  throat  symptoms.  In  the  first  group  the  toxaemia 
is  shown  by  the  height  of  the  temperature,  the  severity  of  the  nervous 
symptoms,  and  the  profound  cardiac  depression.  The  temperature 
quickly  rises  often  to  105°  or  106°  F.,  and  usually  remains  steadily  high 
until  the  death  of  the  patient.  The  nervous  symptoms  are  great  pros- 
tration and  delirium,  which  is  sometimes  active,  but  more  often  low  and 
muttering.  The  pulse  is  very  rapid,  160  to  180  being  not  uncommon; 
it  is  weak,  compressible,  often  irregular,  and  the  muscular  sounds  of  the 
heart  are  feeble.  The  urine  is  scanty  and  almost  invariably  albuminous. 
Haemorrhages  from  the  mouth,  the  nose,  or  other  mucous  membranes 
are  occasionally  seen.  The  duration  of  the  disease  in  this  form  is  gen- 
erally from  five  to  seven  days.  Exceptionally  the  symptoms  develop  with 
greater  intensity,  and  death  follows  in  three  or  four  days.  A  shorter 
duration  than  this,  the  so-called  malignant  scarlet  fever,  is  exceedingly 


In  the  second  group  with  predominant  throat  symptoms  the  first 


912 


THE  SPECIFIC   INFECTIOUS   DISEASES. 


three  or  four  days  may  show  nothing  more  than  cases  of  the  moderate 
type.  Membranous  patches  appear  upon  the  tonsils  and  spread  to  the  soft 
palate,  uvula,  and  pharynx,  sometimes  to  the  nose  and  through  the  Eu- 
stachian tube  to  the  ear,  very  rarely  involving  tlie  larynx.  The  mucous 
membrane  of  the  moutli  is  intensely  congested,  and  often  partly  covered 
by  membrane;  there  are  sordes  on  the  lips  and  teeth,  and  there  may  be 
superficial  ulcers,  which  bleed  readily.  The  glands  of  the  neck  swell 
rapidly,  often  to  a  great  size,  and  the  cellular  tissue  about  them  is  infil- 
trated. The  head  is  thrown  back  to  relieve  the  dyspnoea  which  the  pres- 
sure from  this  swelling  occasions.  There  is  an  abundant  discharge  from 
the  nose  and  mouth ;  the  breath  is  very  offensive.  The  general  symptoms 
are  those  of  a  severe  septicaemia.  The  temperature  is  steadily  high, 
usually  between  103°  and  105°  F.,  for  about  a  week,  after  which  in  cases 
ending  in  recovery  it  slowly  falls  unless  complications  develop   (Figs. 


FiQ.  182. — Ttpical  Temperatttke  Curve  op  Severe  Scarlet  Fever  Ending  in 
Recovery.  Prolonged  course  due  to  severe  throat  symptoms  lasting  from  second  to 
sixth  day,  otherwise  uncomplicated;  boy  twelve  years  old. 


182,  184,  185).  But  even  in  uncomplicated  cases  the  fever  sometimes 
continues  for  three  weeks.  In  fatal  cases  the  temperature  may  be  stead- 
ily high  till  death  (Fig.  183),  or  it  may  fluctuate  widely.  The  pulse 
is  rapid,  weak,  and  irregular.  There  is  complete  anorexia;  both  food 
and  stimulants  may  have  to  be  given  by  gavage.  There  is  low  delirium 
or  apathy,  and  sometimes  all  the  symptoms  of  the  typhoid  condition  are 
present. 

Signs  of  a  broncho-pneumonia  may  be  found  in  the  chest,  and  by 
the  end  of  the  first  week  or  early  in  the  second,  acute  otitis  often  de- 
velops. The  urine  is  rarely  free  from  albumin,  but  the  amount  present 
is  not  usually  great ;  there  may  be  hyaline  and  epithelial  casts,  and  some- 
times blood.  In  some  cases  the  throat  symptoms  predominate;  in  others, 
those  of  general  sepsis,  but  more  frequently  the  two  are  combined  and 
are  directly  proportionate  to  each  other.  In  still  other  cases,  instead  of 
the  membranous  inflammation,  it  may  be  of  a  gangrenous  character, 
and  extensive  sloughing  may  take  place  in  the  pliarynx  or  tlie  cellu- 


SCARLET  FEVER. 


913 


lar  tissue  of  tlie  neck,  sometimes  exposing  or  even  opening  the  great 
vessels. 

The  duration  of  the  symptoms  in  cases  with  severe  angina  is  from 
seven  to  fourteen  days.  There  is  increasing  prostration  and  finally  a 
septic  stupor,  with  death  from  exhaustion,  from  heart  failure,  or  from 


/ 

2- 

3 

-* 

■i~ 

6 

7 

- 

s- 

<? 

/D 

-^n 

/  2- 

/.J 

/<^   ll 

106° 
105° 
104° 

-^ 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

— 

- 

^ 

- 

- 

- 

- 

- 

- 

— 

IE 

-- 

- 

- 

- 

- 

- 

- 

\ 

- 

- 

- 

- 

- 

- 

_ 

- 

~ 

- 

- 

- 

^ 

- 

- 

- 

;- 

1— 

^ 

~ 

- 

- 

- 

- 

^ 

— 

ft 

--H 

- 

T 

- 

- 

- 

A 

- 

- 

- 

- 

- 

- 

- 

- 

- 

- 

-J 

^ 

•^ 

- 

^ 

- 

\ 

- 

- 

1 

- 

- 

- 

-y^ 

— 1 

+ 

- 

- 

- 

- 

-^ 

- 

•• 

-J 

\ 

\ 

= 

7 

^ 

\ 

= 

i 

^ 

s 

z: 

? 

> 

s 

i 

i 

= 

\ 

= 

E 

= 

= 

\ 

\ 

I 

^ 

^ 

S 

I 

Z 

\ 

r 

i 

1 

-•- 

-4 

-- 

J 

- 

-^ 

i 

- 

- 

^ 

- 

if 

ig 

;i 

I 

~ 

i 

t 

I 

~ 

~ 

103° 
102° 
101° 
100° 

n° 

\ 

= 

? 

\ 

i 

z 

E 

E 

E 

S 

E 

E 

z 

E 

E 

= 

: 

- 

- 

E 

E 

E 

E 

^ 

I 

5 

E 

E 

i 

== 

;E 

^ 

^ 

- 

3 

E 

E 

- 

— 

- 

- 

~ 

~ 

— 

— 

- 

- 

— 

- 

- 

_ 

- 

~ 

-^ 

~ 

" 

- 

- 

- 

— 1 

- 

i~ 

— 

- 

^ 

— 

— 1 

— ' 

— 

— 

— 

. 

. 

., 

_ 

_ 

_ 

_ 

_ 

„ 

_ 

_ 

_ 

_. 

„ 

_ 

- 

„ 

_ 

_  ~ 





_ 

_ 

_ 

_ 

_ 

... 

_ 

- 

1— 

- 

- 

- 

I— 

— 

1— 

- 

t— 

- 

u- 

— 

I— 

- 

— 

- 

i~ 

— 

— 

- 

— 

— 

- 

— ' 

— 

- 

- 

- 

- 

— 

- 

— 

. 

_ 

_ 

_ 

_, 

_ 

_ 

_ 

_ 

_ 

_. 

__ 

_ 

.    _ 

_ 

_ 

-_ 

^ 

_ 

„ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

u_ 

-  - 

-  _ 

- 

_ 

_ 

_ 

_ 

-_ 

^ 

_ 

• 

■ 

■ 

- 

- 

- 

- 

- 

■ 

- 

" 

■■ 

— 

" 

■ 

" 

- 

- 

- 

- 

J 

~ 

-■ 

"~ 

"" 

■ 

~ 

■ 

■ 

'■ 

■■ 

■ 

■ 



_ 

_ 

_. 

_ 

_ 

_ 

_ 

^_ 

_ 

_ 

^ 

_^ 

.  _ 

_  _ 

_ 

_ 

_ 

_ 

_ 

_ 

_ 

Fig.  183. — Severe  Scarlet  Fever,  Septic  Type;  Death  on  Fourteenth  Day.  Intense 
angina;  otitis;  nephritis;  necrotic  inflammation  of  cervical  lymph  glands;  girl  seven 
years  old;  death  from  heart  failure. 


some  complication — broncho-pneumonia,  pleurisy,  nephritis,  haemor- 
rhages following  sloughing,  pericarditis,  or  endocarditis.  In  cases  which 
recover,  the  acute  symptoms  nearly  always  continue  for  a  full  month; 
and  after  escaping  the  dangers  of  sepsis  and  the  early  complications, 
the  child  has  still  to  run  the  gauntlet  of  all  the  late  complications — 
nephritis,  pneumonia,  endocarditis,  pyaemia,  etc.  A  case  may  prove  fatal 
as  late  as  the  end  of  the  seventh  week;  nearly  all  such  results  are  due 
to  nephritis  or  to  its  complications. 

4.  Surgical  Scarlet  Fever. — The  existence  of  a  special  form  of  scarlet 
fever  occurring  in  patients  with  recent  wounds  or  those  who  have  been 
subjected  to  surgical  operations,  while  stoutly  maintained  by  several 
writers,  has  been  vigorously  denied  by  others.  The  question  is  one  dif- 
ficult of  solution  on  account  of  the  close  similarity  at  times  existing  be- 
tween the  symptoms  of  scarlet  fever  and  sepsis,  and  the  necessity  of 
deciding  in  an  undoubted  case  whether  the  infection  with  scarlet  fever 
was  dependent  upon  or  coincident  with  the  wound. 

Hamilton,  from  a  study  of  174  reported  cases,  reached  the  conclusion 
that  proof  of  the  existence  of  a  special  form  of  scarlet  fever  rests  upon 
the  reports  of  cases  usually  meagre,  and  careful  analysis  of  these  would 
lead  one  to  consider  them  rather  as  septic  than  as  scarlatinal  infections ; 
that  when  there  was  undoubted  evidence  of  scarlet  fever,  there  was  no 
proof  that  it  was  in  any  way  due  to  the  coincident  wound,  and  that  there 
59 


914  THE  SPECIFIC  INFECTIOUS  DISEASES. 

is  as  yet  no  convincing  proof  in  the  literature  that  surgical  scarlet  fever 
is  anything  more  than  scarlet  fever  in  the  wounded.  On  the  other  hand, 
there  have  been  observed  clinically  cases  which  seem  to  admit  of  no  other 
reasonable  explanation  than  that  an  abrasion  of  the  skin,  a  recent 
wound,  or  even  possibly  a  varicella  vesicle,  may  be  the  point  of  entry 
of  the  scarlatinal  infection,  instead  of  the  more  usual  portal,  the  pharynx. 

Relapses,  Recurrences,  and  Second  Attacks. — As  a  rule,  one  attack  of 
scarlatina  gives  immunity  through  life.  The  exceptions  are  very  few, 
but  are  well  authenticated.  I  have  seen  but  once  an  undoubted  instance 
of  a  second  attack  in  the  same  individual. 

Relapses  or  recurrences  within  a  brief  period  after  the  first  attack 
are  more  frequent.  There  are  to  be  excluded  the  cases  of  pseudo-relapses 
in  which  the  rash,  having  temporarily  subsided  for  two  or  three  days, 
reappears;  also  those  where  the  rash  varies  in  intensity  from  time  to 
time;  and,  lastly,  the  cases  in  which,  occurring  late  in  the  disease,  it  is 
due  to  septicagmia  or  pyaemia.  They  are  comparable  to  the  relapses  of 
typhoid  fever.  They  occur  most  frequently  during  desquamation,  be- 
tween the  seventh  and  twenty-fourth  days.  There  may  be  not  only 
a  new  eruption,  but  a  rise  of  temperature,  sore  throat,  and  vomiting,  just 
as  in  the  initial  attack.  These  recurrences  are  sometimes  shorter  and 
milder  than  the  first  attack,  but  this  is  by  no  means  uniform,  since 
Korner  mentions  eight  cases  where  the  second  attack  proved  fatal. 

In  considering  the  subject  of  second  attacks,  the  liability  to  errors  in 
diagnosis  must  be  borne  in  mind  and  only  cases  included  which  have  pre- 
sented typical  symptoms. 

Special  Symptoms,  Complications,  and  Sequelae. — Temperature. — 
The  temperature  curve  of  this  disease  is  quite  characteristic.  There 
is  usually  seen  an  abrupt  rise,  the  maximum  being  reached  on  the  sec- 
ond day;  there  follows  a  period  of  variable  duration,  generally  lasting, 
according  to  the  severity  of  the  case,  from  two  to  five  days,  in  which  the 
fluctuations  are  very  narrow;  then  a  gradual  decline  to  normal,  which 
is  reached  in  the  milder  cases  in  about  a  week;  in  those  which  are  more 
severe,  in  about  two  weeks.  This  typical  curve  (Figs.  179  and  180)  is 
seen  in  the  great  proportion  of  uncomplicated  cases  which  end  in  recov- 
ery. Deviations  from  it,  therefore,  are  important  as  indicating  that 
some  complication  exists.  The  explanation  is  usually  to  be  found  in  the 
development  of  otitis,  adenitis,  nephritis,  pneumonia,  etc.  Severe  throat 
symptoms  prolong  the  temperature  but  do  not  usually  modify  its  course. 
In  very  severe  cases  ending  fatally  the  high  temperature  is  prolonged. 
In  any  case,  a  rise  after  the  third  day  is  unfavourable. 

Throat. — Three  distinct  forms  of  angina  are  seen  in  scarlatina :  sim- 
ple or  erythematous,  membranous,  and  gangrenous. 

1.  Erythematous  Angina. — Tliis  can  liardly  be  ranked  as  a  com- 
plication, as  it  is  nearly  as  constant  as  the  scarlatinal  rash.     Usually 


SCARLET  FEVER.  915 

there  is  only  the  intense  general  blush  over  the  entire  pharynx  witli 
the  fine  red  points  upon  the  hard  palate;  but  there  may  be  seen  upon 
the  tonsils  grayish-yellow  spots  resembling  those  of  follicular  tonsil- 
litis, which  can  be  wiped  off,  leaving  a  clean  surface.  This  simple 
angina  is  at  its  height  with  the  maximum  temperature,  and  fades  as 
the  temperature  falls.  It  does  not  often  extend  to  adjacent  mucous 
membranes. 

2.  Membranous  Angina. — These  cases  were  formerly  classed  as  scar- 
latinal diphtheria,  and  whether  this  process  was  identical  with  primary 
diphtheria  or  not,  was  for  a  long  time  a  subject  of  much  discussion. 
Cultures  have  shown  that  the  great  majority  of  these  inflammations  are 
not  true  diphtheria,  but  are  due  to  the  streptococcus. 

The  lesions  of  this  form  of  angina  are  considered  in  the  chapter  on 
Membranous  Tonsillitis.  Usually  on  the  second  or  third  day  of  the  dis- 
ease an  exudation  appears  upon  the  tonsils,  and  in  the  milder  cases  it 
covers  only  the  tonsils.  In  the  most  severe  form  it  may  be  seen  within 
twenty-four  hours  of  the  onset,  sometimes  before  the  eruption  appears. 
Beginning  upon  the  tonsils,  the  membrane  rapidly  spreads  to  the  entire 
pharynx,  the  mucous  membrane  of  the  nose,  the  mouth,  the  Eustachian 
tube,  and  even  to  the  middle  ear.  In  colour  it  may  be  gray,  greenish,  or 
almost  black.  There  is  so  much  swelling  of  the  throat  that  swallowing 
becomes  difficult.  The  infiltration  of  the  cellular  tissue  of  the  neck  and 
the  enlarged  lymph  glands  produce  great  external  swelling,  which  may 
extend  like  a  collar  from  ear  to  ear.  The  breath  has  a  foul  odour,  the 
nasal  discharge  is  thin  and  foetid,  and  nasal  respiration  is  obstructed,  so 
that  the  mouth  is  open  constantly.  It  is  surprising  that  the  larynx  is  so 
seldom  invaded. 

These  local  changes  are  accompanied  by  constitutional  symptoms  of 
great  severity,  which  are  due  to  a  general  streptococcus  septicaemia; 
broncho-pneumonia  and  nephritis  are  very  frequent,  otitis  is  almost  con- 
stant, and  suppuration  of  the  lymphatic  glands  is  not  uncommon.  The 
eruption  is  often  irregular  and  late  in  appearing. 

The  frequency  with  which  diphtheria  coexists  with  scarlatina  varies 
greatly.  In  hospital  practice  the  proportion  often  runs  as  high  as  thirty 
or  forty  per  cent.  In  private  practice  it  is  much  lower.  In  some  epi- 
demics it  is  much  more  frequent  than  in  others.  The  streptococcus  an- 
gina is  usually  seen  at  the  height  of  the  disease;  true  diphtheria  may 
occur  at  any  time,  even  during  convalescence.  Very  little  reliance  is  to 
be  placed  upon  the  appearance  of  the  membrane.  The  only  positive 
means  of  differentiation  is  by  cultures,  which  should  invariably  be  made 
from  the  throat  of  every  patient  admitted  to  a  scarlet-fever  hospital,  and 
of  every  case  in  private  practice  showing  any  exudate  upon  the  tonsils. 
If  the  first  culture  is  negative  and  the  throat  symptoms  increase,  re- 
peated cultures  should  be  made. 


916  THE  SPECIFIC  INFECTIOUS  DISEASES. 

3.  Gangrenous  Angina. — This  is  seen  only  in  the  worst  eases  of  scar- 
let fever.  The  process  may  be  gangrenous  from  the  outset,  or  preceded 
by  a  membranous  inflammation.  It  is  sometimes  insidious  in  its  de- 
velopment. There  is  a  foetid  odour  to  the  breatli,  an  irritating  discliarge 
from  the  nose  and  mouth,  with  very  great  glandular  swelling.  The  ton- 
sils are  gray  or  grayish-black  in  colour,  and  large  masses  of  necrotic 
tissue  may  be  removed  with  the  forceps  from  the  tonsils,  uvula,  fauces, 
or  pharynx,  and  sometimes  sloughing  occurs  in  the  cellular  tissue  of  the 
neck.  Blood-vessels  of  considerable  size  are  sometimes  opened,  and 
serious  or  even  fatal  haemorrhage  may  result.  The  constitutional  symp- 
toms are  those  of  great  asthenia,  prostration,  and  profound  cachexia, 
followed  almost  invariably  by  a  fatal  termination. 

Lymph  Nodes. — These  are  swollen  in  all  cases  accompanied  by  severe 
angina.  The  inflammation  may  be  simply  an  acute  hyperplasia,  or  it 
may  go  on  to  suppuration  and  necrosis.  Abscess  does  not  often  occur 
at  the  height  of  the  disease,  but  the  early  swelling  may  almost  completely 
subside  only  to  recur,  and  suppuration  may  take  place  even  as  late 
as  the  fifth  or  sixth  week  of  the  disease.  It  may  be  confined  to  the 
glands  or  be  complicated  by  suppuration  in  the  cellular  tissue  of  the 
neck. 

Cellulitis  of  the  Neck. — This  usually  occurs  toward  the  end  of  the 
first  week,  and  is  associated  with  grave  throat  symptoms.  Rapid  and 
extensive  infiltration  occurs,  the  skin  becomes  tense  and  brawny,  the 
head  is  held  back,  and  there  may  be  considerable  dyspnoea.  The  infil- 
tration may  be  only  in  the  neighbourhood  of  the  lymph  glands  or  it 
may  be  diffuse.  Unless  relieved  by  early  incision,  the  diffuse  form  may 
result  in  suppuration  and  extensive  sloughing,  which  may  be  deep 
enough  to  lay  bare  the  large  vessels  of  the  neck.  This  is  a  complication 
of  the  gravest  possible  import.  Death  may  occur  from  septicaemia  be- 
fore or  after  sloughing  or  from  haemorrhage  due  to  opening  by  ulcera- 
tion of  the  external  carotid  or  some  of  its  branches;  or  there  may  be 
associated  thrombosis  of  t':e  jugular  vein,  leading  to  thrombosis  of  the 
lateral  sinus,  meningitis,  or  pyaemia. 

Ears. — The  otitis  is  due  to  direct  extension  of  the  infection  from 
the  rhino-pharynx.  It  is  the  most  frequent  complication  of  scarlatina, 
and  in  doubtful  cases  may  have  some  diagnostic  importance.  As  a  rule, 
the  younger  the  child  the  greater  the  liability  to  otitis.  It  is  more  fre- 
quent in  winter  than  at  other  seasons,  and  is  closely  connected  with  the 
severity  of  the  throat  symptoms.  In  an  epidemic  occurring  in  the  New 
York  Infant  Asylum  in  spring  and  summer  there  were  73  cases  of  scar- 
latina and  not  one  of  otitis.  In  a  fall  and  winter  epidemic  in  the  same 
institution  two  years  later,  of  43  cases  20  per  cent  had  otitis.  Of  4,397 
cases  reported  by  Finlayson,  otitis  occurred  in  10  per  cent,  and  of  1,008 
cases  reported  by  Caiger,  in  13  per  cent.     In  Burkhardt's  statistics  the 


SCARLET   FEVER. 


917 


proportion  was  as  high  as  33  per  cent.    Of  cases  accompanied  by  severe 
throat  symptoms  otitis  is  present  in  fully  75  per  cent. 

As  a  rule,  both  ears  are  affected.  Otitis  is  most  frequent  early  in  the 
second  week,  but  may  occur  at  any  time,  even  during  convalescence.  In 
the  cases  when  it  develops  at  the  height  of  the  disease  there  are  in  some 
cases  no  new  symptoms;  in  others  there  is  pain  and  deafness  and  a  rise 
in  the  temperature,  which  may  fall  after  paracentesis  or  rupture  of  the 
drum  membrane,  or  there  may  be  extension  to  the  mastoid   (Fig.  184:). 


Fig.  184. — Severe  Scarlet  Fever;  Otitis;  Mastoiditis;  Death.  Typical  symptoms 
and  temperature  curve  until  fourteenth  day;  secondary  rise  of  temperature  from 
otitis;  double  paracentesis  on  the  fifteenth  day;  mastoid  operation  on  the  sixteenth 
day;  death  twelve  hours  later  from  septicaemia;  boy  five  years  old. 


The  otitis  is  often  overlooked  unless  the  ears  are  regularly  examined. 
The  form  of  inflammation  may  be  catarrhal  or  purulent,  the  latter  being 
often  accompanied  by  necrotic  changes. 

Bezold  makes  the  following  report  upon  185  cases  showing  the  dis- 
astrous consequences  of  scarlatinal  otitis :  "  In  30  there  was  entire 
destruction  of  the  membrana  tympani;  in  59  the  perforation  comprised 
two-thirds  or  more  of  the  membrane;  in  15  there  was  total  loss  of  hear- 
ing on  one  side,  and  in  6  of  the  cases  upon  both  sides ;  in  77  of  the  cases 
the  hearing  distance  for  low  voice  was  less  than  twenty  inches." 

As  a  cause  of  permanent  deafness  and  deaf-mutism,  no  disease  of 
childhood  compares  in  importance  with  scarlet  fever.  May  has  collected 
statistics  of  5,613  deaf-mutes,  of  whom  532  owed  their  condition  to 
otitis  following  scarlet  fever. 

Kidneys. — Albuminuria  accompanies  nearly  all  the  severe  cases  of 
scarlet  fever.  In  many  this  is  simply  the  ordinary  febrile  albuminuria 
due  to  acute  degeneration  of  the  kidneys.  In  those  with  severe  throat 
complications,  and  in  nearly  all  the  septic  cases,  there  is  an  acute  diffuse 
nephritis;  the  interstitial  changes  may  be  very  marked  and  the  kidneys 
contain  minute  abscesses.    This  occurs  at  the  height  of  the  febrile  process 


918. 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


and  is  rarely  accompanied  by  dropsy ;  but  albumin,  casts,  and  even  blood 
may  be  found  in  the  urine.  The  most  severe  and  the  most  characteristic 
renal  complication,  and  that  generally  designated  as  post-scarlatinal 
nephritis,  is  a  diffuse  nephritis,  with  changes  in  the  glomeruli  as  the 


Fig.  185. — Scarlet  Fever  of  Moderate  Severity  Followed  by  Fatal  Nephritis. 
Early  symptoms  typical  and  uncomplicated;  twenty-first  day  vomiting;  twenty-fifth 
day  ursemic  convulsions;  death  twenty-sixth  day.  No  dropsy;  urine  never  below 
10  ounces  in  twenty-four  hours;  girl  ten  years  old. 


most  striking  feature.  It  usually  develops  during  the  third  or  fourth 
week  of  the  disease,  and  may  follow  mild  as  well  as  severe  cases  (Fig. 
185).  The  onset  may  be  gradual,  with  dropsy  and  urinary  changes, 
usually  accompanied  by  a  slight  rise  of  temperature ;  or  it  may  be  abrupt, 
without  dropsy  but  with  convulsions,  suppression  of  urine,  and  very 
high  temperature. 

The  characteristic  urine  is  of  a  reddish  or  smoky  colour  and  scanty. 
It  contains  a  large  amount  of  albumen,  often  sufficient  to  render  the 
urine  solid  upon  boiling.  Under  the  microscope  there  are  seen  red 
blood  cells,  pus  cells,  epithelial  cells,  and  casts  of  every  variety.  Death 
may  take  place  from  acute  uraemia,  or  the  attack  may  be  followed  by 
permanent  damage  to  the  kidneys.  It  is  more  fully  described  with  the 
Diseases  of  the  Kidney. 

Joints. — Acute  articular  rheumatism  may  occur  coincidently  with  the 
development  of  the  scarlatinal  rash,  and  occasionally  during  convales- 
cence in  patients  who  have  a  predisposition  to  that  disease.  Acute  swell- 
ing of  the  joints  is  sometimes  of  pyaemic  origin.  In  pyaemic  arthritis  the 
large  joints  are  usually  involved  and  the  lesions  are  apt  to  be  multiple. 
Joint  disease  may  occur  as  a  sequel  of  scarlet  fever,  when  it  is  sec- 
ondary to  disease  of  the  bone  or  to  periarticular  abscesses  opening  into 
the  joint. 

The  foregoing  include  but  a  small  proportion  of  the  joint  complica- 
tions seen  in  scarlet  fever.  The  most  frequent  and  most  characteristic 
form  of  inflammation  is  scarlatinal  synovitis,  often  improperly  called 
scarlatinal  rheumatism.  It  occurs  in  different  epidemics  with  varying 
frequency.  Carslaw  (Glasgow),  in  533  cases  of  scarlet  fever,  met  with 
synovitis  in  60  patients.    It  is  seldom  seen  in  children  under  three  years 


SCARLET   FEVER.  919 

of  age,  and  is  most  frequent  after  five  years.  It  may  occur  in  mild  as 
well  as  in  severe  cases.  According  to  Ashby,  synovitis  develops  toward 
the  end  of  the  first  or  the  beginning  of  the  second  week.  The  symptoms 
are  generally  mild,  and  are  followed  by  prompt  recovery.  Suppuration 
is  rare.  Any  of  the  joints  may  be  attacked,  but  those  of  the  wrist,  hand, 
elbow,  or  knee  are  most  frequently  affected.  The  symptoms  are  redness, 
moderate  pain,  swelling,  which  is  usually  due  to  synovial  distention,  and 
sometimes  a  slight  rise  in  temperature.  The  duration  is  generally  but 
three  or  four  days,  and  in  most  cases  there  is  spontaneous  recovery.  Be- 
sides these  milder  cases  there  occurs  a  much  more  severe  form,  which 
may  develop  later,  even  during  convalescence.  It  is  not  very  acute,  but 
is  accompanied  by  fever,  and  both  the  fever  and  swelling  may  continue  for 
many  weeks.  Eecovery  may  be  complete  or  some  joint  disability  may 
remain  and  chronic  arthritis  may  follow. 

Lungs. — The  pulmonary  complications  of  scarlet  fever  are  neither 
so  frequent  nor  so  important  as  those  of  measles.  Broncho-pneumonia 
is  usually  found  at  autopsy  in  septic  cases  where  death  has  occurred  later 
than  the  third  or  fourth  day,  but  it  is  not  generally  recognisable  so  early 
by  physical  signs. 

In  septic  cases  pleuro-pneumonia  sometimes  occurs  early  in  the  dis- 
ease and  at  other  times  late,  generally  associated  with  nephritis,  but 
occasionally  without  it.  It  is  always  a  serious  condition,  and  not  in- 
frequently af  direct  cause  of  death.  Empyema  may  follow  pleuro-pneu- 
monia or  occur  with  pyaemia  or  nephritis,  but  with  the  latter,  simple 
serous  pleurisy  is  more  common.  OEdema  of  the  lungs  occurs  chiefly 
with  nephritis,  in  which  it  is  the  most  common  cause  of  death. 

Heart. — Cardiac  murmurs  are  frequent  at  the  height  of  the  disease; 
in  fact  they  are  heard  in  almost  all  severe  cases.  Endocarditis  and  peri- 
carditis are  oftenest  seen  in  septic  cases,  and  with  post-scarlatinal  neph- 
ritis. Endocarditis  may  be  simple  or  malignant,  and  may  lead  to  em- 
bolism during  convalescence.  Some  degenerative  changes  in  the  cardiac 
muscle  are  probably  present  in  all  the  severe  cases.  Acute  dilatation  may 
result,  which  is  sometimes  a  cause  of  death. 

Blood. — In  all  cases  there  is  a  rapidly  progressing  antemia  that  lasts 
into  convalescence.  The  reduction  in  the  red  cells  in  an  average  case  is 
about  one  million.  The  chief  interest,  however,  attaches  to  the  number 
and  character  of  the  white  cells.  In  mild  cases  there  may  be  only  a 
moderate  increase  in  their  number,  usually  to  from  10,000  to  14,000. 
It  is  in  cases  of  moderate  severity  that  the  characteristic  changes  are 
found.  In  these  there  is  a  decided  leucocytosis  which  appears  early, 
attains  its  maximum  about  the  fourth  day,  and  gradually  declines  until 
the  normal  is  reached,  which  may  not  be  until  the  third,  fourth,  or  fifth 
week.  The  maximum  is  usually  about  30,000  to  35,000 ;  although  it  may 
be  as  high  as  75,000.     During  the  first  week  the  polymorphonuclear 


920  THE  SPECIFIC   INFECTIOUS  DISEASES. 

neutrophiles  form  from  90  to  95  per  cent  of  these  cells ;  the  eosinophiles 
as  well  as  the  lymphocytes  are  diminished.  After  the  fifth  or  sixth  day, 
there  is  a  rapid  increase  in  the  eosinophiles  which  attain  their  maximum, 
sometimes  20  per  cent  of  the  total  leucocytes,  between  the  fourteenth 
and  twenty-first  days.  After  the  third  week  they  gradually  diminish. 
Exceptionally  there  is  found  in  convalescence  a  relative  lymphocytosis, 
which  may  be  as  high  as  50  per  cent.  Complications,  nephritis  excepted, 
usually  show  actual  as  well  as  relative  increase  in  the  polymorphonuclear 
neutrophiles.  In  malignant  and  rapidly  fatal  cases  there  is  usually  a 
very  small  proportion  of  eosinophiles,  and  little  if  any  leucocytosis,  thougli 
exceptionally  it  may  be  high. 

Digestive  System. — Functional  disturbances  are  very  frequent,  and,  in 
fact,  are  seen  in  most  of  the  cases,  but  organic  changes  are  rare.  Vomit- 
ing is  the  mode  of  onset  in  the  majority  of  cases,  but  rarely  continues 
throughout  the  attack.  Late  in  the  disease  it  is  a  frequent  symptom  of 
ursemia.  Diarrhoea  may  be  associated  with  it  under  both  conditions. 
The  tongue  is  nearly  always  coated,  and  clears  off  in  quite  a  characteristic 
way,  which,  with  the  prominent  papilla,  gives  rise  to  the  "  strawberry  " 
appearance.  Catarrhal  stomatitis  is  a  very  frequent  complication,  and 
in  many  cases  of  severe  membranous  angina  the  same  process  is  seen  in 
the  buccal  cavity. 

Nervous  System. — Nervous  complications  and  sequelae  are  seen  less 
frequently  with  scarlatina  than  with  most  of  the  infectious  diseases  of 
such  severity.  Convulsions  are  frequent  at  the  outset,  and  generally 
indicate  a  severe  attack,  though  not  invariably  so.  Occurring  late  in 
the  disease,  they  are  usually  due  to  uraemia,  and  may  be  a  cause  of  death. 
Meningitis  may  occur  as  a  complication  of  otitis,  in  pyaemic  cases,  and 
sometimes  with  post-scarlatinal  nephritis.  Paralysis  from  peripheral 
neuritis  is  rarely  seen.  Hemiplegia  sometimes  occurs  from  meningeal 
haemorrhage,  or  from  embolism  secondary  to  endocarditis  and  associated 
with  nephritis.  Chorea  was  noted  as  a  sequel  in  only  three  of  533  cases 
reported  by  Carslaw.  In  a  report  of  187  cases  of  epilepsy,  "Wildermuth 
states  that  it  followed  scarlet  fever  in  12  cases.  Insanity  has  been  occa- 
sionally observed,  the  usual  form  being  acute  mania,  with  complete 
recovery  in  a  few  weeks  or  months. 

Gangrene. — Cases  of  symmetrical  gangrene  after  scarlet  fever  have 
been  reported.  The  parts  generally  affected  are  the  buttocks,  thighs, 
and  arms,  but  it  may  occur  almost  anywhere.  The  pathology  of  these 
cases  is  obscure.  The  process  usually  begins  in  several  places  simul- 
taneously, or  in  rapid  succession,  and  advances  steadily  till  death 
occurs. 

Other  Infectious  Diseases. — Diphtheria  is  most  frequently  seen,  and 
may  be  present  even  when  there  is  no  distinct  membrane. 

Scarlatina  may  also  be  complicated  by  measles,  varicella,  or  facial 


SCARLET   FEVER.  921 

erysipelas,  and  occasionally  by  variola  or  typhoid  fever.  The  symptoms 
are  often  an  irregular  commingling  of  those  belonging  to  the  two  dis- 
eases. They  may  begin  simultaneously,  or  more  frequently  one  develops 
as  the  other  is  subsiding. 

Diagnosis. — The  characteristic  symptoms  of  scarlet  fever  are  the 
abrupt  onset,  usually  with  vomiting,  the  marked  elevation  of  tempera- 
ture, the  erythematous  condition  of  the  throat,  the  punctate  eruption  on 
the  hard  palate,  with  the  appearance  of  the  rash  within  twenty-four 
hours,  and  later  the  characteristic  appearance  of  the  tongue.  The  diffi- 
culties of  diagnosis  usually  depend  upon  irregularities  in  the  eruption. 
The  variations  are  seen  in  the  mildest  and  in  the  most  severe  cases. 
In  the  former  the  rash  may  be  of  short  duration,  often  less  than  a  day, 
and  in  consequence  easily  overlooked;  or  it  may  be  present  only  upon 
certain  parts  of  the  body  instead  of  being  diffuse.  In  every  doubtful 
case  the  groins,  axilla?,  and  loins  should  be  closely  scrutinised  for  a  punc- 
tate eruption.  In  very  severe  attacks  also  the  rash  may  be  uncertain. 
It  may  appear  late  or  recede  after  being  fully  out,  or  it  may  be  hsemor- 
rhagic  or  in  irregiilar  blotches  instead  of  a  uniform  blush.  In  all  cases, 
too  much  stress  should  not  be  placed  upon  the  rash  alone. 

Until  we  have  some  exact  means  of  laboratory  diagnosis  as  in  typhoid 
fever,  malaria,  and  diphtheria,  an  absolute  diagnosis  will  in  certain  cases 
be  impossible.  Sometimes  the  diagnosis  remains  doubtful  until  the  end, 
although  ocpasionally  confirmatory  evidence  may  be  obtained  even  in 
convalescence.  Thus,  a  patient  may  desquamate  in  a  manner  so  typical 
as  to  leave  no  doubt  as  to  the  nature  of  the  preceding  illness;  again, 
the  occurrence  of  a  characteristic  sequel,  such  as  nephritis  in  the  third 
or  fourth  week,  may  testify  strongly  for  scarlatina  as  the  primary  disease ; 
and,  finally,  the  outbreak  of  undoubted  cases  among  children  who  have 
been  in  contact  with  the  patient  is  practically  conclusive,  always  pro- 
vided other  sources- of  infection  can  be  excluded.  Desquamation,  how- 
ever, follows  so  many  other  eruptions  that  when  slight  or  irregular  one 
should  not  rely  upon  it  as  an  evidence  of  scarlet  fever,  but  only  upon 
a  typical  exfoliation  upon  the  hands  and  feet.  It  is  a  point  of  some 
practical  importance  not  to  oil  the  skin  of  a  patient  when  awaiting 
desquamation  for  diagnosis,  as  this  alters  very  much  the  characteristic 
appearances.  In  some  puzzling  epidemics  the  length  of  the  incubation 
may  be  of  material  assistance  in  the  diagnosis;  where  this  is  regularly 
more  than  a  week,  one  may  be  pretty  sure  that  he  is  not  dealing  with 
scarlet  fever. 

Scarlet  fever  with  severe  throat  symptoms  and  doubtful  eruption 
can  be  distinguished  from  diphtheria  only  by  cultures,  which  should 
be  made  early  and  repeated  if  the  first  result  is  uncertain.  Measles  is 
distinguished  from  scarlet  fever  by  the  length  of  the  invasion,  the 
catarrhal  symptoms,  and  the  slowly  spreading  eruption,  but  most  of 


922  THE  SPECIFIC   INFECTIOUS  DISEASES. 

all  by  Koplik's  spots.  Much  more  difficult  is  it  to  distinguish  betweon 
mild  scarlatina  and  rubella.  In  rubella  the  important  thing  is  that, 
although  the  rash  may  be  well  marked,  often  covering  the  body,  the 
constitutional  symptoms  are  few  or  entirely  absent.  In  scarlet  fever 
with  an  eruption  of  the  same  intensity  there  is  almost  invariably  a 
considerable  elevation  of  temperature,  usually  102°  or  103°  F.,  and  a 
bright  red  throat. 

There  are  so  many  skin  eruptions  which  may  resemble  that  of  scarlet 
fever,  that  it  is  always  hazardous  to  make  the  diagnosis  of  this  disease 
from  the  eruption  alone.  This  is  especially  true  of  sporadic  cases  occur- 
ring in  infants;  there  is  seen  at  this  age  a  great  variety  of  eruptions, 
usually  associated  with  digestive  disturbances,  which  closely  simulate  a 
scarlatinal  rash;  but  most  of  them  are  of  short  duration.  A  scarlatini- 
form  erythema  is  occasionally  seen  after  diphtheria  antitoxine,  also  in 
influenza,  typhoid  fever,  pneumonia,  and  varicella,  which  may  cause 
them  to  be  mistaken  for  scarlet  fever,  or  may  lead  to  the  conclusion  that 
both  diseases  are  present.  The  same  is  the  case  with  the  septic  erythema 
occurring  in  surgical  patients.  Belladonna,  quinine,  and  occasionally 
antipyrine,  the  salicylates  and  aspirin  may  produce  eruptions  more  or 
less  closely  resembling  that  of  scarlet  fever.  This  is  also  true  of  some 
cases  of  urticaria  and  other  forms  of  skin  disease.  Eruptions  resembling 
scarlet  fever  may  also  arise  from  irritation  due  to  clothing,  to  heat,  to  the 
local  application  of  irritants  to  the  chest,  such  as  camphorated  oil,  etc. 
There  is  little  doubt  that  many  of  the  cases  reported  as  relapsing  scar- 
latina are  really  examples  of  recurring  erythema,  particularly  as  some 
of  the  latter  are  followed  by  a  desquamation  which  is  very  similar  to 
that  after  scarlatina.  In  all  doubtful  conditions  great  importance  is 
to  be  attached  to  the  constitutional  symptoms. 

Prognosis. — There  is  no  disease  in  which  it  is  more  difficult  to  foretell 
the  outcome  than  in  scarlet  fever.  Cases  apparently  of  the  mildest  type 
not  infrequently  develop  serious  symptoms  and  even  complications  that 
could  not  be  foreseen.  Symptoms  indicating  a  bad  prognosis  are,  very 
high  temperature,  especially  one  which  continues  to  rise  for  the  first  three 
or  four  days,  and  severe  nervous  and  throat  symptoms.  The  most  com- 
mon cause  of  death  is  the  disease  itself,  the  scarlatinal  toxaemia.  From 
this  cause  more  than  half  the  deaths  occur.  Next  are  the  complications, 
cardiac,  pulmonary,  renal,  otitic,  mastoid  and  cerebral,  given  in  the  order 
of  their  frequency.  The  mortality  of  scarlet  fever  varies  much  in  dif- 
ferent epidemics.  In  some,  nearly  all  the  cases  are  of  a  mild  type,  and 
the  mortality  may  be  as  low  as  3  or  4  per  cent;  in  others,  a  severe  or 
malignant  type  prevails,  and  it  may  be  as  high  as  40  per  cent.  The 
disease  is,  as  a  rule,  more  fatal  in  the  youngest  infants,  becoming  less 
so  as  age  advances.  This  is  well  shown  in  two  epidemics  in  the  New 
York  Infant  Asylum.    There  were — 


SCARLET  FEVER.  923 

Under  one  year 29  cases;  mortality,  55  per  cent. 

From  one  to  two  years 37      "  "  22    "       " 

From  two  to  three  years 28      "  "  7    "       " 

Over  three  years 23      "  "  0    "       " 

In  the  first  epidemic  the  general  mortality  was  12.5  per  cent;  in 
the  second  it  was  33  per  cent  in  the  same  class  of  children. 

The  following  are  the  mortality  records  from  various  European 
sources : 

Ashby,  Manchester  Hospital 681  cases;  mortality,  12.2  per  cent. 

Koren,  a  single  epidemic 426      "               "          14.0    "       " 

Bendz,  Copenhagen 22,036      "              "          12.2    "       " 

OUivier,  three  Paris  hospitals  for  five  years .  .  893      "               "          14.0    "       " 

Fleischmann,  five  epidemics 1,356      "               "          10.0    "       " 

The  general  mortality  of  the  disease  may  therefore  be  assumed  to  be 
from  13  to  14  per  cent;  it  is,  however,  much  higher  than  this  among 
young  children,  as  shown  by  the  following  figures: 

New  York  Infant  Asylum 116  cases  under  5  years;  mortality,  20  per  cent. 

Ashby,  Manchester  Hospital 259       "        "     5      "  "          23    "       " 

Bendz not  stated     "     5      "  "          13    "       " 

Heubner 136  cases      "     7      "  "         30    "       " 

Fleischmann not  stated     "     4      "  "         43    "       " 

Under  five  years  of  age  the  average  mortality  from  scarlet  fever  is, 
therefore,  between  20  and  30  per  cent. 

Prophylaxis. — Even  the  mildest  cases  should  be  isolated  for  four 
weeks,  and  all  cases  until  desquamation  is  complete.  If  complications 
exist,  such  as  otitis,  rhinitis,  pharyngitis,  empyema,  or  suppurating 
glands,  the  quarantine  should  be  continued  until  these  conditions  are 
cured.  Patients  should  not  be  allowed  to  mingle  with  other  children  for 
at  least  a  month  after  all  symptoms  have  subsided,  and  should  be  for- 
bidden to  sleep  with  other  children  for  three  months.  Children  in  the 
house  who  have  not  been  exposed  to  the  disease  shoiild  be  immediately 
sent  away;  and  those  who  have  been  exposed,  separately  quarantined  for 
at  least  a  week.  After  recovery,  the  patient,  before  mingling  with  other 
children,  should  have  at  least  two  disinfectant  baths,  the  entire  body 
being  scrubbed  with  soap  and  water  and  then  washed  in  a  solution  of 
carbolic  acid  (1  to  50)  or  bichloride  (1  to  5,000),  and  every  particle  of 
clothing  changed.  The  hair  and  the  scalp  should  be  thoroughly  washed 
and  disinfected. 

The  nurse  should  be  quarantined  with  the  patient,  and  should  not 
mingle  with  other  members  of  the  family  until  a  complete  change  of 
clothing  has  been  made,  and  hands  and  face  and  hair  thoroughly  disin- 
fected. The  nurse  and  all  others  in  close  contact  with  a  severe  case 
should  use  frequently  an  antiseptic  gargle  and  a  nasal  spray.    The  room 


924  THE  SPECIFIC   INFECTIOUS   DISEASES. 

should  be  in  that  part  of  the  house  most  easily  quarantined,  usually  on 
the  top  floor;  during  the  attack  it  should  be  stripped  of  upholstery, 
hangings,  and  carpet,  and  should  be  freely  ventilated  and  kept  as  clean 
as  possible.  All  dust  should  be  removed  with  damp  cloths  which  sliould 
afterward  be  burned;  the  floor  should  occasionally  be  sprinkled  with  a 
bichloride  solution  (1  to  1,000).  The  presence  in  the  room  of  vessels 
filled  with  antiseptic  fluids  is  of  no  practical  value.  The  same  may  be 
said  of  sheets  wet  in  carbolic  or  other  solutions  and  hung  about  the 
room.  Carbolic-acid  poisoning  has  been  known  to  result  from  this 
practice.  After  an  attack  it  should  be  remembered  that  the  room  is 
probably  a  greater  source  of  danger  than  the  patient.  Smooth  walls 
should  be  wiped  with  damp  cloths  wrung  out  of  a  bichloride  solution 
(1  to  2,000).  The  wood-work  should  be  washed  in  the  same  solution 
and  the  floor  scrubbed  with  it.  After  a  thorough  cleaning,  while  the 
floor  is  still  wet  and  walls  damp,  the  apartment  should  be  fumigated 
with  sulphur,  or  better  with  formaldehyde.  Of  the  various  metliods  of 
generating  formaldehyde,  that  of  Wilson  ^  is  probably  the  cheapest,  sim- 
plest, and  most  effective.  If  fumigation  is  to  be  efficient  the  room  must 
be  tightly  closed,  all  cracks  being  stopped  with  cotton,  and  larger  open- 
ings about  doors,  windows,  and  fireplaces  sealed  b}'  pasting  paper  over 
them.  Bedding,  cushions,  pillows,  carpets,  etc.,  should  be  hung  over 
chairs  or  upon  lines  strung  about  the  room.  Books  should  be  sus- 
pended from  covers  so  that  the  leaves  are  exposed.  After  fumigation, 
the  room  should  remain  closed  for  twelve  hours.  After  a  severe  case,  the 
walls  should  be  painted  or  whitewashed,  or  if  papered,  the  wall-paper 
should  invariably  be  renewed  and  the  wood-work  repainted.  Simply 
airing  a  room  after  an  attack  is  of  little  or  no  benefit.  An  instance  is 
on  record  of  a  patient  contracting  the  disease  in  a  room  in  which  the 
windows  had  been  open  constantly  for  three  months.  The  carpets, 
bedding,  hangings,  and  upholstery  can  be  disinfected  only  by  steam 
under  pressure.  Where  this  is  impossible,  after  a  severe  case  the  mat- 
tress and  pillows  should  be  burned.  Bedding,  blankets,  and  other  articles 
should  be  boiled. 

The  bedclothes,  linen,  and  clothing  removed  from  the  patient  during 
an  attack,  should  be  put  at  once  into  a  solution  of  carbolic  acid  (1  to 
20),  or  zinc  sulphate  four  ounces,  common  salt  two  ounces,  and  water 
one  gallon,  and  afterward  boiled  in  the   same  solution.      Instead  of 

'  For  each  1,000  cu.  ft.  of  space  there  is  required  1  lb.  of  absolutely  quick  lime, 
6  oz.  of  a  40-per-cent  solution  of  formaldehyde,  2  oz.  of  a  saturated  solution  of  alumi- 
num sulphate.  The  ingredients  may  be  mixed  in  a  bucket  or  bowl,  which  should 
stand  upon  wood  or  in  a  vessel  containing  water,  as  considerable  heat  is  generated. 
The  lime  is  first  moistened  with  water;  then  the  two  solutions  previously  mixed  are 
poured  on  and  thoroughly  mixed  with  the  lime  by  stirring.  The  liberation  of  the 
formaldehyde  gas  takes  place  very  rapidly,  practically  all  of  it  in  fifteen  or  twenty 
minutes.     For  a  large  room  several  receptacles  are  better  than  a  single  large  one. 


SCARLET   FEVER.  925 

handkerchiefs,  pieces  of  old  muslin,  surgeon's  gauze,  or  absorbent  cot- 
ton should  be  used  for  cleansing  the  nose  and  mouth  of  tlie  patient 
and  burned  immediately. 

The  physician  in  attendance  should  leave  his  coat  and  overcoat  in 
an  anteroom,  and  put  on  a  cap  and  a  long  gown  or  rubber  coat,  suffi- 
ciently large  to  cover  all  his  clothing.  Kubber  gloves  may  be  worn  as 
an  additional  jjrecaution.  The  gown  and  cap  sliould  always  be  worn  in 
the  sick-room,  and  boiled  or  disinfected  when  the  case  is  finished.  For  a 
single  visit  the  overcoat  may  be  worn  in  the  room,  but  the  clothing 
should  be  changed  before  visits  to  other  children  are  made.  After  every 
visit  the  physician's  hands  and  face  should  be  tliorouglily  waslied  with 
soap  and  then  with  a  disinfectant  solution.  A  pliysician  in  attendance 
upon  scarlatinal  patients  should  not  attend  obstetric  cases  or  other 
patients  with  recent  wounds. 

Schools  are  hot-beds  for  the  spread  of  scarlet  fever.  The  greatest 
sources  of  danger  are  the  mild  or  walking  cases  in  which  the  disease  has 
not  been  recognised,  and  the  clothing  of  patients  who  have  had  a  severe 
form  of  the  disease.  As  a  rule,  a  child  should  be  kept  from  school  six 
weeks  from  the  beginning  of  the  attack,  and  the  certificate  of  a  physician 
should  be  required  before  readmission,  stating  not  only  that  the  des- 
quamation is  complete,  but  also  that  the  child  is  suffering  from  no 
sequelas.  Other  children  in  the  household  should  not  be  allowed  to  attend 
schools  of  any  kind  during  the  period  of  active  symptoms;  they  should 
be  kept  at  home  on  the  average  for  a  month.  This  precaution  is  neces- 
sary, first,  because  they  might  carry  the  disease  from  the  patient  at  home ; 
secondly,  because  otherwise  they  might  themselves  attend  school  while 
suffering  from  the  disease  in  a  very  mild  form  or  during  the  period  of 
invasion.  When  the  sick  child  is  completely  isolated,  the  danger  from 
the  first  source  is  very  slight.  During  severe  epidemics  it  frequently 
becomes  necessary  to  close  all  schools. 

During  desquamation  the  spread  of  the  disease  may  be  in  a  measure 
prevented  by  the  free  use  of  inunctions  and  warm  antiseptic  baths.  All 
the  excreta  from  the  patient  should  be  disinfected  throughout  the  dis- 
ease, best  by  a  carbolic  solution  (1  to  20).  If  cases  of  scarlet  fever  are 
to  be  transported,  this  should  be  done  only  in  a  vehicle  which  can  be 
easily  disinfected.  Under  all  circumstances  as  few  persons  as  possible 
should  come  in  contact  with  the  patient. 

In  general,  it  is  to  be  remembered  that  the  danger  is  first  from  the 
patient,  secondly  from  the  room,  and  thirdly  from  the  nurse.  Special 
attention  should  always  be  given  to  the  complete  and  immediate  isolation 
of  the  first  case  which  appears  ifi  an  institution  or  community,  which 
should  apply  to  mild  as  well  as  severe  forms  of  the  disease. 

Treatment. — There  is  as  yet  no  specific  for  scarlet  fever.  The  physi- 
cian's duty  in  the  average  case  consists  in  (1)  establishing  proper  quar- 


926  THE  SPECIFIC  INFECTIOUS  DISEASES. 

antine  and  the  carrying  out  of  adequate  means  of  disinfection;  (2)  the 
hygienic  care  of  the  patient;  (3)  directing  the  diet;  (4)  watching' for 
complications,  especially  otitis  and  nephritis.  It  should  be  borne  in  mind 
that  otitis  is  rarely  accompanied  by  pain  or  tenderness,  and  is  recognised 
only  by  an  examination  of  the  ears;  also  that  severe  and  fatal  nephritis 
may  follow  mild  as  well  as  severe  cases. 

Mild  attacks  require  no  medicine.  Children  should  be  kept  in  bed 
for  at  least  a  week  after  the  fever  has  subsided,  and  upon  a  diet  of  milk 
and  farinaceous  food  with  plenty  of  water  for  a  period  of  three  weeks. 
This  is  an  important  matter  in  the  prevention  of  nephritis.  During 
the  height  of  the  eruption,  the  intense  itching  of  the  skin  may  be  allayed 
by  sponging  with  a  bicarbonate  of  soda  solution,  or  by  inunctions  with 
vaseline,  or  by  the  free  use  of  rice  or  talcum  powder.  Plenty  of  fresh 
air  should  always  be  secured  in  the  sick-room.  As  soon  as  the  fever 
and  rash  have  disappeared,  daily  warm  baths  with  soap  and  water  should 
be  used,  after  which  the  entire  body  should  be  anointed  with  vaseline, 
with  the  purpose  of  facilitating  desquamation.  In  case  the  skin  becomes 
irritated  by  this  treatment,  bran  baths  may  be  substituted  for  soap 
and  water. 

The  temperature  does  not  usually  require  interference  when  it  only 
occasionally  rises  to  104°  or  104.5°  F.  But  if  there  is  hyperpyrexia,  or 
a  temperature  which  ranges  from  104°  to  105.5°  F.  or  over,  antipyretic 
measures  are  called  for.  Hydrotherapy  is  much  safer  and  more  certain 
than  drugs.  Sometimes  sponging  is  sufficient,  but  in  the  great  propor- 
tion of  cases  the  pack  or  bath  is  required.  The  use  of  water  in  the 
reduction  of  temperature  is  especially  indicated  in  septic  cases  with 
typhoid  symptoms,  and  in  those  with  pronounced  cerebral  symptoms. 
The  temperature  of  the  water  employed  will  depend  upon  the  duration 
of  its  application.  It  is  generally  better  to  use  prolonged  sponging  or 
bathing  with  tepid  water  than  water  at  a  lower  temperature  for  a  shorter 
period. 

The  nervous  symptoms  are  frequently  better  controlled  by  ice  to  the 
head  and  by  cold  sponging  than  by  medication.  Antipyretic  drugs  may 
be  relied  upon  to  control  restlessness  and  promote  sleep,  and  in  mild 
cases  to  effect  a  moderate  reduction  in  temperature.  Phenacetine  is 
usually  to  be  preferred. 

As  soon  as  the  pulse  becomes  weak  or  rapid  and  irregular,  or  the 
first  sound  of  the  heart  feeble,  stimulants  should  be  given,  no  matter  at 
what  stage  of  the  disease.  In  septic,  or  malignant  cases,  or  in  those 
accompanied  by  severe  angina,  adenitis,  or  cellulitis,  stimulants  should 
be  used  freely.  Digitalis  is  especially  valuable  when  the  pulse  is  weak 
and  the  tension  low.  It  may  be  given  alone  or  combined  with  caffein; 
one  minim  of  the  fluid  extract  of  digitalis,  and  gr.  ^  of  caffein  being 
the  initial  doses  for  a  child  of  five  years. 


MEASLES.  927 

The  erythematous  sore  throat  requires  no  treatment  except  the  use 
of  a  bland  gargle.  If  there  is  a  profuse  nasal  discharge,  gentle  nasal 
syringing  with  a  warm  saline  or  boric-acid  solution  may  be  used  with 
the  hope  of  preventing  infection'  of  the  middle  ear.  The  local  treat- 
ment of  the  throat  is  the  same  as  that  of  other  cases  of  severe  angina. 

Milder  forms  of  adenitis  require  no  local  treatment.  When  severe, 
the  glands  should  be  covered  with  ichtliyol,  and  an  ice-bag  applied  con- 
tinuously. Poulticing  almost  invariably  does  harm.  If  an  abscess  forms, 
early  incision  should  be  practised. 

The  ears  of  patients  with  severe  throat  symptoms  should  be  examined 
daily  in  order  that  there  may  be  no  delay  in  performing  paracentesis 
should  this  become  necessary.  Any  rise  in  temperature  should  direct 
attention  to  the  ears.  The  indications  for  the  operation  are  the  same 
as  in  other  severe  forms  of  otitis. 

The  physician  should  be  constantly  on  the  watch  for  the  development 
of  nephritis,  not  only  during  the  febrile  period,  but  also  during  con- 
valescence. Repeated  examinations  of  the  urine  are  absolutely  necessary. 
These  are  much  facilitated  by  having  a  rack  of  test  tubes  and  the  ordi- 
nary reagents  for  detecting  albumin  in  the  sick-room,  so  that  the  physi- 
cian may  himself  examine  daily  a  fresh  specimen  of  urine.  The  nurse 
should  be  instructed  to  measure  and  record  accurately  the  twenty-four 
hours'  urine  throughout  the  attack.  The  treatment  of  scarlatinal 
nephritis  has  been  considered  in  the  chapter  devoted  to  Diseases  of  the 
Kidney.  Diffiise  cellulitis  of  the  neck  calls  for  free,  early  incision  as  the 
only  means  of  preventing  extensive  sloughing. 

Sera  prepared  by  means  of  several  different  varieties  of  streptococci 
have  been  produced  and  extensively  used  without  any  uniform  or  striking 
success.  One  has  been  produced  by  Moser  (Vienna),  concerning  whose 
effects  there  is  much  more  favourable  evidence.  Escherich,  Bokay,  and 
other  reliable  Continental  observers  in  their  reports  have  declared  that 
its  effects  are  not  less  striking  than  those  obtained  from  diphtheria 
antitoxine.     It  is  not  yet  available  in  this  country. 

During  convalescence,  the  urine  should  be  frequently  examined; 
antiseptic  gargles  and  a  nasal  spray  should  be  used  as  long  as  a  purulent 
discharge  from  the  nose  or  pharynx  continues. 


CHAPTER    II. 

MEASLES. 

{Rubeola,  Morbilli.) 

Measles  is  an  epidemic  contagious  disease,  more  widely  prevalent 
than  any  other  eruptive  fever ;  very  few  persons  reach  adult  life  without 


928  THE  SPECIFIC   INFECTIOUS   DISEASES. 

contracting  it.  One  attack  usually  confers  immunit}'.  It  is  higlily  con- 
tagious even  from  the  beginning  of  the  invasion,  and  spreads  with  great 
rapidity  from  the  patient  to  all  susceptible  persons  exposed.  The  infec- 
tious agent,  however,  does  not  cling  so  long  to  clothing  or  apartments 
as  does  that  of  scarlet  fever.  Measles  has  a  period  of  incubation  of 
from  eleven  to  fourteen  days;  a  gradual  invasion  of  tliree  or  four  days 
with  symptoms  of  an  acute  coryza,  and  a  maculo-papular  eruption  which 
appears  first  upon  the  face  and  spreads  slowly  over  the  body,  and  which, 
lasts  from  four  to  six  days.  This  is  followed  by  a  fine  bran-like  des- 
quamation, which  is  complete  in  about  a  week.  The  mortality  is  low, 
except  among  infants  and  delicate  children,  in  whom  it  may  reach  30 
or  even  40  per  cent.  In  institutions  for  infants  and  young  children 
no  disease  is  more  to  be  dreaded  than  measles,  not  only  on  account  of 
its  severity,  but  from  the  frequency  with  which,  in  such  subjects,  it  is 
complicated  by  broncho-pneumonia. 

Etiology. — The  essential  cause  of  measles  is  as  yet  unknown.  It  is 
generally  believed  to  be  due  to  a  micro-organism,  but,  as  in  the  case  of 
scarlatina,  all  attempts  to  isolate  it  have  thus  far  been  unsuccessful. 
The  virus  is  one  which  possesses  remarkable  powers  of  diffusion,  but 
whose  viability  is  much  less  than  that  of  most  of  the  pathogenic  germs 
which  are  known.  Only  a  short  exposure  is  required  to  communicate 
the  disease,  and  even  close  proximity  to  a  patient  does  not  seem  neces- 
sary. One  instance  has  come  under  my  own  observation  where  measles 
was  apparently  conveyed  by  an  exposure  of  half  an,  hour  across  a  hos- 
pital ward,  a  distance  of  at  least  fifteen  feet. 

Predisposition. — Very  young  infants  do  not  so  readily  contract 
measles,  but  all  other  children  are  extremely  susceptible.  The  disease 
broke  out  in  a  cottage  of  the  New  York  Infant  Asylum  which  was  occu- 
pied by  twenty-three  children,  nearly  all  of  them  being  under  two  years 
old;  only  four  escaped,  all  these  being  under  five  months  old.  In  an 
epidemic  reported  by  Smith  and  Dabney,  110  unprotected  children, 
between  the  ages  of  eight  and  eighteen  years,  were  exposed  and  only 
two  escaped.  In  the  Nursery  and  Child's  Hospital,  during  an  epidemic, 
there  were  62  children  over  two  years  of  age;  five  were  protected  by  a 
previous  attack  and  escaped ;  of  the  remaining  57  children,  55  took  the 
disease.  There  were  also  in  the  institution  113  children  under  two  years 
old;  of  this  number  78  per  cent  took  the  disease;  but,  although  a  num- 
ber were  exposed,  not  one  child  under  six  months  old  contracted  measles. 
The  age  of  the  persons  affected  depends  much  upon  the  length  of  time 
since  the  last  outbreak  of  the  disease.  In  an  epidemic  occurring  in  the 
Island  of  Guernsey,  where  the  disease  had  not  prevailed  for  many  years, 
all  ages  were  affected,  the  youngest  being  twelve  days  old,  and  the  oldest, 
a  man  and  wife,  each  aged  eighty  years.  Somer  has  reported  an  instance 
of  an  eruption  of  measles  appearing  in  a  child  twelve  hours  after  birth; 


MEASLES.  929 

the  mother  was  suffering  from  the  disease  at  the  time.  Gautier  has 
collected  six  additional  cases,  where  measles  either  existed  at  the  time 
of  birth  or  developed  within  a  few  hours  after  it. 

Except,  then,  in  early  infancy,  the  probal)iliti(;s  are  very  strong  tliat 
every  child  exposed  to  measles  will  contract  the  disease.  Occasionally, 
however,  one  is  seen  who  seems  insusceptible  to  the  poison,  no  matter 
how  close  the  exposure. 

Epidemics  of  measles  are  more  frequent  and  more  severe  during  the 
winter  and  spring  months.  They  are  least  frequent  and  mildest  during 
the  autumn  months. 

Incubation. — In  Hi  cases,^  in  which  the  period  of  incubation  could 
be  definitely  traced,  it  was  as  follows : 

Incubation  of  less  than  nine  days 3  cases. 

"  "  nine  or  ten  days 22      '•' 

"  '    eleven  to  fourteen  days 95      " 

"  "  fifteen  to  seventeen  days 19      " 

"  **'  eighteen  to  twenty-two  days 5      " 

Thus  in  66  per  cent  of  the  cases  the  incubation  was  Ijetween  eleven  and 
fourteen  days,  and  in  only  one  case  was  it  less  than  a  week.  The  con- 
stancy of  the  incubation  period  is  strikingly  shown  in  some  epidemics. 
Thus  in  the  one  reported  by  Smith  and  Dabney  in  an  institution  in 
Virginia,  exactly  eleven  days  after  the  rash  appeared  in  the  first  case, 
the  disease  developed  in  twenty  children — no  cases  having  occurred  in 
the  interval. 

Duration  of  the  Infective  Period. — This  is  much  shorter  than  in 
scarlet  fever,  and  the  average  duration  may  be  placed  at  three  weeks. 
Haig-Brown  discharged  fifty -eight  cases  on  or  before  the  twenty-ninth 
day  of  the  disease,  and  in  no  instance  was  measles  spread  by  these 
children.  Eansom,  however,  records  one  instance  in  which  it  was  com- 
municated thirty-one  days  after  the  appearance  of  the  rash. 

Measles  is  highly  contagious  from  the  beginning  of  the  catarrhal 
symptoms.  A  case  occurred  in  the  Babies'  Hospital  under  my  own  ob- 
servation, in  which  a  child  conveyed  the  disease  four  days  before  the  rash 
appeared.  Eansom  reports  another  precisely  similar.  An  instance  has 
been  related  to  me  by  Dr.  S.  W.  Lambert,  where,  of  thirteen  little  girls 
who  were  at  a  children's  party,  only  one  escaped  measles,  the  source  of 
infection  being  a  child  who  showed  no  rash  until  the  following  day ;  the 
child  who  escaped  had  previously  had  measles.  The  period  of  greatest 
contagion  is  still  a  matter  of  dispute,  the  general  belief  being  that  it  is 
coincident  with  the  highest  temperature,  the  full  eruption,  and  the  most 
severe  catarrhal  symptoms. 

'  About  twenty-five  of  these  are  taken  from  my  own  records;  the  remainder  are 
mainly  isolated  cases,  scattered  through  medical  literature.     The  incubation  is  reck-i 
oned  from  the  time  of  exposure  to  the  beginning  of  the  catarrh. 
60 


930  THE  SPECIFIC  INFECTIOUS  DISEASES. 

With  the  fading  of  the  eruption  and  the  subsidence  of  the  catarrh,  the 
communicability  of  measles  diminishes  rapidly.  It  is  relatively  feeble 
during  desquamation,  and  soon  after  this  period  it  usually  ceases  alto- 
gether. It  is  generally  proportionate  to  the  severity  of  the  catarrhal 
symptoms,  and  when  these  are  protracted  it  is  probable  that  the  disease 
may  be  communicated  for  a  much  longer  period  than  that  mentioned. 

Mode  of  Infection. — Measles  is  usually  spread  by  direct  contagion, 
very  infrequently  through  the  medium  of  clothing,  furniture,  or  a  third 
person.  Measles  rarely  if  ever  clings  to  apartments  for  weeks  or  months, 
as  does  scarlet  fever.  Many  instances  are  on  record  in  which  the  dis- 
ease has  been  carried  by  a  third  person;  but,  after  all,  this  rarely  hap- 
pens, unless  the  contact  both  with  the  sick  and  the  well  child  is  very 
close  and  the  interval  short.  It  is  very  seldom  that  measles  is  carried 
by  a  physician  who  takes  even  ordinary  precautions.  In  a  case  reported 
by  Girom,  the  clothing  of  a  patient  is  stated  to  have  conveyed  the  dis- 
ease nineteen  days  after  an  attack,  but  tliis  must  be  regarded  as  very 
exceptional. 

Lesions. — The  only  constant  lesions  of  measles  are  those  of  the  skin 
and  the  mucous  membranes,  chiefly  of  the  respiratory  tract.  According 
to  Neumann,  the  process  in  the  skin  is  of  an  inflammatory  character,  but 
is  more  superficial  than  in  scarlet  fever.  There  is  congestion,  accom- 
panied by  an  exudation  of  round  cells  about  the  small  blood-vessels,  and 
also  about  the  sweat  and  sebaceous  glands,  and  the  papillae.  To  this 
exudation  and  the  oedema,  the  swelling  of  the  skin  is  due.  It  occurs 
everywhere,  but  is  especially  noticeable  upon  the  face. 

The  changes  in  the  mucous  membranes  are  quite  as  much  a  part  of 
the  disease  as  are  those  of  the  skin.  There  is  a  catarrhal  inflammation 
affecting  the  conjunctivae,  nose,  pharynx,  larynx,  trachea,  and  large 
bronchi,  which  varies  in  intensity  with  the  severity  of  the  attack.  In  the 
most  severe  forms  in  infants  and  in  young  children,  this  inflammation 
extends  with  great  uniformity  to  the  small  bronchi,  and  usually  to  the 
air  vesicles,  causing  broncho-pneumonia.  In  severe  cases,  the  lesion  in 
the  pharynx  and  larynx  also,  instead  of  being  catarrhal,  may  be  mem- 
branous; the  larynx  being  much  more  frequently  involved,  and  the  ears 
much  less  so,  than  in  scarlet  fever.  Freeman  has  described  areas  of  focal 
necrosis  in  the  liver  similar  to  those  found  in  diphtheria;  they  were 
present  in  four  of  twelve  cases  examined.  The  lesions  of  the  lungs  and 
of  other  organs  will  be  more  fully  considered  under  Complications. 

The  bacteria  which  are  associated  with  the  lesions  of  the  respiratory 
tract  are  the  staphylococcus  and  the  streptococcus,  separately  or  together, 
and  either  form  may  be  associated  with  the  pneumococcus  (see  Bac- 
teriology of  Broncho-Pneumonia).  Measles  produces  conditions  in  the 
mucous  membranes  of  the  respiratory  tract  which  are  especially  favour- 
able for 'the  development  of  these  bacteria.     They  are  present  in  the 


MEASLES. 


931 


mouth  in  great  numbers;  they  may  cause  pneumonia,  otitis,  and  other 
local  inflammations,  and  the  pneumococcus  or  streptococcus  may  produce 
a  general  septicaemia. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  measles  is  gradual, 
both  the  fever  and  catarrhal  symptoms  increasing  steadily  up  to  the  ap- 
pearance of  the  eruption.  The  characteristic  symptoms  of  the  invasion 
are  those  of  a  severe  coryza — suffusion  of  the  eyes,  increased  lachryma- 
tion,  photophobia,  sneezing,  and  a  discharge  from  the  nose.  The  hoarse, 
hard  cough  indicates  that  the  catarrhal  process  has  involved  the  larynx 
and  trachea,  as  well  as  the  visible  mucous  membranes.  Frequently  the 
patient  complains  of  some  soreness  of  the  throat,  and  on  inspection  there 
is  seen  moderate  congestion  of  the  tonsils,  fauces,  and  pharynx.  On  the 
hard  palate  are  frequently  seen  small  red  spots.  Much  more  character- 
istic are  the  minute  white  spots  upon  the  mucous  membrane  of  the  cheeks, 
known  as  Koplik's  sign  (see  Diagnosis).  The  constitutional  symptoms 
are  indefinite,  and  may  be  met  with  in  almost  any  disease.  There  are 
dulness,  headache,  pains  in  the  back,  and  the  usual  symptoms  of  malaise; 
there  is  rarely  vomiting  or  diarrhoea.  Drowsiness  is  a  frequent  symp- 
tom, and  is  regarded  by  the  laity  as  characteristic. 

The  exceptional  cases  in  which  the  invasion  is  abrupt  are  puzzling. 
There  may  be  a  sudden  accession  of  fever  with  vomiting,  and  even  con- 
vulsions, as  in  a  case  lately  under  my  observation.  Not  infrequently, 
when  the  disease  prevails  epidemically,  the  invasion  is  sudden,  with  high 
fever  and  pulmonary  symptoms  which  are  so  severe  as  to  mask  every- 
thing else  until  the  rash  makes  its  appearance,  the  case  up  to  that  time 
being  often  regarded  as  one  of  primary  pneumonia  or  of  influenza.  The 
duration  of  the  stage  of  invasion — i.  e.,  from  the  beginning  of  the 
catarrh  until  the  eruption — in  270  cases  of  which  I  have  notes,  was 
as  follows: 


1  day  or  less 35  cases. 

2  days 47      " 

3  "     64      " 

4  "    64      " 

6     "     29      " 


6  days 20  cases. 

7  "     6      " 

8  "    2     " 

9  "    2      " 

10     "    1  case. 


From  this  table  it  will  be  seen  that  the  length  of  the  period  of  inva- 
sion varies  considerably — more,  I  think,  in  infants  and  very  young  chil- 
dren (most  of  these  were  under  three  years  old)  than  in  those  who  are 
older.    In  the  greater  number  of  cases  it  lasts  from  two  to  four  days. 

Eruption. — The  rash  usually  appears  on  the  third,  fourth,  or  fifth 
day  of  the  disease — in  the  largest  number  upon  the  fourth  day.  As  a 
rule,  it  is  first  seen  behind  the  ears,  on  the  neck,  or  at  the  roots  of  the 
hair  over  the  forehead.  It  appears  as  small,  dark-red  spots,  which  are 
at  first  few,  scattered,  and  not  elevated,  resembling  flea-bites.  In  twenty- 
four  hours  the  macules  are  much  more  numerous,  and  many  of  them 


932  THE  SPECIFIC  INFECTIOUS  DISEASES. 

have  become  papules.  They  frequently  group  themselves  in  crescentic 
forms.  They  are  usually  separated  by  areas  of  normal  skin,  but  where 
the  rash  is  intense  they  are  frequently  coalescent.  From  the  time  of  its 
first  appearance  to  the  full  development  of  the  rash  on  the  face,  is  usu- 
ally about  thirty-six  hours,  but  may  be  from  one  to  three  days.  With 
a  full  eruption  (Plate  XVI)  there  is  considerable  swelling  of  the  face, 
especially  about  the  eyes,  and  the  features  are  sometimes  scarcely  recog- 
nisable. On  the  second  day  of  the  rash  it  begins  to  appear  upon  the 
neck  beneath  the  chin,  the  upper  part  of  the  chest  and  back ;  on  the  third 
day  the  trunk  is  covered,  and  scattered  spots  are  seen  upon  the  extremi- 
ties. The  rash  appears  last  upon  the  lower  extremities,  and  by  the 
time  it  is  fully  out  upon  them  it  has  usually  begun  to  fade  from  the 
face.  In  mild  cases  it  remains  discrete,  but  in  severe  ones  it  is  fre- 
quently confluent  upon  the  face  and  upon  the  extensor  surfaces  of  the 
extremities.    As  a  rule,  it  covers  the  entire  body,  even  the  palms  and  soles. 

The  eruption  fades  slowly  in  the  order  of  its  appearance,  and  there 
is  left  behind,  in  typical  cases,  a  slight  brownish  staining  of  the  skin 
which  often  remains  for  a  week  or  more.  The  duration  of  the  rash  is 
from  one  to  six  days,  the  average  being  four  days. 

There  are  many  cases  in  which  the  rash  does  not  follow  the  typical 
course  described:  (1)  Instead  of  spreading  gradually,  the  entire  body 
may  be  covered  in  a  few  hours.  (2)  The  rash  may  be  hsemorrhagic. 
This  condition  was  present  in  about  five  per  cent  of  my  cases.  The 
whole  eruption  may  be  haemorrhagic,  or  it  may  be  so  only  upon  certain 
parts — usually  the  abdomen  or  extremities.  Under  such  circumstances 
small  petechial  spots  take  the  place  of  the  macules — the  "  black  measles  " 
of  the  older  writers.  It  is  in  most  cases  a  bad,  but  by  no  means  a 
fatal  symptom.  I  have  seen  it  in  several  cases  that  were  not  especially 
severe.  (3)  The  rash  may  be  very  faint,  and  of  short  duration,  being 
scarcely  elevated  at  all.  (4)  It  may  consist  of  very  minute  papules, 
closely  resembling  the  rash  of  scarlet  fever.  It  is  to  be  remembered,  how- 
ever, that  the  irregular  eruptions  of  scarlet  fever  much  more  frequently 
resemble  measles  than  vice  versa.  (5)  It  may  be  very  scanty,  and  late 
in  its  appearance;  particularly  in  cases  of  great  severity  and  h3'^per- 
pyrexia — the  so-called  malignant  cases.  (6)  Temporary  recession  of 
the  eruption  may  occur  at  any  time  during  the  height  of  the  disease,  and 
is  usually  due  to  heart  failure.  A  recurrence  of  the  eruption  after  it  has 
run  its  usual  course  is  something  which  I  have  never  seen;  although 
such  cases  have  been  reported,  I  believe  them  to  be  very  exceptional. 

During  the  first  two  days  of  the  eruption,  the  local  and  constitutional 
symptoms  increase  in  severity,  both  usually  reaching  their  maximum  at 
the  time  of  the  full  development  of  the  rash  upon  the  face.  The  skin 
is  swollen,  and  the  seat  of  intense  itching  and  burning.  The  eyes  are 
very  red  and  sensitive  to  light,  and  there  is  swelling  of  the  conjunctivae 


PLATE  XVI. 


Eruption  of  Measles. 

On  the  face  and  trunk  the  eruption  is  rather  more  confluent  than  is  usual;  on  the 
upper  part  of  the  chest,  on  the  lower  part  of  the  abdomen,  but  especially  on  the  left  arm, 
many  haemorrhagic  spots  are  seen.  The  eruption  on  the  lower  extremities  and  feet  is 
"typical  in  appearance. 


MEASLES.  933 

with  an  abundant  production  of  mucus  or  muco-pus,  causing  the  lids  to 
adhere.  There  is  pain  on  swallowing,  also  swelling  of  the  glands  at  the 
angle  of  the  jaw  or  in  the  post-cervical  region.  The  cough  is  frequent 
and  very  annoying.  There  is  complete  anorexia,  and  often  diarrhoea. 
The  tongue  is  coated,  and  may  show  at  its  margin  enlarged  papillae, 
somewhat  resembling  the  "  strawberry "  appearance  of  scarlet  fever. 
As  the  rash  fades  the  temperature  declines  rapidly,  often  reaching  the 
normal  in  two  or  three  days.  The  catarrhal  symptoms  now  subside,  and 
soon  the  patient  is  convalescent.  Within  a  day  or  two  after  the  fever 
has  ceased,  the  rash  disappears. 

Desquamation. — This  begins  almost  as  soon  as  the  rash  has  subsided, 
and  is  first  noticed  on  the  face  and  neck,  where  the  eruption  first  ap- 
peared. The  nature  of  the  desquamation  is  invariably  fine,  branny  scales, 
never  in  large  patches,  as  in  scarlet  fever.  It  is  often  quite  indistinct 
and  may  be  overlooked.  Its  usual  duration  is  from  five  to  ten  days.  It 
may,  however,  be  prolonged  for  two  weeks.  The  amount  of  desquama- 
tion varies  considerably  in  the  different  cases.  It  is  most  marked  in 
those  in  which  there  has  been  an  intense  eruption.  There  is  frequently 
noticed  at  this  time  an  odour  about  the  patient  which  is  quite  charac- 
teristic of  measles.  During  this  stage  the  cough  often  persists  and  the 
eyes  remain  weak  and  very  sensitive  to  light,  but  in  other  respects  the 
patient  usually  feels  perfectly  well. 

1.  The  Mild  Cases. — The  mildest  cases  are  distinguished  by  low  tem- 
perature, which  at  the  height  of  the  eruption  usually  reaches  102°  F.,  but 
rarely  lasts  more  than  four  days.  The  eruption  is  often  scanty,  and  is 
never  confluent.  The  swelling,  itching,  and  other  cutaneous  symptoms 
are  wanting,  as  is  also  the  intense  red  colour  of  the  skin.  The  rash  is 
frequently  obscure,  and,  without  the  other  symptoms,  hardly  sufficient 
for  diagnosis.  The  catarrhal  symptoms  are  more  uniform  than  the  rash, 
but  these  are  very  mild  as  compared  with  the  usual  form.  The  duration 
of  the  rash  is  shorter,  desquamation  is  scarcely  perceptible,  and  there  are 
no  complications. 

2.  The  Cases  of  Moderate  Severity. — The  course  of  measles  is  much 
more  regular  in  children  over  three  years  old  than  in  infancy.  In  the 
former,  the  symptoms  of  invasion  come  on  gradually,  and  the  tempera- 
ture rises  steadily  until  the  appearance  of  the  eruption,  which  is  in  most 
cases  on  the  third  or  fourth  day  of  the  disease.  Figs.  186  and  187  rep- 
resent the  typical  temperature  curve  in  average  uncomplicated  cases. 
Such  a  curve  was  seen  in  44  per  cent  of  173  cases  in  which  careful 
observations  were  made.  Sometimes  the  decline  in  the  fever  is  very 
rapid,  almost  a  crisis,  as  in  Fig.  186,  but  more  often  it  falls  gradually, 
as  in  Fig.  187.  In  such  cases  the  duration  of  the  fever  is  from  five  to 
nine  days,  the  average  being  about  a  week.  The  other  symptoms  follow 
very  closely  the  course  of  the  fever.     The  maximum  temperature  is 


934 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


nearly  always  coincident  with  the  full  rash  upon  the  face,  at  this  time 
usually  being  in  uncomplicated  cases  from  103°  to  104°  F.  in  older  chil- 
dren, and  104°  to  105°  F.  in  infants  and  young  children. 


OAT 

1 

2 

3 

4 

5 

6 

7 

8 

1 

Z 

1 

loe' 

105° 
104° 
103° 
108° 
101° 
100° 

99° 
98° 

M     E 

U     E 

M     E 

M     E 

U     E 

M     E 

M     E 

U     E 

X 
X 

h 

r 

A 

/ 

f\ 

/ 

J 

V 

s 

1 

i^ 

N 

y 

DAT 

1 

2 

3 

4 

5 

6 

7 

8 

9 

I 
Z 

1 
1 

106° 
105° 
104' 
103° 
108° 
101° 

loo" 

99° 
98° 

U      E 

M     E 

y    E 

M    E 

M     E 

M     E 

H     E 

M     E 

u    E 

X 

X 

, 

A 

^ 

A 

A 

V 

r 

A 

y 

l^ 

/ 

J 

"A 

^ 

> 

i/ 

V 

l^ 

Fig.  186.  —  Temperattjre  Curve  in  Un- 
complicated Measles,  Showing  the 
Gradual  Rise  and  Critical  Fall. 
Patient  ten  years  old;  x  -=  first  eruption; 
^  =  full  eruption  on  the  face. 


Fig.  187. — Typical  Curve  in  Uncompli- 
cated Measles,  with  Gradual  Risb 
AND  Gradual  Fall.  Patient  three 
years  old. 


A  not  very  uncommon  temperature  curve  is  that  of  Fig.  188,  where 
the  onset  of  the  disease  is  marked  by  a  sudden  rise  to  102°  or  even 
104°  F.,  with  a  fall  nearly  or  quite  to  normal  on  the  second  day,  after 

which  the  fever  rises  grad- 
ually, as  in  the  first  group. 
This  curve  was  seen  in  five 
per  cent  of  my  cases. 

3.  The  Severe  Cases. — 
In  Fig.  189  is  shown  a 
type  of  the  disease  which  is 
more  frequent  in  infants 
than  in  older  children,  the 
important  features  being  the 
late  eruption  and  the  con- 
tinuance of  the  high  fever 
for  several  days  after  the 
rash  has  begun  to  fade. 
Such  a  prolonged  course  and  so  high  a  temperature  are  almost  invariably 
due  to  some  complication,  usually  broncho-pneumonia.  Where  the  pneu- 
monia goes  on  to  the  production  of  areas  of  consolidation,  the  fever  usu- 
ally continues  for  three  and  sometimes  for  four  weeks,  even  though 
terminating  in  recovery. 

Figs.  190  and  191  illustrate  two  types  of  the  disease  which  are  often 
seen  when  measles  is  complicated  by  pneumonia.  In  cases  like  that 
shown  in  Fig.  189  the  onset  is  abrupt  with  high  temperature,  prostra- 
tion, and  pulmonary  symptoms  not  unlike  those  of  primary  pneumonia. 


DAY 

1 

2 

3 

4 

5 

C 

7 

8 

9 

10 

11 

12 

I 
Z 

a 
I 

100° 
106° 
104° 
103° 
102° 
101° 

100° 
99' 
98' 

M     £ 

U     E 

II     E 

M     E 

M     £ 

M     E 

II     E 

M     E 

M     E 

U     E 

H     E 

II     E 

X 

X 

X 

* 

/ 

\ 

A 

\ 

h 

/ 

V 

\ 

A 

/ 

\ 

1 

Y 

\ 

V 

V 

^ 

V 

^ 

V 

V 

\ 

/ 

Fig.  188.  —  A  Not  Infrequent  Temperature 
Curve  in  Measles,  Showing  Abrupt  Invasion, 
BUT  Subsequent  Course  Typical.  Uncom- 
plicated case;  patient  nine  months  old. 


MEASLES. 


935 


A  temperature  curve  resembling  this  was  seen  in  28  of  173  cases.  The 
rash  is  often  late  in  appearance;  it  is  faint  and  altogether  irregular; 
it  may  recede  after  the  first  day  and  reappear  after  an  interval  of  one 
or  two  days.  The  catarrhal  symptoms  are  not  marked,  but  the  whole 
force  of  the  disease  seems  to  be  expended  upon  the  lungs.  The  diag- 
nosis of  these  cases  presents  great  difficulties,  and  very  often  it  would 


DAY 

1 

2 

3 

1 

5 

G 

7 

8 

9 

10 

u 

12 

13 

u 

15 

16 

17 

t- 

a 

I 

z 

I 
< 

106° 
105° 
104° 
103" 
102" 
101° 
100° 
99° 
98° 

M      E 

M      E 

M      E 

M      E 

M     £ 

M      E 
X 

M      E 

M      E 

M      £ 

M     E 

M      E 

M     E 

M     E 

M    E 

M     E 

M      E 

M     E 

X 

1 

A 

A 

/ 

t 

1 

/ 

\r 

\P 

/ 

f 

A 

./\ 

X 

P 

/ 

V 

1/ 

V 

/ 

/ 

1 

\ 

h 

1/ 

¥ 

/ 

\ 

J 

j 

y 

If 

\ 

A 

/ 

\ 

V 

If 

V 

v 

V 

^ 

,    _> 

FiQ.   189. — Measles  with  Prolonged  Invasion.     Continuance  of  high  temperature 
after  full  eruption  due  to  severe  bronchitis  and  diarrhoea;  child  two  years  old. 

not  be  made  but  for  the  fact  that  there  are  other  cases  of  measles  in 
the  family  or  the  institution.  This  form  is  usually  seen  in  infants,  and 
it  is  usually  fatal. 

In  other  cases  marked  by  a  sudden  severe  onset,  the  system  seems  to 
be  overpowered  by  the  poison  of  the  disease  itself.  There  is  profound 
depression,  and  hyperpyrexia,  and  the 
patient    may    die    from    toxaemia    with 


D*r 

1 

2 

3 

I 

5 

6 

7 

8 

9 

10 

ui 

I 

z 

I 
1 

106° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 
98° 

M    E 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

M      E 

X 

r 

f 

A 

/ 

A 

/ 

^ 

J 

J 

V 

\r 

V 

1 

/ 

/ 

V 

V 

V 

V 

/ 

Y 

y 

I 

D«V 

1 

2 

3 

1 

5 

H 
ui 

X 

z 
a 

X 

if 

108° 
107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 

99° 
98° 

M     B 

M     E 

M     E 

M     E 

M     E 

ill 

X 

'^ 

; 

i 

J 

1 

/ 

I 

/ 

/ 

/ 

/■ 

i 

/ 

Fia.  190. — Fatal  Attack  op  Measles,  Compli- 
cated BY  Broncho-Pneumonia.  Very  severe 
symptoms  from  the  onset;  patient  eighteen 
months  old ;  death  on  tenth  day. 


Fig.  191.  —  Fatal  Attack  of 
Measles,  Complicated  by 
Broncho-Pneumonia.  Early 
invasion  mild,  but  rapid  de- 
velopment of  severe  symptoms 
on  fourth  day ;  rash  on  last  day ; 
patient  eight  months  old. 


cerebral  symptoms  before  the  appearance  of  the  rash  or  just  as  it  is  be- 
ginning to  show  itself.  Sometimes  the  pulmonary  symptoms  are  entirely 
wanting;  at  others  the  rash,  if  it  appears,  is  haemorrhagic. 


936  THE  SPECIFIC   INFECTIOUS  DISEASES. 

In  still  another  group  of  cases  the  onset  is  not  violent,  and  for  the 
first  two  days  the  attack  may  appear  to  be  of  only  average  severity;  but 
there  may  then  develop,  often  quite  suddenly,  pulmonary  symptoms  of 
such  intensity  as  to  cause  death  within  twenty-four  hours.  The  erup- 
tion, if  seen  at  all,  is  faint  and  not  characteristic  (Fig.  191). 

A  secondary  rise  in  the  temperature  after  it  has  once  fallen  to  nor- 
mal was  seen  in  8  of  173  cases,  being  due  to  the  development  of  otitis, 
ileo-colitis,  or  pneumonia. 

Complications  and  Sequelae. — The  most  frequent  and  most  important 
complication  of  measles  is  broncho-pneumonia,  and  next  to  this  are  ileo- 
colitis, otitis,  and  membranous  laryngitis.  Most  of  the  others  are  in- 
frequent; all  complications  are  relatively  rare  in  children  over  four 
years  old. 

Lungs. — The  greatest  danger  in  measles  arises  from  pulmonary 
complications,  and  the  frequency  is  greatest  in  children  under  two  years 
of  age.  In  two  epidemics  in  the  Nursery  and  Child's  Hospital,  em- 
bracing about  300  cases,  nearly  all  in  children  under  three  years  old, 
broncho-pneumonia  occurred  in  about  40  per  cent  of  the  cases.  Of  those 
who  had  pneumonia,  70  per  cent  died.  Fortunately,  such  a  record  as 
this  is  never  seen  outside  of  asylums  or  hospitals  for  young  children. 
Of  2,477  cases,  embracing  several  epidemics  of  measles  among  children 
of  all  ages,  pneumonia  occurred  in  10  per  cent.  My  own  experience  in 
the  post-mortem  room  fully  bears  out  the  statement  of  Henoch,  that  a 
certain  amount  of  pneumonia  is  found  in  almost  every  fatal  case.  Pneu- 
monia is  more  frequent  and  its  mortality  is  higher  in  spring  and  winter 
epidemics  than  in  those  occurring  at  other  seasons.  It  may  develop  at 
any  time  from  the  beginning  of  invasion  until  convalescence,  but  it 
most  frequently  begins  about  the  time  of  full  eruption. 

Lobar  pneumonia,  although  rare,  occasionally  occurs  as  a  complica- 
tion in  children  over  three  years  old.  In  some  epidemics  many  of  the 
cases  of  pneumonia  are  complicated  by  severe  pleurisy,  which  adds  much 
to  the  danger  from  the  disease.  This  form  is  frequently  followed  by 
empyema.  Pneumonia  is  always  to  be  suspected  when  the  temperature 
continues  high  after  the  full  appearance  of  the  rash. 

Bronchitis  of  the  large  tubes,  always  accompanied  by  tracheitis,  is 
seen  in  every  case  of  measles,  possibly  excepting  a  few  of  the  very 
mildest.  This  is  so  constant  a  feature  as  hardly  to  be  ranked  as  a 
complication.  In  nearly  all  of  the  severe  cases  the  bronchitis  extends 
to  the  medium-sized  and  smaller  tubes. 

Larynx. — A  mild  catarrhal  laryngitis  accompanies  almost  every  case 
of  measles.  Severe  catarrhal  laryngitis  is  present  in  about  ten  per  cent 
of  the  eases;  it  may  give  symptoms  which  closely  resemble  those  of 
membranous  laryngitis,  and  the  two  are  no  doubt  often  confused. 

Membranous  laryngitis  is  especially  seen  in  the  epidemics  of  instit 


MEASLES.  937 

tutions.  As  a  cause  of  death  in  older  children  it  ranks  next  to  pneu- 
monia. When  it  develops  at  the  height  of  the  disease,  it  is  sometimes 
due  to  the  streptococcus ;  hut  when  it  develops  at  a  later  period,  it  is 
usually  due  to  the  diphtheria  bacillus.  The  streptococcus  inflamma- 
tion is  in  most  cases  associated  with  similar  changes  in  the  pharynx  or 
tonsils,  but  not  always.  True  diphtheria,  occurring  as  a  complication 
of  measles,  not  infrequently  begins  in  the  larynx.  The  streptococcus 
inflammation  may  be  as  serious  in  this  connection  as  is  true  diphtheria, 
from  the  probability,  which  amounts  almost  to  a  certainty,  of  the  devel- 
opment of  broncho-pneumonia.  No  complication  is  more  to  be  dreaded 
than  this.  The  diagnosis  between  the  true  and  pseudo-diphtheria  may 
sometimes  be  made  by  the  time  of  development,  but  only  with  certainty 
by  cultures.  I  once  saw  in  measles,  where  no  false  membrane  was  present 
in  the  rest  of  the  larynx,  a  necrotic  inflammation  with  almost  entire 
destruction  of  the  vocal  cords — a  condition  which  may  be  compared  to 
that  seen  in  the  tonsils  or  epiglottis  in  scarlatina. 

Throat. — A  catarrhal  angina  is  part  of  the  disease,  and  is  as  charac- 
teristic of  measles  as  is  the  eruption  upon  the  skin.  There  is  acute  con- 
gestion and  swelling  of  the  tonsils,  uvula,  palate,  and  pharynx.  In  a 
certain  proportion  of  cases,  very  much  less  frequently  than  in  scarlatina, 
the  development  of  membranous  patches  is  seen  upon  the  tonsils  and  ad- 
jacent mucous  membranes.  These  occur  in  two  or  three  per  cent  of  the 
cases.  They  are  to  be  regarded  in  the  same  light  as  similar  conditions 
complicating  scarlet  fever,  with  these  differences,  that  in  measles  there 
is  much  greater  likelihood  of  the  extension  of  the  disease  to  the  larynx, 
while  extension  to  the  nose  and  ears  is  much  less  probable.  True  diph- 
theria, however^  may  complicate  measles,  and  cases  of  membranous  in- 
flammation of  the  tonsils  or  pharynx  developing  late  in  measles  are 
usually  due  to  the  Klebs-Loeffier  bacillus. 

Although  in  most  cases  the  inflammations  of  the  pharynx  and  ton- 
sils which  accompany  measles  are  not  serious  when  they  are  due  to  the 
streptococcus,  they  are  sometimes  quite  as  severe  as  any  that  accompany 
scarlet  fever.  They  may  cause  death  from  general  sepsis  apart  from  any 
affection  of  the  larynx. 

Digestive  System. — Gastric  disorders  are  not  more  common  than  in 
other  febrile  diseases;  but  diarrhoea  is  very  frequent,  and  in  summer  it 
may  be  even  more  serious  than  the  pulmonary  complications.  All  forms 
of  diarrhoea  are  seen,  from  that  which  results  from  simple  indigestion 
to  the  severe  types  of  ileo-colitis.  This  complication  is  most  often  seen 
in  children  under  two  years  old.  The  most  severe  intestinal  symptoms 
are  not  usually  seen  at  the  height  of  the  primary  fever;  but,  beginning 
at  this  time,  they  often  increase  in  severity,  and  are  most  marked  in  the 
second  and  third  weeks  of  the  disease. 

Catarrhal  stomatitis  is  present  in  almost  every  case  of  measles;  less 


938  THE  SPECIFIC  INFECTIOUS  DISEASES. 

frequently  the  herpetic  form  is  seen.  Ulcerative  stomatitis  is  not  uncom- 
mon, particularly  in  institutions.  One  of  the  worst  complications  of 
measles,  but  fortunately  a  rare  one,  is  gangrenous  stomatitis,  or  noma. 
This  usually  occurs  in  inmates  of  institutions,  or  in  children  with  bad 
surroundings  who  were  previously  in  wretched  condition.  It  is  nearly 
always  fatal. 

Gangrenous  inflammations  of  other  parts  of  the  body  are  sometimes 
seen  after  measles,  especially  of  the  ear,  the  vulva,  or  the  prepuce. 

Nervous  System. — I  have  seldom  seen  convulsions  at  the  onset  of 
measles.  During  the  progress  of  the  disease  they  are  not  so  rare,  and 
may  occur  in  connection  with  otitis,  meningitis,  or  severe  broncho- 
pneumonia— chiefly  in  infants. 

Meningitis  is  rare,  but  either  the  simple  or  the  tuberculous  form 
may  occur,  more  often,  however,  as  a  sequel  than  as  a  complication. 
Insanity,  usually  of  a  temporary  character,  occasionally  follows  measles. 
In  the  epidemic  of  108  cases  reported  by  Smith  and  Dabney,  insanity 
was  noted  three  times,  all  the  cases  terminating  in  recovery.  Epilepsy 
and  chorea  are  rare  sequelae. 

Ears. — Otitis  is  a  frequent  complication  in  some  epidemics ;  in  others 
it  is  seldom  seen.  In  one  hospital  epidemic  it  was  noted  in  14  per  cent 
of  the  cases.  This  epidemic  occurred  in  early  spring  and  affected  very 
young  children,  both  of  which  circumstances  are  favourable  for  the 
development  of  otitis.  Usually  both  ears  are  affected,  but  the  otitis  of 
measles  is,  as  a  rule,  less  serious  than  that  of  scarlet  fever. 

Eyes. — Simple  catarrhal  conjunctivitis  accompanies  nearly  every  case 
of  measles.  In  the  severe  form  there  is  a  muco-purulent  catarrh,  which 
may  attain  any  degree  of  severity.  In  neglected  cases,  and  among  chil- 
dren who  are  poorly  nourished,  especially  in  asylums,  the  disease  is  apt 
to  extend  to  the  cornea.  Chronic  conjunctivitis  often  persists  after 
measles,  particularly  in  the  class  of  children  just  mentioned. 

Lymph  Nodes. — Swelling  of  the  lymphatic  glands  of  the  neck  is 
frequent,  but  not  generally  severe,  and  rarely  terminates  in  suppuration. 
Chronic  enlargement  may  continue  for  months,  and  sometimes  the  glands 
may  become  tuberculous.  Similar  changes  and  similar  consequences 
may  occur  in  the  glands  of  the  tracheo-bronchial  group. 

Kidneys. — The  infrequency  of  renal  complications  in  measles  is  in 
striking  contrast  to  scarlet  fever.  Transient  febrile  albuminuria  is  not 
uncommon,  but  a  serious  degree  of  nephritis,  either  clinically  or  at 
autopsy,  I  have  never  seen,  and  literature  furnishes  but  few  cases. 

Heart. — Both  endocarditis  and  pericarditis  have  occurred  in  the 
course  of  measles,  but  they  belong  to  the  rare  complications.  The  same 
may  be  said  of  changes  in  the  muscular  walls  of  the  heart. 

SMn. — As  complications,  erysipelas,  furunculosis.  impetigo,  and 
pemphigus  have  been  noted;  but  all  are  rare. 


MEASLES.  939 

HcBTnorrhages. — Associated  with  the  hemorrhagic  type  of  the  erup- 
tion, severe  and  even  fatal  haemorrhages  may  occur  from  the  mucous 
membranes,  and  the  latter  are  sometimes  seen  without  the  liaemorrhagic  . 
eruption. 

Blood. — There  is  a  leucocytosis  of  15,000  to  30,000  beginning  soon 
after  infection,  even  before  the  invasion,  and  increasing  for  four  or  five 
days.  During  the  eruption  the  number  of  leucocytes  falls  gradually  to 
normal  or  below.  A  marked  leucocytosis  at  this  time  or  later  points  to 
a  complication,  but  its  absence  during  eruption  does  not  exclude  one. 
The  differential  count  shows  the  increase  to  be  in  the  polymorphonuclear 
cells. 

Other  Infectious  Diseases. — Measles  in  institutions  is  often  compli- 
cated by  diphtheria.  Scarlet  fever  or  varicella  occasionally  occurs  during 
measles,  though  it  is  rare  that  the  two  eruptions  are  exactly  simultaneous. 
Epidemics  of  measles  and  whooping-cough  frequently  occur  together  or 
follow  each  other.  The  relation  of  measles  to  tuberculosis  seems  to  be 
particularly  close.  In  some  caees  general  or  pulmonary  tuberculosis 
follows  directly  in  the  wake  of  measles,  which  seems  to  furnish,  espe- 
cially in  the  lungs,  conditions  which  are  favourable  for  the  development 
of  latent  tuberculosis.  As  a  late  manifestation  the  most  common  one 
is  tuberculosis  of  the  bones,  occurring  as  hip-joint  disease,  caries  of  the 
spine,  etc.  An  attack  of  measles  in  a  child  with  tuberculous  antecedents 
should,  therefore,  always  be  looked  upon  with  apprehension. 

Diagnosis. — A  sign  of  the  greatest  diagnostic  value  is  the  buccal  erup- 
tion. Although  it  appears  that  this  was  described  many  years  ago  by 
Flindt,  of  Denmark,  it  is  to  Koplik,  of  New  York,  that  the  credit  belongs 
of  its  independent  discovery  and  publication  in  1896.  It  is  generally 
known  as  "  Koplik's  sign."  The  unit  of  the  eruption  is  a  bluish-white 
speck  upon  a  red  ground;  only  a  few  of  these  may  be  present  or  the 
mucous  membrane  may  be  fairly  peppered  with  them  (Plate  XVII). 
Often  they  are  not  seen  except  by  careful  search,  for  which  strong  sun- 
light is  necessary;  artificial  light  is  not  satisfactory.  The  spots  are 
best  seen  on  the  inside  of  the  cheeks  opposite  the  molar  teeth,  and  in 
most  cases  only  there;  but  they  may  be  present  on  almost  any  part  of 
the  buccal  mucous  membrane.  Their  diagnostic  value  is  due  to  the  fact 
that  they  are  nearly  always  present,  that  they  are  not  found  in  other 
diseases,  and  tliat  they  usually  appear  two  or  three  days  before  the  skin 
eruption.     They  generally  disappear  at  the  time  of  full  eruption. 

I  have  recently  had  an  opportunity  to  study  the  value  of  this  sign  in 
two  epidemics  of  measles  at  the  New  York  Foundling  Hospital.  Care- 
ful notes  were  kept  in  the  second  epidemic  of  187  cases.  Koplik's  spots 
were  unmistakably  present  in  169  cases,  absent  in  8,  doubtful  in  10. 
In  78  cases,  fever,  rash,  and  Koplik's  spots  were  all  present  at  the  first 
observation.    In  54  patients  the  sign  was  noted  one  day  before  the  rash; 


940  THE  SPECIFIC  INFECTIOUS  DISEASES. 

iu  35,  two  days  before;  in  4,  three  days  before;  in  3,  four  days  before; 
and  in  2,  five  days  before.  In  2  the  spots  were  not  seen  until  after  the 
skin  eruption ;  in  one  case  they  were  present  without  any  eruption.  As 
this  patient  had  been  exposed  and  liad  a  prolonged  fever,  it  seems  fair 
to  regard  the  case  as  one  of  measles.  In  only  one  case  was  the  buccal 
eruption  seen  before  any  elevation  of  temperature. 

These  facts,  amply  confirmed  by  other  observations, '  indicate  that 
Koplik's  sign  is  of  value  in  enabling  us  to  make  a  diagnosis  from  one 
to  three  days  before  it  is  possible  by  the  skin  eruption,  also  in  furnish- 
ing a  new  means  of  distinguishing  measles  from  the  other  eruptive 
fevers,  as  well  as  from  rashes  due  to  drugs,  antitoxine,  etc. 

Other  important  symptoms  are  the  coryza,  the  gradual  rise  in  tem- 
perature, and  the  eruption  which  appears  first  upon  the  neck  and  face, 
and  slowly  extends  over  the  body.  Cases  which  present  the  greatest  diffi- 
culties in  diagnosis  are  usually  the  very  severe  ones  and  those  in  infants. 

Prognosis. — This  depends  upon  the  age  and  previous  condition  of 
the  patient,  the  character  of  the  epidemic,  and  the  season  of  the  year. 
Except  in  children  under  three  years  of  age,  the  deaths  from  measles 
are  few;  but  in  institutions  containing  young  children,  no  epidemic 
disease  is  so  fatal. 

The  general  mortality  of  the  disease  is  from  4  to  6  per  cent;  but  in 
epidemics  in  institutions  for  young  children  it  has,  in  my  experience, 
ranged  from  15  to  35  per  cent.  The  following  table  gives  the  figures  of 
an  epidemic  in  one  institution: 

From  six  to  twelve  months 42  cases;  mortality,  33  per  cent. 

"     one  to  two  years 51      "  "         50    "       " 

"     two  to  three  years 27      "  "         30    "       " 

"     three  to  four  years 20      "  "  14    " 

"     four  to  five  years 3      "  "  0    "       " 

In  aiiy  single  case  the  important  symptoms  for  prognosis  are  the 
temperature  and  the  character  of  the  eruption.  An  initial  temperature 
above  103°  F.,  or  one  which  remains  high  until  the  eruption  appears,  is 
a  bad  symptom.  So  also  is  one  which  rises  after  a  full  eruption,  or 
which  does  not  fall  as  the  rash  fades.  The  following  table  shows  the 
highest  temperature  and  mortality  in  161  hospital  cases: 

Highest  temperature  not  over  102°  F.  .     6  cases;  mortality,  0  per  cent. 
"  "  102°  to  103.5°  F..   14     "  "         7    " 

u  u  1Q40    «  1Q4  50  F       49     <.  '(       16    " 

"  "  105°    "  105.5°  F .  .  65      "  "       40    ''       " 

"  "  106°  F.  or  over  ...   27      "  "       80    ''      • " 

A  favourable  eruption  is  one  of  a  bright  colour,  covering  the  body, 
remaining  discrete,  and  spreading  gradually.  It  is  unfavourable  for  the 
eruption  to  appear  late,  to  be  very  faint,  scanty,  or  haemorrhagie,  or  to 
recede  suddenly,  as  this  is  usually  due  to  a  weak  heart. 


PLATE  XVII. 


The  Buccal  Eruption  of  Measles  (Koplik's  Spots). 

A.  This  represents  the  earliest  stage ;  the  spots  are  few,  rather  larsre.  widely  sei>a- 
rated,  and  usually  show  a  distinct  areola ;  the  mucous  membrane  is  normal  in  color. 

B.  The  later  appearance  and  that  most  frequently  seen. 

Near  the  center  of  the  field  the  spots  are  closer  together,  although  still  remaining 
individually  distinct;  the  mucous  membrane  is  somewhat  congested.  At  the  margin 
of  the  field  they  are  fainter  and  lack  the  areola,  representing  a  still  later  period,  such 
as  is  seen  before  they  disappear  altogether,  although  in  some  cases  they  are  not  more 
distinct  than  this  at  anv  stage. 


MEASLES.  941 

Of  51  fatal  cases,  the  cause  of  death  was  broncho-pneumonia  in  45, 
ileo-colitis  in  4,  atid  membranous  laryngitis  in  2.  More  than  half  the 
deaths  occurred  during  the  second  week,  the  earliest  being  upon  the 
fifth  day  of  the  disease. 

The  ultimate  result  of  an  attack  of  measles  may  not  be  evident  for 
some  time.  Cases  in  which  the  temperature  persists  for  two  or  three 
weeks  without  assignable  cause  after  the  disease  is  apparently  over, 
should  be  watched  with  the  greatest  solicitude.  The  explanation  of  this 
is  most  frequently  to  be  found  in  the  lungs,  although  the  physical  signs 
are  often  obscure.  The  condition  may  be  either  subacute  pneumonia 
or  pulmonary  tuberculosis.  Even  though  the  attack  of  measles  may  not 
have  been  in  itself  severe,  seeds  are  often  sown  the  full  fruits  of  which 
are  not  seen  until  long  afterward.  Chronic  glandular  enlargements 
which  may  or  may  not  be  tuberculous,-  chronic  bronchitis,  chronic  laryn- 
gitis, subacute  or  chronic  nasal  catarrh,  hypertrophy  of  the  tonsils,  and 
adenoid  growths  of  the  pharynx — all  are  frequent  sequelse. 

Prophylaxis. — Measles  is  often  regarded  by  the  laity  as  so  mild  a 
disease  that  its  prevention  is  thought  to  be  of  little  importance,  and  no 
effort  is  made  to  limit  its  extension.  The  great  probability  that  every  per- 
son at  some  time  in  his  life  will  have  the  disease,  is  no  justification  of  un- 
necessary exposure.  Although  in  older  children  measles  is  usually  mild, 
this  is  not  so  in  infants,  who  should  be  carefully  protected  from  exposure. 
Special  care  should  also  be  taken  to  avoid  the  exposure  of  delicate  chil- 
dren or  those  with  a  strong  tendency  to  pulmonary  disease  or  to  tuber- 
culosis. In  institutions  it  is  of  the  utmost  importance  to  secure  prompt 
and  complete  isolation  of  the  first  case  which  appears. 

The  disease  being  usually  spread  by  the  patient  and  rarely  from 
apartments,  it  follows  that  while  early  isolation  is  more  important, 
there  is  not  required  the  same  thorough  cleansing  and  disinfection  which 
should  follow  every  case  of  scarlet  fever.  In  an  institution,  the  ward  or 
cottage  from  which  a  case  has  been  removed  should  be  quarantined  for 
at  least  sixteen  days  after  the  appearance  of  the  last  case,  and  absolute 
security  can  not  be  said  to  exist  until  the  end  of  three  weeks.  The  same 
rule  should  be  applied  in  private  families  where  children  who  have  been 
exposed  should  be  quarantined  apart  from  the  patient,  but  not  sent  away. 
Under  ordinary  circumstances  the  quarantine  of  a  case  of  measles  should 
last  three  weeks  from  the  beginning  of  invasion.  It  should  be  continued 
longer  if  there  is  pneumonia,  otitis,  or  a  nasal  discharge. 

Thorough  cleansing  and  disinfection  of  the  sick-room  should  be  done 
before  it  is  again  occupied  l)y  children,  and  it  should  remain  vacant 
at  least  two  weeks.  Children  should  be  kept  from  all  schools  while 
the  disease  is  in  their  homes,  chiefly  because  they  are  otlierwise  li- 
able to  spread  the  disease  while  suffering  from  the  early  symptoms  of 
invasion. 


942  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Treatment. — Measles  is  a  self -limited  disease,  and  there  are  no  known 
measures  by  which  it  can  be  aborted,  its  course  shortened,  or  its  severity 
lessened.  The  indications  are  therefore  to  treat  serious  symptoms  as 
they  arise,  and,  as  far  as  possible,  to  prevent  complications,  which  are 
the  principal  cause  of  death. 

The  sick-room  should  be  darkened,  as  the  eyes  are  very  sensitive  to 
light.  Every  child  with  measles  should  be  put  to  bed  and  kept  there  with 
light  covering  during  the  entire  febrile  period.  There  can  be  no  possible 
advantage  in  causing  a  child  to  swelter  by  thick  covering,  under  the  delu- 
sion that  the  disease  may  be  modified  thereby.  The  food  should  be  light, 
fluid,  and  given  at  regular  intervals.  If  the  conjunctivitis  is  severe,  iced 
cloths  should  be  applied  to  the  eyes,  which  should  be  kept  clean  by  the 
frequent  use  of  a  saturated  solution  of  boric  acid,  the  lids  being  prevented 
from  adhering  by  the  application  of  vaseline  or  simple  ointment.  The 
intense  itching  and  burning  of  the  skin  may  be  relieved  by  inunctions 
of  plain  or  carbolised  vaseline,  or  by  bathing  witli  a  solution  of  bicar- 
bonate of  soda.  The  cough,  when  distressing,  may  be  allayed  by  small 
doses  of  opium,  either  in  the  form  of  codeine  or  the  brown  mixture.  The 
restlessness,  headache,  and  the  general  discomfort  which  accompany  the 
height  of  the  fever  may  be  relieved  by  an  occasional  dose  of  phenacetine 
or  antipyrine.  As  soon  as  the  rash  has  subsided,  a  daily  warm  bath 
should  be  given,  followed  by  inunctions  to  facilitate  desquamation  and 
prevent  the  dissemination  of  the  fine  scales. 

The  important  indications  to  be  met  in  the  severe  cases  are  very 
high  temperature,  cardiac  depression,  and  nervous  symptoms — dulness, 
stupor,  sometimes  coma,  or  convulsions.  In  some  of  the  cases  there  is 
in  addition  dyspnoea  and  cyanosis,  showing  severe  acute  pulmonary  con- 
gestion. For  the  nervous  symptoms  and  high  temperature,  nothing  is  so 
reliable  as  the  cold  bath  or  pack  and  the  nearly  continuous  use  of  ice 
to  the  head.  I  do  not  think  there  is  any  evidence  that  the  use  of  cold 
increases  the  liability  to  pneumonia;  but  cold  extremities,  feeble  pulse, 
and  cyanosis,  when  associated  with  high  temperature,  call  for  the  hot 
mustard  bath,  although  ice  should  still  be  applied  to  the  head.  The  indi- 
cations for  stimulants  and  the  methods  of  using  them  are  the  same  as  in 
broncho-pneumonia,  which  is  usually  present  in  cases  requiring  them. 

To  diminish  the  chances  of  pneumonia,  it  is  necessary  that  every 
patient  should  be  kept  in  bed  during  the  attack,  and  care  exercised  to 
avoid  exposure.  But  still  more  important  is  it  in  hospitals  and  institu- 
tions where  most  of  the  cases  of  pneumonia  occur,  to  allow  the  patients 
plenty  of  air  space,  never  crowding  them  together  in  small  wards.  If 
possible,  cases  complicated  by  pneumonia  should  be  separated  from  sim- 
ple cases.  The  pneumococcus  and  the  streptococcus  are  found  in  the 
mouth  in  such  numbers  that  systematic  disinfection  of  the  mouth  may 
prove  of  some  value. 


RUBELLA.  943 

The  danger  of  diphtheria  as  a  complication  may  be  greatly  lessened 
if  during  epidemics  of  measles  in  institutions  every  case  receives  an 
immunising  dose  of  diphtheria  antitoxine. 

The  bronchitis  and  broncho-pneumonia  of  measles  should  be  man- 
aged as  when  they  occur  as  primary  diseases,  since  the  coexistence  of 
measles  furnishes  no  new  indications.  The  same  is  true  of  the  diarrhoea, 
conjunctivitis,  otitis,  membranous  laryngitis,  pharyngitis,  and  tonsillitis. 
Should  cultures  show  the  presence  of  the  diphtheria  bacillus,  the  case 
should  be  treated  like  one  of  diphtheria. 

During  convalescence  the  eyes  should  be  used  very  carefully  for  at 
least  several  weeks.  Should  the  cough  and  slight  fever  persist,  with  or 
without  physical  signs  in  the  chest,  the  patient  should,  if  possible,  be 
sent  away  to  a  warm,  dry,  elevated  district,  as  the  development  of 
tuberculosis  is  always  to  be  feared.  Cod-liver  oil  should  be  given  con- 
tinuously throughout  the  succeeding  cool  season,  and  iron,  wine,  and 
other  tonics  according  to  indications.  The  cough  itself  should  be  treated 
as  when  it  follows  an  ordinary  bronchitis,  creosote  being  more  generally 
useful  than  any  other  drug. 


CHAPTEE    III. 

RUBELLA. 

{German  Measles;  Rotheln.) 

Rubella  is  a  contagious  eruptive  fever  which  is  rarely  seen  except 
when  prevailing  epidemically.  It  is  characterised  by  a  short  invasion, 
with  mild,  indefinite  symptoms,  usually  lasting  but  a  few  hours,  and  by 
an  eruption  which  is  generally  well  marked  but  of  variable  appearance. 
The  constitutional  symptoms  are  very  mild,  and  the  disease  rarely  proves 
fatal,  not  often  being  even  serious.  For  a  long  time  rubella  was  con- 
founded with  measles  and  scarlet  fever,  as  the  eruption  sometimes  resem- 
bles one  and  sometimes  the  other  disease.  Its  identity  is  now  fully  estab- 
lished, and,  as  Striimpell  well  says,  its  existence  is  doubted  only  by  those 
who  have  never  seen  it. 

Rubella  is  a  contagious,  eruptive  fever,  and  not  a  simple  affection  of 
the  skin;  it  prevails  independently  either  of  measles  or  of  scarlet  fever; 
its  incubation,  eruption,  invasion,  and  symptoms  differ  materially  from 
those  of  both  these  diseases;  it  attacks  indiscriminately  and  with  equal 
severity  those  who  have  had  measles  and  scarlet  fever  and  those  who 
have  not,  nor  does  it  protect  in  any  degree  against  either  of  them;  it 
never  produces  anything  but  rubella  in  those  exposed  to  its  contagion; 
it  occurs  but  once  in  the  same  individual. 

Etiology. — Rubella  is  beyond  question  contagious,  but  is  decidedly 
less  so  than  either  measles  or  scarlet  fever;  so  that  some  observers 


944  THE  SPECIFIC  INFECTIOUS  DISEASES. 

have  doubted  its  contagion  altogether.  It  can  be  communicated  at 
any  time  during  its  course,  but  is  especially  contagious  during  the 
early  stage.  Epidemics  usually  prevail  in  the  winter  or  spring.  As 
in  the  other  eruptive  fevers,  a  striking  immunity  is  seen  in  infants 
under  six  months  old ;  but,  with  this  exception,  all  ages  are  liable  to  the 
disease. 

The  incubation  of  rubella  varies  considerably;  the  usual  period  is 
from  fourteen  to  twenty-one  days,  although  the  limits  are  from  ten  to 
twenty-two  days. 

Symptoms. — Invasion. — This  is  rarely  more  than  half  a  day,  and  in 
many  cases  no  prodromata  whatever  are  noticed,  the  rash  being  the  first 
thing  to  attract  attention.  In  a  few  cases  there  are  mild  catarrhal  symp- 
toms, with  general  malaise  and  slight  fever.  At  other  times  there  may 
be  vomiting,  convulsions,  delirium,  epistaxis,  rigors,  headache,  or  dizzi- 
ness; but  all  are  to  be  regarded  as  very  exceptional. 

Eruption. — Frequently  a  child  wakes  in  the  morning  covered  with 
the  rash,  no  symptoms  having  been  previously  noticed.  It  generally  ap- 
pears first  upon  the  face,  and  spreads  rapidly  to  the  whole  body,  the  lower 
extremities  being  last  covered.  Less  than  a  day  is  usually  required  for 
its  full  development.  Exceptionally  the  eruption  comes  first  upon  the 
chest  and  back,  and  sometimes  nearly  the  whole  body  is  covered  almost 
at  once.  The  rash  is  occasionally  observed  in  the  roof  of  the  mouth 
before  it  is  visible  on  the  face.  In  a  considerable  number  of  cases  the 
entire  body  is  not  covered ;  but  the  rash  is  more  constantly  seen  upon  the 
face  than  upon  any  other  part  of  the  body. 

Its  character  is  subject  to  considerable  variation.  The  eruption  is 
most  frequently  composed  of  very  small  maculo-papules ;  they  are  of  a 
pale-red  colour,  and  vary  in  size  from  a  pin's  head  to  a  pea.  The  spots 
are  usually  discrete,  but  may  cover  the  greater  part  of  the  body  where  it 
is  seen.  On  the  face  it  is  frequently  confluent,  and  often  appears  here 
as  large,  irregular  blotches  of  a  red  colour.  From  this  description  the 
rash  will  be  seen  to  resemble  that  of  measles  more  than  that  of  any  other 
disease.  Very  often,  however,  there  is  a  fairly  uniform  red  blush 
which  bears  a  close  resemblance  to  the  rash  of  scarlet  fever ;  but  even  in 
such  cases  there  will  nearly  always  be  found  upon  some  part  of  the  body, 
usually  the  wrists,  fingers,  or  forehead,  some  typical  maculo-papules. 
Between  these  two  extremes  all  variations  are  seen.  The  colour  of  the 
eruption  is  sometimes  dark  red,  and  rarely  it  has  been  noted  to  be  haemor- 
rhagic.  The  degree  of  elevation  above  the  surface  is  also  variable ;  some- 
times this  is  so  marked  as  to  give  to  the  skin  a  "  shotty  "  feel,  while  in 
others  the  elevation  is  scarcely  perceptible.  The  duration  of  the  erup- 
tion is  usually  three  days.  Occasionally  it  lasts  only  two  days,  and  it  may 
last  but  one;  it  is  rare  for  it  to  remain  as  long  as  four  days.  It  fades 
in  the  order  of  its  appearance,  and  more  rapidly  than  the  eruption  of 


RUBELLA.  945 

measles.  A  slight  brown  pigmentation  of  tlic  skin  sometimes  remains 
for  a  few  days  after  the  rash. 

The  highest  temperature  is  coincidelit  with  the  full  eruption;  this 
does  not  usually  exceed  101°,  and  often  it  is  only  100°  F.  As  a  rule, 
the  temperature  continues  but  two  da3^s,  falling  as  the  eruption  fades. 
Very  often  the  fall  to  normal  is  abrupt.  Rarely  more  severe  cases  are 
seen  in  which  the  fever  lasts  for  two  or  three  days,  being  101°  or  108°  F. 
during  the  invasion,  and  rising  to  103°  F.  or  more  during  the  full  erup- 
tion. The  other  symptoms  are  in  most  cases  even  less  marked  than  the 
fever.  Occasionally  catarrhal  symptoms  resembling  a  mild  attack  of 
measles  are  present,  or  a  sore  throat  suggesting  mild  scarlet  fever;  but 
more  frequently  all  these  symptoms  are  absent.  The  eruption  is  usually 
out  of  all  proportion  to  the  other  signs  of  disease. 

Swelling  of  the  post-cervical  glands  is  one  of  the  most  constant  fea- 
tures of  rubella.  In  most  epidemics  it  is  seen  in  nearly  all  cases;  but 
as  a  symptom  for  differential  diagnosis  it  is  not  of  great  importance,  as 
it  is  not  uncommon  in  measles  and  scarlet  fever.  The  glandular  swelling 
is  most  marked  at  the  height  of  the  disease;  it  is  never  very  great,  and 
subsides  slowly  without  suppuration.  Vomiting  and  diarrhoea  are  rare. 
Swelling  and  itching  of  the  skin  are  usually  present  and  sometimes 
marked.     There  is  no  leucocytosis  in  this  disease. 

Forchheimer  has  described  an  eruption  on  the  mucous  membrane  of 
the  throat,  or  "  enanthem,"  which  he  believes  to  be  characteristic.  It 
consists  of  minute,  bright,  rosy- red  points,  seen  on  the  uvula  and  soft 
palate,  rarely  on  the  hard  palate.  It  is  present  only  in  the  first  twenty- 
four  hours. 

Desquamation. — This  is  exceedingly  variable.  It  is  sometimes  en- 
tirely wanting;  writers  who  have  observed  some  fairly  typical  epidemics 
have  stated  that  it  did  not  occur.  In  most  cases,  however,  some  des- 
quamation is  present,  though  it  may  be  so  slight  as  to  be  discovered  only 
by  a  close  examination.  It  is  usually  in  tlie  form  of  fine  scales  over  the 
body  and  extremities.  In  a  few  cases  it  is  more  pronounced,  and  may 
be  in  larger  flakes  or  patches. 

Prognosis. — There  are  few  diseases  so  free  from  danger  as  rubella. 
Complications  and  sequelae  are  ver}'^  seldom  seen,  and  when  present  are 
usually  of  the  mildest  character. 

Diagnosis. — The  principal  interest  attaching  to  rubella  is  in  its  diag- 
nosis. This  is  a  matter  of  extreme  difficulty,  and  often  it  is  an  impossi- 
bility. The  characteristic  thing  about  the  disease  is  a  well-marked  erup- 
tion with  very  few  other  symptoms.  Cases  so  closely  resemble  mild 
scarlet  fever  that  the  differentiation  by  symptoms  may  be  impossible;  it 
must  be  made  by  the  circumstances  under  which  it  occurs,  especially  a 
prevailing  epidemic.  tScarlet  fever  with  a  low  temperature  and  abundant 
rash  should  ahvavs  be  regarded  with  suspicion;  also  an  abundant  rash 
61 


946  THE  SPECIFIC  INFECTIOUS   DISEASES. 

with  little  or  no  desquamation.  The  longer  period  of  incubation  in 
rubella  may  be  of  assistance.  Koplifs  spots  furnish  a  valuable  means  of 
distinguishing  measles  from  rubella.  These  ditBculties  in  diagnosis  can 
be  appreciated  only  by  one  who  has  seen  epidemics  of  measles  and  scarlet 
fever  in  institutions,  and  has  watched  the  mild  course  of  undoubted 
cases  of  these  diseases  which  have  there  occurred. 

It  is  always  hazardous  to  make  the  diagnosis  of  rubella  unless  the 
disease  is  prevailing  epidemically.  Sporadic  cases  in  which  this  diagnosis 
is  made  are,  I  believe,  almost  invariably  instances  of  mild  measles  or 
scarlet  fever.  The  first  cases  of  rubella  in  an  epidemic  are  usually  over- 
looked. The  continued  absence  in  succeeding  cases  of  the  characteristic 
symptoms  and  complic-ations  of  measles  or  scarlet  fever  should  suggest  to 
the  physician  that  he  is  probably  dealing  with  rubella. 

Treatment. — Xone  whatever  is  required  for  the  disease  excepting 
isolation,  which  should  be  complete  until  the  diagnosis  is  positively  deter- 
mined ;  after  this  it  is  hardly  necessary.  The  individual  symptoms  and 
c-omplic-ations  are  to  be  treated  as  tbey  arise. 


CHAPTER    IV. 

VARICELLA. 

(Ckicken-pox.) 

Yabicella  is  an  acute,  contagious  disease,  characterised  by  a  cuta- 
neous eruption  of  papules  and  vesicles  and  by  mild  constitutional  s}Tnp- 
toms,  serious  complications  and  sequelae  being  verv'  rare.  Although  long 
confounded  with  varioloid,  its  existence  as  a  distinct  disease  has  been 
generally  admitted  for  many  years. 

Etiology. — It  is  well  established  that  the  contagium  of  the  disease  is 
contained  in  the  vesicles,  as  it  may  be  communicated  by  inoculation  with 
their  contents.  The  specific  poison,  however,  has  not  yet  been  isolated. 
Taricella  is  contracted  by  exposure  to  another  case  or  through  the  me- 
dium of  a  third  person.  It  affects  children  of  all  ages,  one  attack  being 
as  a  rule  protective.  It  is  very  contagious,  resembling  measles  in  this 
respect.  The  period  of  incubation  is  quite  uniformly  from  fourteen  to 
sixteen  days. 

Symptoms. — Slight  fever  and  general  indisposition  may  be  noticed 
for  twenty-four  hours  before  the  appearance  of  the  eruption,  but  in  most 
cases  the  eruption  is  the  first  symptom.  It  usually  appears  first  upon 
the  face  or  trunk,  as  small,  red,  widely  scattered  papules.  The  papules  in 
moet  cases  come  in  crops,  new  ones  continuing  to  appear  for  three  or 
four  days,  even  upon  the  same  part  of  the  body..  The  earlier  ones  have 
generally  begun  to  dry  up  by  the  time  the  later  ones  appear,  so  that  all 


VARICELLA.  947 

stages  of  the  eruption  ma}'  be  present  at  one  time  in  the  same  region, 
this  being  one  of  the  diagnostic  features.  The  papules  are  at  first  verv 
small,  but  gradually  increase  in  size,  and  are  surrounded  by  an  areola 
from  one-fourth  to  half  an  inch  in  widtli.  Many  of  them  go  no  further 
than  this  stage,  but  the  majority  become  vesicular.  The  vesicles  are  usu- 
ally flat,  and  vary  a  good  deal  in  size — the  largest  lH?ing  about  one-fourth 
of  an  inch  in  diameter.  The  process  of  drying  up  generally  begins  at  the 
centre,  wliich  causes  a  slight  depression,  giving  the  vesicle  a  somewhat 
umbilic-ated  appearanc-e.  The  areola  is  most  distinct  at  the  time  of  the 
fully  formed  vesicle,  and  fades  as  the  latter  dries.  Crusts  now  form, 
which  fall  off  in  from  five  to  twenty  days,  depending  upon  the  depth  to 
which  the  skin  has  been  involved.  In  the  majority  of  cases  no  mark  is 
left,  but  after  the  most  severe  attacks,  when  the  true  skin  has  l^een  in- 
volved, scars  remain,  and  occ-asionally  there  is  quite  deep  pitting.  Such 
marks  are  few  in  number,  and  are  most  likely  to  occur  upon  the  face. 

Sometimes,  especially  upon  hands  and  feet,  the  vesicle  appears  with- 
out having  been  preceded  by  a  papule;  often  there  is  no  areola,  and  the 
vesicle  resembles  a  drop  of  water  upon  healthy  skin.  In  most  cases  pus- 
tules are  not  seen,  but  they  may  develop  in  c-onsequenc-e  of  irritation  or 
infection,  the  result  of  scratching,  or  in  children  who  are  poorly  nour- 
ished. Under  these  circumstanc-es  deeper  uk-eration  may  occur,  lasting 
for  weeks.  In  rare  cases  there  may  be  a  necrotic  inflammation  about  the 
site  of  the  pock,  a  condition  to  which  is  sometimes  given  the  name  rart- 
cella  gangrenosa.  It  is  not  peculiar  to  varicella,  and  is  described  else- 
where under  the  head  of  Gangrenous  Dermatitis. 

The  pocks  are  usually  most  abundant  over  the  back  and  shoulders. 
In  mild  cases  only  twenty  or  thirty  may  be  found  upon  the  entire  body, 
but  in  severe  cases  the  skin  in  certain  regions  may  be  nearly  covered. 
The  eruption  is  never  confluent.  The  pocks  are  usually  seen  on  the 
hairy  scalp,  and  often  on  the  mucous  membrane  of  the  mouth  or  pharynx 
— a  point  of  some  diagnostic  value.  In  the  latter  situation  the  appear- 
ance is  first  as  a  tiny  vesicle,  and  later  as  a  superficial  ulcer  resembling 
that  of  herpetic  stomatitis.  Marfan  and  Halle  have  described  cases  of 
varicella  of  the  larynx.  Croupy  symptoms  were  present,  and  in  one 
case  which  proved  fatal  from  pneumonia  a  tiny  ulcer  was  found  on  the 
vocal  cords. 

The  temperature  is  highest  when  the  eruption  is  most  rapidly  appear- 
ing, this  usually  being  the  second  or  third  day.  In  an  average  case  it 
reaches  only  101°  or  102°  F.,  and  lasts  but  two  days;  in  severe  cases  it 
may  rise  to  104°  or  105°  F.,  and  lasts  for  four  or  five  days.  It  falls  grad- 
ually to  normal  as  the  rash  fades.  The  other  symptoms  are  mild  and 
not  characteristic. 

Complications. — The  most  important  complication  is  erysipelas, 
which  develops  about  the  pocks,  particularly  when  they  are  deep  and  at- 


948  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tended  witli  some  ulceration.  I  have  known  of  three  fatal  cases  from  this 
cause.  Adenitis,  either  simple  or  suppurative,  and  abscesses  in  the  cel- 
lular tissue,  are  occasionally  seen.  Nephritis  is  very  infrequent,  but  a 
number  of  cases  are  recorded.  It  may  occur  at  the  height  of  the  dis- 
ease, but  more  often  at  a  later  period,  like  the  nephritis  of  scarlet  fever. 
Varicella  is  quite  frequently  complicated  by  other  infectious  diseases.  In 
the  New  York  Infant  Asylum  epidemics  of  varicella  and  scarlet  fever  at 
one  time  occurred  together,  and  in  at  least  a  dozen  children  both  diseases 
were  seen  at  the  same  time. 

Diagnosis. — The  diagnosis  of  varicella  is  usually  easy,  provided  the 
following  points  are  kept  in  mind:  first,  that  the  eruption  comes  out 
slowly  and  in  crops,  so  that  papules,  vesicles,  and  crusts  may  be  seen  upon 
the  skin  in  close  proximity;  secondly,  that  the  umbilication  is  due  only 
to  the  mode  of  drying  up  of  the  vesicle,  which  begins  at  the  centre; 
thirdly,  the  appearance  of  the  pocks  upon  the  mucous  membranes,  and 
the  history  of  exposure.  It  is  distinguished  from  urticaria  and  other 
forms  of  skin  disease  ))y  the  presence  of  fever. 

Treatment. — Although  it  is  usually  a  trivial  disease,  isolation  of  cases 
of  varicella  should  be  enforced  in  schools  and  in  institutions  containing 
many  infants.  In  the  home,  unless  the  other  children  are  delicate  or  in 
poor  condition,  quarantine  is  unnecessary.  The  disease  may  probably  be 
conveyed  as  long  as  the  crusts  are  present,  hence  isolation  should  be 
maintained  until  they  have  fallen  off.  In  most  cases  constitutional 
symptoms  of  the  disease  are  so  mild  as  to  require  no  treatment. 

Locally,  the  itching,  when  annoying,  may  be  allayed  by  sponging 
with  a  solution  of  bicarbonate  of  soda,  a  one-per-cent  solution  of  car- 
bolic acid  or  the  use  of  carbolised  vaseline.  When  the  crusts  have  formed, 
this  ointment  or  vaseline  containing  two  per  cent  ichthyol  should  be 
applied.  Care  is  necessary  to  keep  the  skin  clean,  and,  in  the  case  of 
infants,  to  prevent  scratching.  In  severe  cases  the  urine  should  in- 
variably be  examined. 


CHAPTER    V. 
VACCINIA— VACCINATION. 

Vaccinia  (cowpox)  is  a  febrile  disease  induced  in  man  by  inocula- 
tion with  the  virus  obtained  either  directly  from  the  cow  (bovine  virus) 
or  from  a  person  who  has  been  inoculated  (humanised  virus).  The  dis- 
ease is  not  contagious  in  the  ordinary  sense  of  the  term,  but  is  communi- 
cated by  inoculation  either  accidental  or  intentional. 

The  nature  of  the  protection  against  smallpox  which  vaccination 
affords  is  even  now  but  imperfectly  understood.     The  fact,  however,  re- 


VACCINIA. 


949 


mains  one  of  the  best  attested  in  medical  history.  Its  effect  when  sys- 
tematically practised  is  graphically  shown  in  the  accompanying  chart 
(Fig.  192).  It  is  the  imperative  duty  of  tlie  physician  to  see  to  it  tliat 
every  young  infant  is  vaccinated. 


After  Uic  Law  of  1874 
was  passed. 


18U«-187« 
Avera^ 
jearlj  Deaths 
from  small- 
pox Id  ererj 

lOO.UOO 
inbabitaatH. 


ILjIU 


Annual  Deftthg 

from  small-poz 

in  eveij  100,000 

inhabiunta. 


HOLLAND. 


1B6G-1872 

ATermge 

yearlj  Deaths 

from  small* 

pox  In  eveiy 

100,000 
lahabitanta. 


il 


Lixiil 


lAu 


Annual  Deaths 

from  smalt-pox 

in  ererj  100,000 

Inhabitants. 


AUSTRIA. 


_110 


-  SO  a 


_  50O 


1808-1674 
Arenge 
jearlj  Deaths 
from  small- 
pox In  every 

100,000' 
Inhabitants. 


Annual  Deaths 

from  suiall-pox 

In  ererj  100,000 

Inhabitants. 


Fig.  192. — Table  Showing  the  Protective  Power  of  Vaccination.     (Carsten.) 


Re-vaccination. — Regarding  the  duration  of  the  protective  power  of 
a  single  vaccination,  positive  statements  are  impossible.  Nearly  all 
writers  are  agreed  that  vaccination  should  be  done  in  infancy,  again  at 
puberty,  and  a  third  time  at  about  the  age  of  twenty  or  twenty-five. 
Many  also  insist  upon  re-vaccination  at  about  the  seventh  year.  It  is  a 
safe  rule  when  smallpox  is  prevalent  to  vaccinate  every  person  who  has 
not  been  successfully  vaccinated  within  five  years. 


950  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Choice  of  Lymph. — The  substitution  of  bovine  for  humanised  virus 
is  now  well-nigh  universal.  It  has  precluded  the  possibility  of  trans- 
mitting syphilis  and  greatly  lessened  the  chances  of  other  forms  of  in- 
fection. A  further  advance  has  lately  been  made  by  the  introduction  of 
"  glycerinated  "  lymph.  As  now  prepared,  the  lymph  is  taken  from  the 
calves  under  the  most  rigid  aseptic  precautions  and  emulsified  with 
glycerin.  The  few  saprophytic  bacteria  present  soon  die,  so  that  when 
properly  prepared  the  glycerinated  virus  is  practically  sterile.  It  should 
not  be  distributed  until  it  has  been  carefully  tested  for  patliogenic  organ- 
isms of  all  kinds,  particularly  the  tetanus  bacillus.  It  is  preserved  and 
distributed  in  capillary  tubes  hermetically  sealed ;  these  are  much  safer 
than  quills  or  ivory  points,  which  may  easily  become  contaminated  by 
handling.  After  the  lymph  has  been  taken,  the  calves  are  killed  in  order 
to  make  certain  that  they  were  free  from  disease.  The  practical  advan- 
tages of  glycerinated  lymph  are  so  great  that  it  has  been  officially 
adopted  by  the  Governments  of  the  United  States,  Great  Britain,  Ger- 
many, and  many  other  countries. 

Time  for  Vaccinating. — In  selecting  a  time  for  vaccination,  the  cliild's 
age  and  general  health  must  be  taken  into  consideration.  It  is  pretty 
well  established  that  the  constitutional  disturbance  is  much  less  in  in- 
fancy than  in  later  childhood,  and  less  in  very  young  infants  (under  one 
month)  than  in  those  of  five  or  six  months.  A  good  rule  for  general 
practice  is  to  vaccinate  every  healthy  infant  as  soon  as  its  nutrition  is 
established,  this  being  in  most  cases  during  the  first  three  months  of 
life.  In  delicate  infants  or  in  those  whose  nutrition  is  a  matter  of 
great  difficulty,  those  who  are  syphilitic,  those  suffering  from  eczema  or 
any  other  form  of  active  skin  disease,  vaccination  should  be  deferred 
until  the  child  is  in  good  condition,  unless  it  is  likely  to  be  exposed  to 
smallpox.    As  a  rule,  vaccination  should  be  avoided  during  dentition. 

Methods  of  Vaccinating. — In  my  experience  it  is  better  to  vaccinate 
in  one  place  rather  than  to  make  two  or  three  inoculations.  If  more  than 
one  is  made  they  should  be  at  least  an  inch  apart.  Either  the  leg  or  the 
arm  may  be  chosen;  in  young  infants  it  is  usually  easier  to  protect  the 
vaccine  sore  upon  the  leg  than  upon  the  arm ;  in  children  old  enough 
to  run  about,  the  arm  is  to  be  preferred,  as  being  more  easily  kept  at  rest. 
Tlie  point  selected  for  inoculation  should  be  either  the  outer  aspect  of  the 
left  calf,  about  the  junction  of  the  middle  with  the  upper  third  of  the  leg, 
or,  if  the  arm  is  chosen,  the  insertion  of  the  left  deltoid.  The  skin  should 
be  washed  with  soap  and  water,  dried,  and  then  washed  with  alcohol. 

The  New  York  Health  Department  supplies  with  each  tube  of  lymph, 
a  needle,  a  bit  of  rubber  tubing,  and  a  sterilised  tooth-pick  with  one  flat 
end.  The  needle  should  be  sterilised  in  an  alcohol  flame,  and  a  single 
scratch  made  not  more  than  one-eighth  of  an  inch  long,  just  deep  enough 
to  draw  blood.     The  ends  of  the  capillary  tube  are  broken  off,  one  end 


VACCINIA.  951 

inserted  in  the  rubber  tube,  and  the  lymph  blown  out  of  the  tube  upon 
the  broad  end  of  the  tooth-pick,  then  applied  to  the  scratched  surface 
and  rubbed  in  for  a  full  minute.  The  wound  should  not  be  covered 
until  dry ;  this  usually  requires  from  fifteen  to  twenty  minutes.  It  may 
then  be  covered  with  a  sterilised  bandage.  If  thoroughly  dried  no  dress- 
ing is  necessary.  The  limb  should  not  be  washed  for  twenty-four 
hours. 

The  Normal  Course  of  Vaccinia. — The  course  of  a  proper  vaccination- 
pock  is  quite  uniform,  and  one  which  does  not  follow  this  course  should 
not  be  considered  protective.  The  wound  heals  and  nothing  is  noticed 
until  the  third  or  fourth  day,  when  a  red  papule  makes  its  appearance. 
Usually  in  twenty-four  hours  more  a  small  vesicle  appears  which  enlarges 
until  the  sixth  or  seventh  day,  reaching  its  full  development  about  the 
ninth  day.  Its  shape  and  size  depend  somewhat  upon  the  scarification 
(Figs.  193-197).  The  vesicle  is  usually  from  one-fourth  to  one-half  inch 
in  diameter;  it  is  of  a  pearly  gray  colour  and  has  a  depressed  centre. 
During  the  next  two  days  an  areola  forms  about  the  vesicle  extending 
from  it  a  variable  distance,  usually  one  or  two  inches  into  the  healthy 
skin.  Its  size  depends  upon  the  intensity  of  the  infection.  This  areola 
is  normally  of  a  bright  red  colour  and  accompanied  by  some  induration. 
It  is  generally  at  its  height  about  the  ninth  day.  The  vesicle  usually 
dries  down  to  a  firm,  dark  crust  which  remains  from  one  to  thrcH) 
weeks  and  falls  off,  leaving  a  bluish  scar  which  fades  to  white,  becoming 
somewhat  honey-combed.  When  the  process  is  at  its  height  some  consti- 
tutional disturbance  is  usually  present;  there  may  be  loss  of  appetite, 
fretfulness,  and  general  indisposition,  and  the  temperature  is  usually  ele- 
vated from  one  to  three  degrees.  The  lymph  nodes  in  the  groin  or  axilla 
may  be  tender  and  swollen.  These  symptoms  generally  last  for  three  or 
four  days. 

If  in  a  young  infant  the  first  inoculation  is  unsuccessful,  at  least 
three  trials  should  be  made  with  good  virus,  and  in  the  event  of  further 
failure,  after  a  year  vaccination  should  be  repeated.  A  failure  to  inocu- 
late does  not  mean  insusceptibility  to  smallpox,  as  is  often  popularly  be- 
lieved, but  most  frequently  arises  from  the  fact  that  the  virus  is  inert. 
I  have  known  one  case  in  which  the  seventh,  and  another  in  which  the 
tiiirteenth,  inoculation  was  successful  after  previous  failures;  occasion- 
ally there  are  seen  children  who  can  not  be  inoculated  at  all. 

Constitutional  symptoms,  as  previously  stated,  may  be  absent  in  very 
young  infants;  but  in  others  there  is  quite  constantly  present  a  fever 
which  runs  a  fairly  regular  course.  It  usually  begins  on  the  fourth  or 
fifth  day,  is  remittent  in  type,  and  rises  gradually,  reaching  its  high- 
est point  with  the  full  development  of  the  vesicle.  At  this  time  even 
without  complications  it  may  touch  104°  or  105°  F.  The  duration  of  the 
fever  in  cases  running  the  usual  course  is  four  or  five  days.    Accompany- 


Fig.  193.     Fifth  day. 


Fig.  194.     Seventh  day. 


Fig.  195.     Ninth  day. 


Fig.  196.     Eleventh  day.  Fk;.  l'J7.     Ti  nth  .lay. 

Figs.  193-197. — Vaccine  Vesicles.     (Two-thirds  natural  size.) 
Figs.  193,  194,  19.5,  and  196  show  typical  appearance  of  vesicle  at  the  different  stages  when 

a  verj' small  scarification  Ls  made. 
Fkj.  197  shows  the  effect  of  a  larger  scarification  with  a  more  intense  areola.    The  amount 
of  inflammation  is  excessive  but  not  unusual. 
952 


VACCINIA. 


953 


ing  the  fever  there  may  be  anorexia,  restlessness,  loss  of  sleep,  slight  in- 
digestion, and  other  symptoms  of  a  general  indisposition. 

Both  the  local  and  the  general  symptoms  are  sometimes  more  severe. 
This  may  depend  upon  the  susceptibility  of  the  child,  even  though  tlie 
lymph  is  pure  and  the  vaccination  properly  done.  Tiie  original  vesicle 
may  be  much  larger  than  usual,  and  small  secondary  vesicles  may  form 
in  the  neighbourhood.  In  very  rare  instances  a  generalised  eruption  of 
true  vaccine  vesicles  occurs  with  fever  and  other  general  symptoms  of  cor- 
responding severity  (Fig.  198).  Single  vesicles  may  be  produced  on  dis- 
tant parts  of  the  body  as  a  result  of  auto-inoculation,  usually  by  scratch- 
ing. Where  eczema  of  the 
face  is  present,  inoculation 
is  not  infrequently  carried 
thither.  Most  of  the  very 
sore  arms  and  legs,  how- 
ever, are  due  to  infection 
from  pyogenic  bacteria 
contained  in  the  lymph,  or 
to  their  accidental  intro- 
duction at  the  time  of  vac- 
cination or  subsequently. 
In  the  milder  cases,  the 
swelling  and  other  evi- 
dences of  local  inflamma- 
tion are  more  marked  than 
in  a  normal  vaccination;  a 
drop  or  two  of  pus  forms 
beneath  the  scab,  and  when  the  latter  comes  away  an  excavation  is  left 
which  heals  in  two  or  three  weeks.  Or,  the  inflammation  may  extend 
more  deeply  into  the  connective  tissue,  to  be  followed  by  more  extensive 
suppuration  or  sloughing,  leaving  an  ugly  ulcer  an  inch  or  more  in 
diameter  wliicli  slowly  fills  by  granulation  in  from  five  to  eight  weeks. 
Sometimes  the  period  of  incubation  is  unduly  prolonged,  so  that  the 
vesicle  does  not  form  until  the  twelfth  or  fourteenth  day,  although  its 
subsequent  course  may  be  normal.  In  other  cases,  the  incubation  is  shorter 
tlian  usual,  and  the  vesicle  may  appear  as  early  as  the  third  or  fourth  day. 

Much  has  been  written  about  the  so-called  "  raspberry  excrescence  " 
which  not  very  infrequently  takes  the  place  of  a  proper  vesicle.  It  is  of 
a  dark  red  colour,  elevated,  smooth  or  slightly  granular,  not  sensitive, 
having  no  areola  and  no  constitutional  symptoms.  It  generally  per- 
sists for  two  or  three  weeks,  and  slowly  disappears,  leaving  no  scar.  It  is 
usually  the  result  of  virus  of  feeble  activity,  and  if  it  gives  any  protection 
it  is  very  slight.  Such  cases  should  always  be  re-vaccinated,  and  in  my 
experience  re-vaccination  is  usually  successful. 


Fig.  198. — Generalised  Vaccinia. 
Boy  eight  years  old. 


954  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Complications  and  Sequelae. — Post-vaccine  eruptions  are  many  and 
of  great  variety.  The  most  frequent  is  a  general  roseola,  usually  occur- 
ring at  the  height  of  the  local  process.  Other  eruptions  seen  are  urti- 
caria, and,  rarely,  purpura.  Complications  are  chiefly  from  accidental 
infection.  Syphilis  and  tuherculosis  are  excluded  hy  the  modern  method 
of  procuring  the  lymph.  Tetanus  can  result  only  from  carelessness 
or  neglect  of  suitable  precautions  in  preparing  the  lymph;  proper 
legal  restrictions  regarding  its  production  should  make  this  impossible. 
The  most  common  form  of  local  infection  is  cellulitis,  which  may  termi- 
nate in  suppuration  or  sloughing  at  the  site  of  vaccination,  and  some- 
times may  cause  suppuration  of  the  neighbouring  lymph  nodes.  Ery- 
sipelas may  develop  at  any  time  before  the  skin  is  entirely  healed;  it  is 
usually  due  to  neglect  of  proper  precautions  in  the  care  of  the  vaccine  sore. 

The  mortality  of  vaccination  is  stated  by  Voigt,  from  careful  statistics 
drawn  from  German  sources,  to  have  been  35  in  2,275,000  cases,  including 
both  primary  and  secondary  vaccinations.  Of  the  deaths,  19  were  due  to 
erj'sipelas,  8  to  gangrene,  2  to  cellulitis,  3  to  "  blood  poisoning,"  and  3  to 
other  causes.  The  occurrence  of  tetanus  after  vaccinia  has  already  been 
mentioned.  With  proper  precautions  in  preparing  lymph  it  will  not  oc- 
cur.    In  fact,  nearly  all  the  deaths  are  from  causes  which  are  prevental)le. 

Treatment. — The  whole  purpose  of  treatment  is  to  prevent  infection. 
The  first  essentials  are  a  clean  limb,  pure  virus,  and  a  sterile  needle:  the 
next,  to  allow  thorough  drying  of  the  wound  before  the  clothing  touches 
it.  After  this  nothing  is  necessary  until  the  vesicle  forms.  Then  the 
important  thing  is  to  prevent  scratching  and  the  irritation  hy  the  cloth- 
ing. All  vaccine  shields  are  objectionable.  For  an  infant  nothing  is 
better  than  the  sterilised  gauze  bandage,  which  can  be  kept  in  place  by 
pewing  to  the  stocking  or  sleeve  of  the  shirt.  Any  constriction  of  the 
limb  is  injurious.  For  older  children  the  simplest  dressing  is  a  pad  of 
sterile  gauze  fastened  to  the  limb  by  two  pieces  of  adhesive  plaster. 
Should  the  vesicle  rupture  and  discharge  serum,  it  should  be  kept  clean 
and  dry  by  dusting  daily  with  boric  acid.  When  the  local  symptoms  are 
at  all  severe  the  limb  should  be  kept  at  rest.  An  infected  vaccination 
wound,  like  any  other  infected  wound,  requires  careful  surgical  treat- 
ment; disastrous  results  often  follow  the  use  of  poultices  and  other  aj)pli- 
cations  much  in  vogue  in  domestic  practice. 


CHAPTER    VI. 

PERTUSSIS. 

(Whooping-Cough.) 

Pertussis  is  a  contagious  disease  which  prevails  epidemically  and  in 
most  large  cities  endemically.     Although  it  may  affect  persons  of  any 


PERTUSSIS.  955 

age,  it  is  generally  seen  in  young  children,  and  as  a  rule  it  occurs  but 
once  in  the  same  individual.  While  in  later  childliood  pertussis  may  be 
ranked  as  one  of  the  milder  infectious  diseases,  in  infancy  it  is  one  of  the 
most  fatal.  Its  principal  complications  are  broncho-pneumonia  and  con- 
vulsions. Pertussis  is  characterised  by  catarrhal  and  nervous  symptoms. 
The  catarrh  affects  the  mucous  membrane  of  the  respiratory  tract,  and  is 
probably  due  to  a  specific  form  of  infection.  It  is  accompanied  by  a 
hyperaesthetic  condition  of  this  mucous  meml)rane.  The  most  prominent 
nervous  manifestation  is  a  peculiar  spasmodic  cough  which  occurs  in 
paroxysms,  and  from  which  the  disease  takes  its  name.  The  cough  is  no 
doubt  of  reflex  origin,  from  an  irritation  which  has  been  located  by  dif- 
ferent writers  in  various  parts  of  the  respiratory  tract.  In  addition  to 
these  conditions,  there  is  present  in  pertussis  a  marked  irritability  of  the 
nervous  system,-which  in  infancy  often  shows  itself  by  convulsions. 

Etiology. — Everything  that  is  known  of  pertussis  suggests  a  micro- 
organism as  its  cause.  Present  evidence,  moreover,  points  strongly  to  a 
bacillus  first  described  by  Bordet,  although  this  lacks  the  final  proof  of 
the  production  of  the  disease  by  inoculation.  Bordet's  bacillus  is  a  small 
(ham-negative  organism  which  in  many  points  resembles  the  influenza 
bacillus.  It  is  cultivated  with  difficulty,  but  grows  best  on  ])otato-blood- 
agar.  Subcultures  do  not  require  haemoglobin  for  their  growth.  It  is 
difficult  to  obtain  the  organism  from  the  respiratory  secretion  unless  the 
plug  of  bronchial  mucus  brought  up  after  a  paroxysm  of  coughing  is 
secured,  as  it  develops  chiefly  deep  in  the  respiratory  tract.  It  is  found 
only  in  the  early  stage  of  pertussis,  rarely  longer  than  a  week  after  the 
whoop  develops.  The  influenza  bacillus  is  very  frequently  associated 
with  it. 

Proximity  to  a  patient  seems  all  that  is  required  to  communicate  the 
disease,  and  even  close  proximity  is  not  necessary.  There  seems  to  be  no 
doubt  that  the  disease  may  be  contracted  in  the  open  air. 

Predisposition. — Fully  one-half  the  cases  of  pertussis  occur  during 
the  first  two  years  of  life.  The  following  are  the  statistics  of  Szabo 
(Buda-Pesth),  showing  the  ages  at  which  the  disease  was  met  with  in 
4,591  cases,  comprising  the  records  of  one  clinic  for  thirty-four  years: 


Under  one  year 1,028  cases. 

One  to  two  years 1,008      " 

Two  to  three  years 659      " 


Three  to  four  years 904  cases. 

Four  to  seven  years 803      " 

Over  seven  years 189      " 


Pertussis  thus  shows  a  stronger  tendency  to  affect  young  infants  than 
does  any  otlier  contagious  disease.  A  number  of  cases  are  on  record  in 
which  it  has  occurred  during  the  first  month,  and  one  has  recently  come 
to  my  notice  where  a  child  twelve  days  old  was  attacked,  whose  mother 
was  suffering  from  the  disease.  The  disease  is  nearly  twice  as  frequent 
in  the  winter  and  spring  as  in  the  summer  and  autumn.  Epidemics  of 
pertussis  often  occur  at  the  same  time  with  or  follow  those  of  measles. 


956  THE  SPECIFIC   INFECTIOUS  DISEASES. 

The  susceptibility  to  pertussis  is  very  great,  and  is  equalled  only  by 
that  to  measles.  Biedert  reports  tliat  of  401  children  exposed  during 
an  epidemic  in  a  certain  village,  366,  or  ninety-one  per  cent,  took  the 
disease. 

Infective  Period. — Pertussis  may  be  communicated  from  the  very  be- 
ginning of  the  catarrhal  stage;  it  is  more  contagious  at  this  period  than 
later.  There  seems  little  doubt  that  it  is  contagious  throughout  the 
spasmodic  stage  and  possibly  longer.  Quarantine  is  generally  required 
for  two  months,  and  in  many  cases  for  a  longer  time.  The  usual  source 
of  the  contagion  is  the  patient,  rarely  the  room  or  the  clothing.  While 
pertussis  may  be  carried  by  a  third  person,  this  is  very  unlikely  unless 
one  has  been  in  very  close  contact  with  the  patient,  and  goes  at  once 
without  change  of  clothing  to  another  child. 

Incuhation. — The  very  gradual  onset  of  pertussis  renders  it  impos- 
sible in  the  majority  of  cases  to  fix  the  exact  date,  and  hence  to  estab- 
lish the  definite  duration  of  the  period  of  incubation.  In  cases  where 
this  could  best  be  determined  it  has  usually  been  from  seven  to  fourteen 
days,  or  about  the  same  as  in  measles.  If,  after  an  exposure,  sixteen 
days  pass  without  the  development  of  a  cough,  the  probabilities  are  very 
strong  that  the  disease  has  not  been  contracted. 

Lesions. — The  only  constant  lesion  of  pertussis  consists  in  a  catarrhal 
inflammation  of  varying  intensity,  which  affects  the  mucous  membrane 
of  the  larynx,  trachea,  and  bronchi,  and  sometimes  that  of  the  nose  and 
pharynx.  If  the  child  dies  during  a  paroxysm,  either  with  or  without 
con\'ulsions,  the  brain  is  found  intensely  congested  and  may  be  the  seat 
of  punctate  haemorrhages,  or  even  larger  extravasations.  The  lungs 
always  show  emphysema  if  the  attack  has  been  severe  or  protracted. 
The  other  pulmonary  lesions  are  due  to  complications,  the  most  fre- 
quent of  which  is  broncho-pneumonia.  Catarrhal  enteritis  and  colitis 
are  not  infrequent. 

Symptoms. — The  symptoms  of  pertussis  are  usually  divided  into  three 
stages — the  catarrhal,  the  spasmodic,  and  the  stage  of  decline. 

The  catarrhal  stage  continues  on  the  average  for  about  ten  days, 
although  cases  show  considerable  variation  on  this  point.  Some  chil- 
dren whoop  almost  from  the  very  beginning  of  the  disease,  while  otliers 
may  cough  for  three  or  four  weeks  before  a  typical  whoop  is  noticed. 
The  symptoms  in  the  beginning  are  indistinguishable  from  those  of  an 
ordinary  attack  of  subacute  tracheo-bronchitis,  and  unless  there  has 
been  an  exposure  to  pertussis  no  suspicion  is  excited.  After  five  or  six 
days,  however,  the  cough,  instead  of  abating  as  in  an  ordinary  cold,  grad- 
ually increa§es  in  severity  and  occurs  in  paroxysms.  At  first  these  are 
mild,  and  there  are  only  two  or  three  a  day,  but  they  gradually  increase 
in  frequency  and  severity  until  the  typical  whoop  is  heard  which  marks 
the  beginning  of  the  spasmodic  stage.    During  the  first  stage  there  may 


PERTUSSIS.  957 

be  symptoms  of  a  mild  grade  of  catarrhal  inflammation  of  the  nose, 
pharynx,  and  larynx,  and  often  there  is  a  slight  elevation  of  temperature. 

The  Spasmodic  Stage. — In  a  typical  paroxysm  of  average  severity  the 
child,  who  can  usually  foretell  it,  will  often  run  for  support  to  the  lap 
of  the  mother  or  the  nurse,  or  seize  a  chair  with  both  hands.  There 
now  occurs  a  series  of  explosive  coughs,  from  ten  to  twenty  in  number, 
coming  in  such  rapid  succession  that  the  child  can  not  get  his  breath 
between  them;  the  face  becomes  of  a  deep  red  or  purple  colour,  sometimes 
almost  black ;  the  veins  of  the  face  and  scalp  stand  out  prominently ; 
the  eyes  are  suffused,  and  seem  almost  to  start  from  their  sockets;  there 
follows  a  long-drawn  inspiration  through  the  narrowed  glottis,  produc- 
ing the  crowing  sound  known  as  the  whoop ;  and  then  another  succession 
of  rapid  coughs  follows  and  another  whoop.  In  a  single  severe  paroxysm, 
which  lasts  two  or  three  minutes,  the  child  may  whoop  half  a  dozen 
times;  with  the  final  paroxysm  a  mass  of  tenacious  mucus  is  usually 
brought  up.  In  a  young  child  vomiting  is  almost  certain  to  follow,  if 
food  lias  been  recently  taken.  Epistaxis  sometimes  occurs  with  nearly 
every  severe  paroxysm,  but  in  most  cases  the  bleeding  is  slight.  After 
a  severe  attack  the  child  is  at  times  so  exhausted  as  to  be  hardly  able  to 
stand.  There  is  profuse  perspiration;  his  mind  is  confused,  and  he  may 
be  completely  dazed.  In  infants  the  attack  may  result  in  a  degree  of 
asphyxia  requiring  artificial  respiration.  Those  old  enough  to  describe 
their  sensations  tell  of  a  sense  of  impending  suffocation,  the  suffering 
from  which  is  almost  indescribable. 

The  number  of  severe  paroxysms  or  "  kinks  "  in  twenty-four  hours 
varies,  according  to  the  severity  of  the  case,  from  half  a  dozen  to  forty 
or  fifty.  There  are  always  many  more  of  a  milder  form.  Paroxysms 
are  often  excited  by  eating  or  drinking  anything  cold,  by  a  draught  of 
air,  or  by  imitation;  they  are  usually  more  frequent  during  the  night 
than  the  day,  and  in  a  close  room  than  in  the  open  air. 

In  less  severe  cases  no  paroxysms  of  the  grade  above  described  may 
occur,  and  no  typical  whoop  may  be  heard  throughout  the  attack;  but 
the  paroxysmal  nature  of  the  cough  which  continues  until  the  plug  of 
mucus  is  expelled,  the  watery  eyes,  and  the  vomiting  which  follows  a 
paroxysm,  stamp  the  disease  as  pertussis.  In  young  infants  the  whoop 
is  frequently  not  marked.  The  child  sometimes  coughs  until  he  is  asphyx- 
iated, and  yet  no  whoop  occurs.  The  paroxysms  are  also  modified  by 
intercurrent  disease,  especially  by  attacks  of  pneumonia  or  severe  bron- 
chitis. At  such  times  they  usually  become  less  frequent  and  less  typical, 
and  may  be  absent  for  several  days,  returning  as  the  complication  sub- 
sides. 

The  seat  of  the  irritation  which  produces  the  cough  has  been  vari- 
ously located  by  different  observers.  Some  have  thought  it  to  be  in  the 
nose,  others  in  the  trachea,  the  bronchi,  or  the  larynx.    It  is  very  prob- 


958  THE  SPECIFIC   INFECTIOUS  DISEASES. 

able  that  it  may  not  always  be  in  the  same  place  and  that  the  infectious 
catarrh,  which  is  really  the  most  important  element  in  the  disease,  may 
vary  in  its  intensity  and  location  in  different  cases.  The  weight  of  evi- 
dence seems  to  be  that  in  the  great  majority  of  cases  the  source  of  irrita- 
tion is  in  the  larynx  or  trachea.  From  laryngoscopic  examinations  made 
during  the  disease.  Yon  Herff  found  the  mucous  membrane  of  tlie  larynx 
to  be  swollen  and  congested,  and  occasionally  the  seat  of  small  haemor- 
rhages or  superficial  ulcers.  He  states  that  the  frequency  and  severity 
of  the  paroxysms  corresponded  with  the  degree  of  laryngitis,  and  he 
found  that  a  paroxysm  could  always  be  excited  by  irritating  tiie  mucous 
membrane  between  the  arytenoid  cartilages.  During  a  paroxysm  he 
observed  that  there  was  a  collection  of  mucus  on  the  posterior  laryngeal 
wall,  the  removal  of  which  had  the  effect  of  shortening  the  paroxysm. 

Eossbach  made  laryngoscopic  examinations,  with  negative  results  so 
far  as  the  larynx  was  concerned,  but  he  states  that  a  plug  of  mucus  could 
always  be  seen  in  tlie  lower  trachea  for  one  or  two  minutes  before  the 
paroxysm  occurred.  There  is  little  doubt  that  this  collection  of  mucus 
is  the  exciting  cause  of  the  paroxysm,  as  it  is  a  familiar  clinical  fact  that 
the  paroxysm  continues  until  this  is  dislodged. 

The  average  duration  of  the  spasmodic  stage  is  about  one  mouth 
It  increases  in  intensity  for  the  first  two  weeks,  remains  stationary  for 
about  a  week,  and  then  gradually  diminishes  in  severity.  The  course  and 
duration  of  this  stage  are,  however,  subject  to  wide  variations.  In  mild 
cases  it  may  last  only  a  week ;  in  severe  cases,  especially  in  tlie  winter 
season,  it  may  continue  for  three  months,  at  times  almost  subsiding,  but 
lighting  up  again  with  all  its  previous  severity  with  every  fresh  attack 
of  cold.  After  it  has  entirely  ceased  the  whoop  may  return  with  an 
attack  of  bronchitis,  and  continue  for  a  month  or  more.  This  is  not  to 
be  regarded  as  a  trile  relapse  of  pertussis.  The  habit  of  the  paroxysmal 
cough  once  established,  it  tends  to  recur  with  every  slight  bronchitis, 
often  for  months  afterward. 

The  Stage  of  Decline. — Gradually  the  severity  of  the  paroxysms  abates, 
the  whoop  ceases,  and  the  cough  resembles  more  and  more  that  of  ordi- 
nary bronchitis.  This  stage  usually  continues  about  three  weeks,  but 
may  be  prolonged  indefinitely  in  the  winter  months. 

Complications. — Hcemorrhages. — The  haemorrhages  of  pertussis  are 
mechanical,  and  depend  upon  the  intense  venous  congestion  which  ac- 
companies the  paroxysm.  Epistaxis  is  the  most  frequent  variety,  and 
occurs  in  a  considerable  proportion  of  the  severe  cases,  in  a  few  with 
almost  every  severe  paroxysm,  but  it  is  rarely  severe  enough  to  require 
local  treatment.  Haemorrhages  from  the  mouth  may  have  their  origin 
either  in  the  pharynx  or  the  bronchi,  the  blood  being  brought  up  by  the 
cough;  such  haemorrhages  are  usually  small.  Conjunctival  haemorrhages 
are  less  frequent,  and  are  usuaDy  slight,  although  I  have  seen  the  entire 


PERTUSSIS.  959 

conjunctiva  covered.  In  a  case  under  my  observation  there  was  bleeding 
from  both  ears  witli  every  severe  paroxysm,  for  more  tlian  a  week.  This 
child  had  previously  suffered  from  scarlatinal  otitis,  with  perforation  of 
the  drum  membrane.  Small  extravasations  into  tlie  cellular  tissue  be- 
neath the  eyes  are  occasionally  seen,  giving  an  appearance  somewhat 
like  an  ordinary  "  black  eye."  Intracranial  haemorrhages  are  not  fre- 
(luent,  but  many  examples  have  been  recorded,  and  they  may  be  severe 
enough  to  produce  death.  They  are  usually  meningeal,  very  rarely 
cerebral;  according  to  their  extent  and  location  they  may  produce 
hemiplegia,  monoplegia,  aphasia,  facial  paralysis,  or  disturbances  of 
sight,  hearing,  or  sensation;  in  addition,  there  may  be  convulsions  or 
rigid  it}',  but  rarely  complete  coma.  The  extravasations  are  sometimes 
small  and  the  symptoms  which  they  produce  may  disappear  at  the  end 
of  a  few  weeks.  More  extensive  haemorrhages  may  cause  death.  In 
almost  every  instance  these  haemorrhages  have  occurred  as  a  direct  result 
of  the  severe  paroxysms.  Purpura  haemorrhagica  is  occasionally  seen 
as  a  sequel  of  pertussis. 

Respiratory  System. — The  most  serious  complications  of  pertussis  are 
connected  with  the  lungs.  By  far  the  largest  proportion  of  deaths  is 
due  to  pulmonary  complications,  usually  broncho-pneumonia.  This  is 
more  frequent  in  winter  and  spring  than  in  the  summer  months,  and  is 
especially  to  be  dreaded  during  infancy.  In  later  childhood  lobar  pneu- 
monia is  occasionally  seen.  Pneumonia  rarely  begins  before  the  second 
week  of  the  disease,  and  most  frequently  develops  at  the  height  or  toward 
the  close  of  the  spasmodic  stage.  The  physical  signs  present  no  peculiar- 
ities; the  cough  changes  somewhat  in  character  during  the  pneumonia, 
and  the  whoop  may  not  be  heard.  The  prognosis  of  the  pneumonia  is 
bad,  because  of  the  debilitated  condition  of  the  children  at  the  time  of 
its  occurrence.  A  great  danger  is  from  the  supervention  of  convulsions, 
this  being  a  frequent  mode  of  termination.  As  there  is  always  consider- 
able emphysema  the  rapidity  of  breathing  is  frequently  out  of  proportion 
to  the  temperature,  which  often  is  only  moderately  elevated.  If  the  child 
escapes  the  dangers  of  the  acute  stage,  death  may  still  occur  from  ex- 
haustion, owing  to  the  protracted  course  which  the  disease  frequently 
nms. 

Bronchitis  of  the  large  tubes  is  present  in  almost  all  the  severe  cases, 
and  is  not  of  itself  serious.  Bronchitis  of  the  small  tubes  has  the  same 
dangers  and  the  same  complications  as  broncho-pneumonia. 

Vesicular  emphysema  has  been  present,  I  think,  in  every  case  which 
I  have  seen  upon  the  post-mortem  table;  a  certain  amount  of  it,  no 
doubt,  occurs  in  every  severe  case.  It  is  produced  by  the  forcible  cough 
of  the  paroxysm.  In  very  severe  cases  interstitial  emphysema  is  also 
found.  Rupture  of  the  air-blebs  which  form  on  the  surface  of  the  lung 
may  lead  to  emphysema  of  the  cellular  tissue  of  the  mediastinum,  and 


960  THE  SPECIFIC  INFECTIOUS  DISEASES. 

the  air  may  find  its  way  along  tlie  great  vessels  into  the  neck,  and  finally 
into  the  subcutaneous  cellular  tissue  of  the  entire  body.  Cases  of  general 
subcutaneous  emphysema  have  been  reported  by  Croker  and  by  Hodge, 
both  of  which  ended  fatally,  one  in  three  and  one  in  eight  days  from 
the  beginning  of  the  emphysema.  In  the  great  majority  of  the  cases 
vesicular  emphysema  is  not  permanent. 

Digestive  System. — During  the  summer,  infants  with  pertussis  are 
almost  certain  to  suffer  from  diarrhoea;  it  may  be  only  an  occasional 
symptom,  or  the  attack  may  be  severe  and  prolonged,  resulting  in  the 
development  of  ileo-colitis.  The  intestinal  complications  may  be  almost 
as  serious  in  summer  as  are  those  of  the  respiratory  tract  in  winter. 
Vomiting  is  even  more  frequent  than  diarrhoea,  and  while  it  may  be  dis- 
tressing at  an}'  age,  it  is  especially  so  in  infancy.  So  frequently  does  the 
taking  of  food  excite  vomiting,  that  the  nutrition  of  these  patients  often 
becomes  a  matter  of  the  greatest  difficulty,  and  in  fact  the  most  serious 
problem  in  the  management  of  a  case.  Malnutrition  and  even  marasmus 
may  follow,  or  the  general  resistance  of  the  child  may  become  so  reduced 
by  lack  of  food  that  it  falls  a  ready  prey  to  pneumonia. 

Nervous  System. — There  may  be  convulsions,  coma,  paralysis,  aphasia, 
disturbances  of  sight  or  hearing,  and  in  rare  cases  even  the  mental  con- 
dition may  be  affected.  The  most  serious  of  these  complications  are 
convulsions.  They  are  much  more  frequent  in  infancy  than  later,  and 
particularly  in  those  who  are  rachitic,  in  whom  they  are  often  fatal.  Con- 
vulsions are  of  course  more  common  in  severe  attacks,  but  they  may  occur 
suddenly  where  there  has  previously  been  no  cause  for  anxiety.  They 
are  especially  to  be  dreaded  if  pneumonia  is  present.  The  attack  of  con- 
vulsions may  be  the  culmination  of  the  extreme  degree  of  nervous  irri- 
tability which  accompanies  the  paroxysm,  it  may  be  due  to  asphyxia,  or 
to  an  intracranial  lesion;  if  the  latter,  there  is  usually  meningeal  hasmor- 
rhage.  This  is  to  be  suspected  if  there  are  continued  convulsions  for 
several  hours,  with  general  rigidity  or  hemiplegia. 

Disturbances  of  sight  are  not  infrequent  in  severe  cases;  usually 
these  are  transient,  but  there  may  be  blindness  lasting  two  or  three  days 
or  even  weeks.  The  transient  symptoms  depend  most  likely  upon  cir- 
culatory changes  that  occur  in  the  brain  during  the  paroxysm,  while 
those  which  last  for  two  or  three  weeks  are  probably  due  to  meningeal 
haemorrhage.  Disturbances  of  hearing  are  rare.  The  different  forms 
of  paralysis  occurring  with  pertussis  may  likewise  be  transient  or  per- 
manent. They  are  to  be  explained  in  the  same  way  as  the  disturbances 
of  the  special  senses.    The  most  common  form  is  hemiplegia. 

Albuminuria  is  not  infrequent,  being  found  in  sixty-six  of  eighty- 
six  examinations  by  Knight.  The  quantity  of  albumin  is  rarely  large, 
and  it  may  be  accompanied  by  a  few  hyaline  casts.  Both  are  probably 
the  result  of  circulatory  disturbances  in  the  kidney.     Other  complica- 


PERTUSSIS.  961 

tions  of  pertussis  are  hernia,  prolapsus  aui,  and  ulcer  of  the  frenum 
linguae. 

Diagnosis. — The  only  constant  features  of  pertussis  are  the  course  of 
the  disease  and  its  communicability.  In  many  cases  the  typical  whoop 
is  never  heard.  There  are  no  symptoms  by  which  a  positive  diagnosis 
can  be  made  in  the  catarrhal  stage ;  but  a  cough  not  accompanied  by  fever 
or  physical  signs,  which  steadily  increases  in  severity  for  two  weeks, 
in  spite  of  treatment,  and  which  occurs  chiefly  at  night,  is  always  suspi- 
cious. When,  in  addition,  the  cougli  begins  to  come  in  paroxysms,  ac- 
companied by  suffusion  of  the  face  and  occasionally  by  vomiting,  there 
can  be  little  doubt  even  though  no  whoop  is  heard.  If  the  disease  is 
prevalent  the  diagnosis  is  practically  certain.  Mild  cases  which  do  not 
go  even  as  far  as  the  symptoms  mentioned  are  most  puzzling.  But  if 
there  is  a  history  of  exposure,  if  the  cough  continues  from  four  to  six 
weeks,  little  influenced  by  treatment,  and  if  other  cases  follow,  the  dis- 
ease must  be  pertussis.  Without  evidence  of  communicability,  however, 
one  may  be  in  doubt  even  after  the  disease  is  over.  In  early  infancy 
any  cough  may  have  more  or  less  of  a  spasmodic  character,  and  a  fairly 
typical  whoop  is  often  heard  in  the  course  of  an  ordinary  bronchitis. 
I  have  several  times  seen  abortive  or  very  short  attacks  in  one  member 
of  a  family  of  children,  the  others  having  th.e  disease  in  a  typical  form. 
Occurring  by  themselves  such  cases  can  not  be  recognised. 

Irritation  of  the  pneumogastric  or  recurrent  laryngeal  nerve  from 
enlarged  tracheal  or  bronchial  lymph  nodes,  whether  of  a  simple  or  tuber- 
culous character,  may  give  rise  to  a  spasmodic  cough,  which  in  certain 
cases  may  be  indistinguishable  from  pertussis.  The  prolonged  duration 
of  these  cases  is  sometimes  the  only  diagnostic  point;  but  the  paroxysms 
are  usually  not  so  severe  as  in  true  pertussis,  and  the  course  is  generally 
less  typical. 

The  presence  of  a  leucocytosis  may  be  of  considerable  aid  in  diag- 
nosis.^ 

Prognosis. — The  most  important  factor  in  the  prognosis  of  the  dis- 
ease is  the  age  of  the  patient.  After  the  fourth  year  it  is  indeed  rare 
that  either  a  fatal  result  or  serious  complications  are  seen;  but  during 
infancy,  and  particularly  during  the  first  year,  there  are  few  diseases 
more  to  be  dreaded.  This  is  especially  true  on  account  of  the  connection 
of  whooping-cough   with   the   three   most   fatal   conditions    of   infancy 

1  Frohlich  and  Meunier  first  called  attention  to  the  leucocytosis  accompanying 
pertussis,  far  exceeding  that  of  any  other  afebrile  disease  of  the  respiratory  tract.  It 
appears  in  the  early  part  of  the  convulsive  stage,  and  disappears  slowly  with  improve- 
ment. The  count  is  usually  between  15,000  and  25,000,  although  it  may  reach 
50,000.  There  is  an  increase  in  the  lymphocytes  at  the  expense  of  the  neutro- 
philes.  The  lymphocjrtes  may  form  60  to  80  per  cent  of  the  total  leucocytes.  The 
leucocytosis  is  little  influenced  by  complications,  and  even  during  broncho-pneu- 
monia the  lymphoc3rtes  continue  to  be  in  excess. 
62 


962  THE  SPECIFIC  INFECTIOUS  DISEASES. 

— broncho-pneumonia,  diarrhoeal  diseases,  and  convulsions.  Fully  two- 
thirds  of  the  deaths  from  whooping-cough  occur  during  the  first  year  of 
life.  The  prognosis  is  very  much  worse  in  infants  under  three  months 
than  in  those  who  are  older  and  consequently  have  more  resistance.  It 
is  better  in  the  summer  than  in  the  winter,  because  broncho-pneumonia 
is  then  less  frequent.  It  is  particularly  bad  in  delicate  infants,  in  those 
who  are  rachitic,  in  those  who  are  prone  to  attacks  of  bronchitis,  in 
those  who  have  suffered  previously  from  pneumonia,  and  in  those  with 
a  strong  tendency  to  tuberculosis. 

The  exact  mortality  of  whooping-cough  it  is  difficult  to  state  in  fig- 
ures. During  the  first  year  of  life  it  is  probably  not  far  from  twenty-five 
per  cent,  although  it  diminishes  rapidly  after  this  time.  In  foundling 
asylums  and  hospitals  for  infants  it  is  to  be  ranked  among  the  most 
fatal  diseases,  and  in  some  epidemics  the  mortality  in  such  institutions 
is  as  high  as  fifty  per  cent. 

Fully  two-thirds  of  the  deaths  during  whooping-cough  are  from 
broncho-pneumonia;  the  next  most  frequent  cause  is  diarrlireal  diseases. 
Convulsions  may  be  the  mode  of  death  in  either  of  the  above  conditions, 
or  may  occur  apart  from  them.  During  the  first  year,  death  often  results 
from  marasmus,  the  child  having  been  reduced  by  the  prolonged  disease. 
Occasionally  death  is  due  to  asphyxia  following  a  severe  paroxysm,  to 
intracranial  haemorrhage,  or  to  general  emphysema. 

As  a  predisposing  cause  of  tuberculosis,  pertussis  is  second  only  to 
measles;  In  both  diseases  tuberculosis  develops  in  much  the  same  way 
and  from  practically  the  same  causes. 

Prophylaxis. — Pertussis  is  a  contagious  disease,  and  a  child  suffering 
from  it  should  be  isolated  from  other  children  whenever  this  is  possible. 
Children  with  pertussis  should  never  be  allowed  to  attend  school,  and 
needless  exposure  should  always  be  avoided. 

Young  infants,  delicate  children,  and  those  with  a  predisposition  to 
tuberculosis,  should  be  most  carefully  protected  against  exposure,  since 
it  is  in  them  chiefly  that  the  disease  is  likely  to  be  serious.  As  it  is 
from  the  patient  that  the  disease  is  nearly  always  contracted,  there 
does  not  exist  the  same  necessity  for  the  fumigation  and  disinfection  of 
apartments  as  after  other  contagious  diseases.  In  institutions,  however, 
this  should  always  be  practised,  and  in  private  houses  if  the  room  is 
subsequently  to  be  occupied  by  an  infant. 

It  is  as  undesirable  as  it  is  impossible  to  confine  a  child  with  per- 
tussis to  a  single  room  during  the  attack;  all  those  persons  for  whom 
exposure  would  be  dangerous  should  therefore  be  sent  away  from  the 
house.  Quarantine  should  continue  for  at  least  six  weeks,  or  until  the 
spasmodic  stage  is  over. 

Treatment. — We  have  as  yet  no  specific  remedy  for  pertussis.  The 
important  tiling  in  most  cases  is  the  hygiene  or  general  management  of 


PERTUSSIS.  963 

the  case;  fully  half  of  the  cases  seen  in  practice  require  nothing  more. 
Much  harm  is  done  by  indiscriminate  drug  giving. 

General  Measures. — Fresh  air  is  important  throughout  the  attack. 
It  is  almost  invariable  that  the  paroxysms  are  fewer  while  patients  are 
out  of  doors,  and  more  frequent  when  they  are  in  close  rooms.  Older 
children  with  pertussis  may  go  out  even  in  winter  except  on  stormy,  raw, 
or  windy  days.  With  infants  and  delicate  children,  the  outdoor  treatment 
in  cold  weather  so  enthusiastically  advocated  by  some  writers  should  be 
used  with  the  greatest  caution.  It  should  certainly  not  be  permitted 
if  the  patient  has  even  the  slightest  amount  of  bronchitis.  My  own  ex- 
perience is  that  during  the  winter  in  a  climate  like  that  of  New  York 
or  New  England,  the  class  of  patients  just  referred  to  are  better  off 
indoors,  taking  their  airing,  if  at  all,  in  their  rooms.  In  warm  weather 
or  in  a  mild  climate  all  children  should  be  kept  in  the  open  air  as  much 
as  possible. 

A  change  of  climate  is  desirable  when  the  cough  is  unduly  prolonged, 
also  for  delicate  children  in  winter.  A  warm  place  at  the  seashore  is 
one  which  is  most  likely  to  be  beneficial.  The  improvement  following  a 
sea  voyage  is  often  very  marked,  surpassing  even  a  residence  at  the  sea- 
shore. 

The  rooms  occupied  by  children  suffering  from  pertussis  should  be 
frequently  changed,  thoroughly  aired,  and  occasionally  fumigated.  A 
change  of  rooms,  clothing,  bedding,  etc.,  sometimes  exerts  a  marked  in- 
fluence on  the  course  of  very  prolonged  attacks,  the  inference  being  that 
continued  re-infection  takes  place.  Such  a  change  should  be  made  twice 
a  week,  and  it  is  of  special  importance  in  hospitals,  where  many  chil- 
dren quarantined  in  a  ward  seem  to  cough  interminably. 

Careful  feeding  and  attention  to  the  bowels  are  matters  of  the  great- 
est importance;  with  infants  particularly,  chronic  indigestion  and  ab- 
dominal distention  have  a  very  marked  effect  in  increasing  the  frequency 
of  the  paroxysms.  The  abdominal  support  furnished  by  a  snugly  fitting 
band,  adds  materially  to  the  comfort  of  the  patient  in  a  severe  attack. 
Feeding  is  difficult  since  vomiting  occurs  so  easily.  In  most  cases  it  is 
necessary  to  repeat  the  meal  in  a  short  time,  if  the  first  one  has  been 
vomited.  Children  over  two  years  old  should  in  all  such  cases  be 
kept  upon  a  fluid  diet,  chiefly  of  milk.  For  infants,  milk  should  be 
diluted,  and  in  many  instances  it  should  also  be  partially  peptonised. 
Any  medication  which  causes  disturbance  of  the  stomach  should  be 
omitted. 

Local  applications  to  the  rhino-pharynx  or  to  the  larynx  may  be  made 
by  means  of  a  spray  or  swab.  Eesorcin  and  carbolic  acid,  each  in  a  one- 
per-cent  solution,  are  most  used.  These  applications  are  made  once  or 
twice  daily.  I  have  never  seen  from  any  of  the  above  methods  the  ben- 
eficial results  claimed,  and  I  believe  them  to  have  been  exaggerated.    The 


964  THE  SPECIFIC  INFECTIOUS  DISEASES. 

application  of  cocaine  to  the  larynx  should  never  be  employed  in  young 
children  on  account  of  the  danger  of  poisoning. 

Inhalations  are  of  much  more  value.  They  are  useful  to  modify  the 
catarrh  by  allaying  irritation,  facilitating  the  expulsion  of  the  mucus, 
and  possibly  as  antiseptics.  Those  most  employed  are  carbolic  acid, 
creosote,  and  cresolene.  In  my  experience  creosote  is  the  best.  These 
substances  may  be  used  upon  cotton  in  a  respirator,  or  vapourised  over  an 
alcohol  lamp.  The  possibility  of  absorption  should  not  be  forgotten, 
and  the  urine  should  be  watched.  Where  the  paroxysms  are  frequent 
and  of  great  severit}^,  chloroform  may  be  used  to  ward  off  convulsions 
or  prevent  dangerous  asphyxia.  In  such  conditions  O'Dwyer  used  intu- 
bation with  striking  benefit.  The  tube  entirely  overcomes  the  glottic 
spasm  which  is  the  chief  cause  of  suffering  and  danger. 

Internal  Medication. — Of  the  innumerable  drugs  which  have  been 
recommended  for  this  disease,  there  are  two  which  possess  undoubted 
advantages  over  all  others,  viz.,  belladonna  and  antipyrine.  In  giving 
belladonna  it  is  important  to  begin  with  a  small  dose  and  gradually  in- 
crease both  its  frequency  and  size  until  the  physiological  effects  of  the 
drug  are  produced.  To  an  infant  two  years  old,  one-fourth  of  a  minim 
of  the  fluid  extract  may  be  given  every  four  hours  as  an  initial  dose, 
gradually  increasing  to  every  two  hours;  if  atropine  is  used,  gr.  -g^ 
may  be  given  in  the  same  way.  Although  belladonna  usually  has  a  de- 
cided influence  ia  reducing  both  the  frequency  and  the  severity  of  the 
parox3^sms,  it  causes  many  unpleasant  symptoms,  and  its  effects  must 
be  closely  watched. 

Antipyrine  has  been  in  my  experience  more  generally  useful  than 
any  other  single  drug.  It  may  be  given  with  safety,  even  to  young  in- 
fants, in  considerably  larger  doses  than  are  ordinarily  employed.  For  a 
child  six  months  old  the  initial  dose  may  be  one  grain  every  three  hours ; 
later  this  may  be  given  every  two  hours.  For  a  child  two  years  old  the 
initial  dose  may  be  two  grains  repeated  every  four  to  six  hours,  grad- 
ually increasing  up  to  two  grains  every  two  hours.  Should  pneumonia 
develop,  the  antipyrine  should  be  discontinued.  A  combination  of  the 
bromide  of  sodium  with  antipyrine  is  often  better  than  the  latter  given 
aloiie. 

Nearly  all  drugs  which  allay  nervous  irritability  have  a  certain 
amount  of  effect  in  controlling  the  paroxysms  of  pertussis;  codeine, 
chloral,  and  trional  are  useful  where  the  night  attacks  are  so  severe  as  to 
prevent  sleep.  I  do  not  believe  that  any  form  of  internal  medication 
or  local  treatment  shortens  pertussis;  but,  inasmuch  as  the  disease  is 
self-limited,  great  benefit  to  the  patient  results  from  the  reduction  of  the 
number  and  the  diminution  of  the  severity  of  the  paroxysms. 

In  establishing  the  value  of  any  method  of  treatment,  it  should  be  re- 
membered that  the  number  of  cases  in  which  the  duration  of  the  disease 


MUMPS.  965 

is  short  is  large,  and  also  tliat  almost  any  nietliod  of  treatment  if  em- 
ployed after  the  attack  has  reached  its  height  will  he  thought  heneficial, 
as  the  natural  tendency  is  then  to  improve.  The  value  of  any  particular 
line  of  treatment  is  to  be  judged  in  a  given  case  only  l)y  its  effect  in 
reducing  the  number  and  severity  of  the  paroxysms.  This  ouglit  to  be 
evident  in  the  case  of  drugs  within  two  or  three  days,  and  can  only  be 
determined  by  keeping  a  careful  record  of  the  number  of  severe  parox- 
ysms day  and  night.    Xo  drug  succeeds  equally  well  in  all  cases. 

In  a  mild  case,  where  the  number  of  paroxysms  does  not  exceed 
eight  or  ten  during  the  day,  where  there  is  no  vomiting  and  the  general 
health  is  not  affected,  it  is  not  usually  advisable  to  continue  the  adminis- 
tration of  any  drugs  throughout  the  disease.  A  single  dose  of  antipyrine 
or  codeine  at  night  may  be  all  that  is  necessary.  All  cases  in  infants 
must  be  watched  with  great  care  and  the  parents  warned  of  the  possible 
dangers  which  may  supervene  suddenly,  even  in  the  course  of  mild 
attacks.  For  severe  cases  antipyrine  should  be  given  to  diminish  the 
frequency  and  the  severity  of  the  paroxysms,  and  inhalations  of  creosote 
used  if  much  catarrh  is  present.  All  the  fresh  air  possible  should  be 
allowed.  For  older  children  the  same  plan  of  treatment  may  be  followed, 
or  quinine  or  belladonna  may  be  substituted  for  the  antipyrine. 

As  these  drugs  are  given  solely  for  the  purpose  of  diminishing  the 
frequency  and  severity  of  the  paroxysms,  their  continuous  use  should 
be  deferred  until  the  symptoms  are  sufficiently  severe  to  greatly  disturb 
the  child,  the  benefit  at  this  period  being  more  striking  than  if  they  are 
begun  early  and  used  continuously. 


CHAPTER    VII. 

MUMPS. 

{Epidemic  Parotitis.) 

Mumps  is  a  contagious  disease  characterised  by  swelling  of  the  par- 
otid, and  sometimes  of  the  other  salivary  glands,  with  constitutional 
symptoms  which  are  usually  mild.  Both  severe  complications  and  a 
fatal  termination  are  extremely  infrequent.  The  disease  is  not  a  very 
common  one,  and  general  epidemics  are  rare. 

Pathology  and  Lesions. — The  contagious  character,  definite  incuba- 
tion, and  typical  course,  stamp  the  disease  as  a  general  one  due  to  a 
specific  organism.  This  is  probably  a  very  minute  Gram-negative  diplo- 
coccus.  It  can  be  demonstrated  in  Steno's  duct,  in  the  testicles  when 
epididymitis  is  present,  and  frequently  in  the  blood.  It  is  probable  that 
infection  takes  place  through  the  salivary  ducts. 

The  precise  nature  of  the  changes  in  the  gland  is  still  a  matter  of 


966  THE  SPECIFIC  INFECTIOUS  DISEASES. 

dispute,  as  opportunities  for  pathological  examination  are  very  rare. 
From  existing  evidence  it  would  appear  that  the  gland  substance  is  first 
involved,  and  afterward  the  surrounding  connective  tissue.  The  gland 
is  the  seat  of  an  intense  hyperemia  and  oedema ;  tlie  walls  of  the  salivary 
ducts  are  swollen,  and  the  ducts  are  obstructed.  While  the  primary  dis- 
ease does  not  tend  to  excite  suppuration,  pyogenic  germs  may  occasionally 
gain  entrance  and  an  abscess  form ;  but  this  is  to  be  regarded  as  a  rare 
accidental  infection. 

In  the  great  proportion  of  cases  the  parotids  alone  are  affected,  al- 
though the  same  changes  are  occasionally  found  in  the  other  salivary 
glands.  There  are  no  other  essential  lesions  of  the  disease,  those  which 
are  found  depending  upon  complications. 

Etiology. — Mumps  is  spread  by  contagion,  close  contact  being  usually 
required  to  communicate  the  disease,  although  it  is  known  to  have  been 
carried  by  a  third  person  and  even  by  clothing.  The  susceptibility  of 
children  to  the  poison  of  mumps  is  much  less  than  is  the  case  with  the 
other  contagious  diseases,  so  that  only  a  small  number  of  those  who  are 
exposed  take  the  disease.  The  greatest  predisposition  is  between  the 
fourth  and  fourteenth  years.  Infants  are  rarely  affected,  although  a 
case  in  a  child  three  weeks  old  is  vouched  for  by  so  good  an  observer  as 
Demme. 

Mumps  is  contagious  from  the  beginning  of  the  symptoms.  Two 
cases  have  come  under  my  notice  in  which  the  disease  was  communicated 
before  any  swelling  was  seen.  It  is  impossible  to  fix  with  certainty  the 
duration  of  the  infective  period.  The  disease  is  undoubtedly  communi- 
cable for  several  days  after  the  swelling  has  subsided;  and  for  safety  a 
case  should  be  isolated  for  three  weeks  from  the  beginning  of  symptoms, 
or  at  least  ten  days  after  the  swelling  has  disappeared. 

Incubation. — In  forty-eight  collected  cases  in  which  the  incubation 
was  definitely  determined,  it  varied  between  three  and  twenty-five  days. 
It  was  less  than  fourteen  days  in  only  four  cases,  and  in  twenty-six  of 
the  forty-eight  cases  it  was  between  seventeen  and  twenty  days.  In  three 
cases  of  my  own  in  which  it  could  be  definitely  fixed,  the  incubation  was 
nineteen  days  in  one  case  and  twenty  days  in  two  cases.  The  average 
period  of  incubation,  then,  may  be  stated  to  be  from  seventeen  to  twenty 
days. 

Symptoms. — In  the  milder  eases  the  local  symptoms  are  the  first  to 
attract  attention;  in  those  which  are  more  severe  there  are  frequently 
prodromal  symptoms  of  from  twelve  to  forty-eight  hours'  duration — 
anorexia,  headache,  vomiting,  pains  in  the  back  and  limbs,  and  fever. 
Soltmann  has  reported  a  case  ushered  in  by  convulsions.  The  initial 
temperature  in  a  mild  attack  is  100°  to  101°  F. ;  in  a  severe  one,  from 
102°  to  104°  F. 

Of  the  local  symptoms,  the  pain  usually  precedes  the  swelling;  it  is 


MUMPS.  967 

increased  by  movement  of  the  Jaws,  by  pressure,  and  sometimes  by  the 
presence  of  acid  substances  in  the  mouth.  It  is  usually  referred  to  the 
posterior  part  of  the  jaw  just  below  the  ear.  The  swelling  may  begin 
simultaneously  in  both  parotids,  but  more  frequently  one  side  is  involved 
a  day  or  two  in  advance  of  the  other.  It  usually  reaches  its  maximum  on 
the  third  day,  often  on  the  second,  remains  stationary  for  two  or  three 
days,  and  then  subsides  gradually.  The  degree  of  swelling  varies  with 
the  severity  of  the  attack.  When  it  is  marked,  the  patient  may  be  so 
changed  in  appearance  as  scarcely  to  be  recognisable;  it  fills  the  lateral 
region  of  the  neck  between  the  jaw  and  the  sterno-mastoid  muscle  and 
extends  forward  upon  the  face  to  the  zygomatic  arch,  so  that  the  centre 
of  the  tumour  is  usually  the  lobe  of  the  ear.  The  other  salivary  glands 
may  swell  simultaneously  with  the  parotids,  or  several  days  later,  even 
after  the  parotid  tumour  has  disappeared.  Occasionally  swelling  of  the 
submaxillary  or  the  sublingual  glands  occurs  before  that  of  the  parotid, 
and  in  rare  instances  these  may  be  the  only  glands  affected. 

As  a  rule,  the  parotid  of  both  sides  is  involved.  Of  283  cases  both 
sides  were  affected  in  215.  When  one  side  alone  is  involved,  it  is  the 
left  a  little  more  frequently  than  the  right.  The  interval  between  the 
swelling  of  the  two  sides  may  be  a  week,  or  even  five  or  six  weeks,  but 
usually  it  is  only  two  or  three  days. 

The  salivary  secretion  is  usually  very  much  diminished,  and  the  dry 
mouth  causes  great  discomfort.  An  exceptional  instance  has  been  re- 
ported by  Simon,  in  which  a  distressing  salivation  occurred,  the  secre- 
tion amounting  to  six  or  eight  ounces  daily. 

Although  as  a  rule  the  patient  is  not  seriously  ill,  mumps  may  in 
rare  cases  produce  most  alarming  and  even  dangerous  symptoms.  The 
temperature  may  for  several  days  reach  104°  F.  or  more,  deglutition  may 
be  extremely  difficult,  pressure  on  the  jugular  veins  may  lead  to  venous 
hypersemia  of  the  brain,  causing  headache  and  sometimes  delirium ;  there 
is  sometimes  great  prostration  and  the  symptoms  of  the  typhoid  condi- 
tion. These  severe  attacks  are  nearly  always  in  children  over  twelve 
years  old. 

The  constitutional  symptoms  of  mumps  usually  last  from  three  to 
five  days ;  the  swelling  continues  on  an  average  a  little  less  than  a  week. 
If  the  case  has  been  a  severe  one,  slight  swelling  may  continue  for  two 
weeks  or  even  longer.  Eelapses,  in  which  the  opposite  side  from  the  one 
first  affected  is  involved,  are  quite  frequent,  occurring  in  about  ten  per 
cent  of  the  cases. 

Complications  and  Sequelae. — In  childhood  the  complications  are  few 
and  usually  unimportant;  but  in  adolescence  they  are  occasionally  seri- 
ous. Orchitis  is  exceedingly  rare  in  childhood;  of  230  cases  observed 
by  Eilliet  and  Barthez,  this  was  seen  in  but  ten,  and  only  three  of  these 
cases  were  under  fifteen  years,  and  no  case  under  twelve  years  old.    When 


968  THE  SPECIFIC   INFECTIOUS  DISEASES. 

orchitis  occurs  it  is  generally  toward  the  end  of  the  second  or  the  begin- 
ning of  the  third  week;  it  is  usually  marked  by  an  accession  of  fever, 
sometimes  by  a  chill ;  if  severe,  nervous  symptoms  may  be  present.  The 
body  of  the  testicle  and  not  the  epididymis  is  generally  affected.  The 
acute  s}Tnptoms  continue  for  three  or  four  days,  and  the  entire  duration 
of  the  attack  is  about  a  week ;  although  the  testicle  is  often  enlarged  for 
some  time  afterward,  and  atrophy  of  the  organ  may  follow. 

In  females,  congestion  and  swelling  of  the  breasts,  ovaries,  or  labia 
majora  may  occur;  and,  although  these  complications  are  all  very  rare, 
most  of  them  have  been  observed  even  in  young  children. 

Nephritis  has  in  a  few  instances  followed  mumps,  sometimes  coming 
on  as  late  as  four  or  five  weeks  after  the  attack.  Single  cases  have  been 
reported  by  Croner,  Isham,  Henoch,  and  others.  IS^ervous  sequelae  are 
more  frequent,  but  even  these  are  rare.  I  have  seen  a  case  of  multiple 
neuritis  in  a  boy  of  twelve  which  developed  two  weeks  after  a  severe  at- 
tack of  mumps.  The  paralysis  was  general,  lasted  for  six  weeks,  and 
was  followed  by  complete  recovery.  Jaffrey  has  reported  a  similar  case. 
Facial  paralysis  three  weeks  after  mumps  has  been  reported  by  Hillier, 
apparently  due  to  an  extension  of  inflammation  from  the  gland  to  the 
seventh  nerve. 

Pearce  has  collected  an  interesting  series  of  forty  cases  of  deafness 
following  mumps,  in  which  there  was  no  sign  of  otitis,  the  symptoms 
coming  on  suddenly  with  vertigo,  a  staggering  gait,  and  often  with  vomit- 
ing. In  most  of  the  cases  the  deafness  was  unilateral  and  the  loss  of 
hearing  was  permanent.  The  cause  assigned  was  disease  of  the  auditory 
nerve,  the  seat  of  the  trouble  being  in  the  labyrinth.  Toynbee  has  re- 
ported an  instance  of  haemorrhage  into  the  labyrinth.  Otitis  media  is 
rarely  seen. 

Suppuration  of  the  parotid  gland  occurs  in  about  one  per  cent  of  the 
cases,  and  is  probably  due  to  accidental  infection.  Gangrene  and  slough- 
ing of  the  parotid  were  observed  twice  by  Demme  in  117  cases;  both  of 
these  proved  fatal.  Pneumonia,  meningitis,  endocarditis,  and  pericar- 
ditis have  been  observed  as  complications  of  mumps,  although  all  are 
extremely  rare. 

Prognosis. — In  the  great  proportion  of  cases  mumps  is  a  mild  dis- 
ease, and  terminates  in  complete  recovery  in  a  few  days.  In  young 
children  complications  are  infrequent,  and  those  which  occur  are  rarely 
severe. 

Diagnosis. — Mumps  is  most  likely  to  be  confounded  with  acute  swell- 
ing of  the  cervical  lymph  nodes.  In  a  parotid  swelling,  the  lobe  of  the 
ear  is  near  the  centre  of  the  tumour,  which  extends  backward  to  the 
sterno-mastoid  muscle  and  forward  upon  the  face  as  far  as  the  zygomatic 
arch,  embracing  the  angle  and  ramus  of  the  jaw. 

A  swollen  lymph  node  is  usually  entirely  below  the  ear  and  behind 


DIPHTHERIA.  969 

the  jaw,  not  extending  upon  the  face.  The  tumour  is  generally  smaller 
and  more  circumscribed  if  only  a  single  node  is  involved,  and  it  comes 
on  much  more  slowly  than  does  mumps.  When  only  the  submaxillary 
or  sublingual  glands  are  affected,  the  diagnosis  from  swollen  lymph  nodes 
is  sometimes  impossible  except  by  the  course  of  the  disease.  Mumps  is 
characterised  by  the  rapidity  with  which  the  swelling  occurs,  and  by  its 
relatively  short  duration. 

Treatment. — The  disease  is  self-limited  and  the  individual  symptoms 
rarely  distressing,  so  that  in  most  cases  very  little  treatment  is  required. 
If  constitutional  symptoms  are  present  the  patient  should  be  kept  in 
bed,  and  if  there  are  none  he  should  be  confined  to  the  house.  The  gland 
should  be  protected  by  cotton  or  spongio-piline,  and  if  the  pain  is  severe 
heat  should  be  applied.  The  diet  should  be  liquid,  on  account  of  the 
pain  produced  by  mastication.  The  mouth  should  be  kept  clean  by  the 
use  of  some  antiseptic  mouth-wash.  The  general  symptoms  and  compli- 
cations are  to  be  treated  according  to  the  indications  presented.  Cases 
of  mumps  occurring  in  schools  or  institutions  should  be  quarantined  for 
three  weeks,  and  in  private  practice  where  there  are  susceptible  persons. 
Fumigation  and  disinfection  after  an  attack  are  unnecessary. 


CHAPTER    VIII. 
DIPHTHERIA. 

Diphtheria  may  be  defined  as  an  acute,  specific,  communicable  dis- 
ease due  to  the  bacillus  of  Klebs  and  Loeffier.  It  is  usually  characterised 
by  the  formation  of  a  false  membrane  upon  certain  mucous  membranes, 
especially  those  of  the  tonsils,  pharynx,  nose,  or  larynx.  Like  other 
pathogenic  organisms,  however,  this  germ  acts  with  varying  intensity, 
and  may  cause  inflammation  of  all  degrees  of  severity,  from  a  mild 
catarrhal  angina  to  the  most  serious  membranous  inflammation;  but 
to  all  alike  the  term  diphtheria  should  be  applied.  In  its  mild  form  it 
may  be  almost  without  constitutional  symptoms;  but  in  its  severe  form 
it  is  attended  by  great  general  prostration,  cardiac  depression,  and 
anaemia,  it  is  frequently  complicated  by  pneumonia  and  nephritis,  and 
it  may  be  followed  by  localised  or  general  paralysis;  it  then  constitutes 
one  of  the  diseases  most  to  be  dreaded  in  childhood. 

Etiology. — The  Bacillus  Diphtherice. — This  was  first  described  by 
Klebs  in  1883,  and  during  the  following  year  it  was  isolated  by  Loeffier 
and  shown  to  be  pathogenic.  It  varies  considerably  in  size  and  shape 
even  in  the  same  culture.  In  a  specimen  it  occurs  singly  or  in  pairs, 
sometimes  in  chains  of  three  or  four;  the  bacilli  may  lie  parallel,  but 
frequently  two  form  an  acute  or  an  obtuse  angle.    They  are  straight  or 


970  THE  SPECIFIC  INFECTIOUS  DISEASES. 

slightly  curved,  and  sometimes  branching ;  they  may  be  swollen  or  club- 
shaped  at  their  ends. 

Distribution  and  Mode  of  Communication. — In  most  large  cities  diph- 
theria prevails  endemically,  with  periods  in  which  outbreaks  of  consider- 
able severity  are  observed.  In  the  country  it  prevails  chiefly  as  an 
epidemic.  The  disease  is  often  introduced  into  remote  districts  in  some 
inexplicable  manner,  and  before  its  nature  is  recognised  a  large  number 
of  persons  may  be  exposed,  and  an  epidemic  results. 

Diphtheria  does  not  arise  de  novo.  Every  case  has  its  origin  in  a 
previous  case  either  directly  or  remotely.  The  bacilli  may  enter  the 
body  through  the  inspired  air;  they  may  be  taken  into  the  mouth  with 
toys  or  other  articles  upon  which  they  have  lodged,  or  by  kissing,  and 
sometimes  by  accidental  inoculation.  As  a  rule,  the  bacilli  first  gain  a 
foothold  upon  the  mucous  membrane  of  the  tonsils,  nose,  or  larynx. 

Direct  infection  is  the  cause  in  the  great  majority  of  the  cases.  There 
is  no  proof  that  the  bacilli  are  contained  in  the  breath  of  a  person  suf- 
fering from  the  disease.  They  are  present  in  great  numbers  in  the  saliva 
and  mucus  from  the  mouth  and  nose,  often  being  distributed  by  sneezing, 
coughing,  or  even  by  talking.  They  are  contained  in  pieces  of  membrane 
which  are  discharged;  they  are  not  present  in  the  urine  or  faeces.  The 
most  contagious  cases  are  those  of  pharyngeal  diphtheria  on  account  of 
the  amount  of  discharge  which  accompanies  them.  The  least  contagious 
are  those  in  which  the  membrane  is  limited  to  the  larynx  and  lower  air 
passages. 

Direct  infection  may  occur  from  persons  convalescent  from  diph- 
theria, whose  throats  still  contain  virulent  bacilli,  or  from  persons  suf- 
fering from  a  mild  form  of  the  disease,  which  is  not  recognised  as  diph- 
theria. In  the  latter  way  it  is  often  spread  in  schools.  It  has  been 
repeatedly  shown  that  a  person  may  harbour  virulent  bacilli  in  his  nose  or 
throat,  and  may  even  communicate  the  disease  to  others,  without  himself 
suffering  from  diphtheria  at  any  time. 

The  length  of  time  during  which  a  patient  with  diphtheria  may  con- 
vey the  disease  to  others  is  somewhat  uncertain.  Transmission  is  possi- 
ble so  long  as  virulent  bacilli  remain  in  the  throat;  these  are  frequently 
found  two  weeks  after  the  membrane  has  disappeared  and  the  patient  is 
regarded  as  entirely  well,  and  in  a  few  cases  they  are  found  five  or  six 
weeks  or  longer  after  recovery. 

Indirect  infection  is  not  uncommon,  and  may  occur  from  the  bed  or 
clothing  of  the  patient,  from  the  carpet,  furniture,  wall-paper  or  hang- 
ings of  the  room,  from  toys  or  picture-books,  from  dishes,  feeding  bottles, 
or  drinking-cups,  from  swabs  and  brushes  used  for  local  applications 
to  the  throat,  from  spoons  and  tongue-depressors,  and  from  surgical  in- 
struments with  which  tracheotomy  or  intubation  has  been  done.  Diph- 
theria may  be  carried  by  a  third  person,  but  rarely  except  by  one  who 


DIPHTHERIA.  971 

has  been  in  close  contact  with  the  patient — either  the  physician  or  nurse. 
The  frequency  of  diphtheria  in  physicians'  families  bears  witness  to  the 
great  danger  of  infection  in  this  manner. 

Bacilli  may  retain  their  virulence  for  an  indefinite  period.  Both 
Park  and  Loeffler  found  cultures  in  blood-serum  to  be  virulent  after  seven 
months ;  Roux  and  Yersin,  bacilli  in  dried  membrane  to  be  virulent  after 
twenty  weeks;  and  Abel,  upon  a  child's  toy  after  five  months. 

Domestic  animals  may  in  rare  instances  be  carriers  of  infection,  and 
in  the  case  of  pigeons,  at  least,  they  may  themselves  suffer  from  the  dis- 
ease. Diphtheria  has  been  repeatedly  spread  by  milk,  but  very  rarely 
through  the  contamination  of  a  water  supply. 

Predisposing  Causes. — Local  conditions  in  the  throat  influence  very 
largely  the  occurrence  of  diphtheria.  An  important  predisposing  cause 
is  the  existence  of  a  chronic  catarrhal  inflammation  of  the  mucous  mem- 
branes of  the  nose  and  throat,  so  frequently  found  in  children  suffering 
from  adenoid  growths  of  the  pharynx  or  from  enlarged  tonsils.  These 
adenoid  growths,  the  tonsillar  crypts,  and  the  cavities  of  carious  teeth, 
may  harbour  the  bacilli  for  a  considerable  time  both  before  and  after 
an  attack.  The  condition  of  the  mucous  membranes  of  the  nose  and 
pharynx  in  other  acute  infectious  diseases  furnishes  a  marked  predis- 
position to  diphtheria.  This  is  most  striking  in  the  case  of  measles 
and  scarlet  fever;  it  is  seen  less  frequently  in  typhoid  fever  and 
influenza. 

The  two  sexes  are  about  equally  liable  to  the  disease.  Children 
under  ten  are  much  more  often  affected  than  those  who  are  older,  the 
greatest  susceptibility  as  regards  age  being  between  the  second  and  fifth 
years. 

While  diphtheria  is  seen  throughout  the  year,  it  is  more  frequent  dur- 
ing the  cold  than  the  warm  months. 

The  incubation  of  diphtheria  is  short.  In  most  of  the  cases  in  which 
it  could  be  definitely  traced  it  has  been  between  two  and  five  days.  The 
virulence  of  the  bacillus  varies  much  in  different  cases  and  in  different 
seasons,  and  while  it  is  frequently  true  that  persons  infected  from  a  mild 
type  of  the  disease  have  a  mild  attack,  and  those  infected  from  a  ma- 
lignant one  a  severe  attack,  there  is  no  certainty  that  such  will  be  the 
sequence.  Park  states  that,  out  of  many  hundreds  tested  in  the  laboratory 
of  the  New  York  Health  Department,  by  far  the  most  virulent  bacillus 
was  obtained  from  the  throat  of  a  boy  who  had  what  was  clinically  a  very 
mild  form  of  tonsillar  diphtheria. 

The  immunity  conferred  by  one  attack  of  diphtheria  is  not  of  long 
duration,  amounting  probably  to  a  few  months  only;  but  the  passive 
immunity  conferred  by  antitoxine  is  still  shorter,  lasting  but  a  few 
weeks.  In  patients  therefore  to  whom  antitoxine  has  been  given,  a  sec- 
ond attack  may  occur  after  a  very  brief  time. 


972 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


Lesions. — The  essential  lesions  of  diphtheria  consist  not  in  the  pro- 
duction of  a  memhrane,  Imt,  as  long  ago  pointed  out  by  Oertel,  in  cer- 
tain acute  degenerative  changes  in  the  cells  of  the  body  caused  by  the 
diphtheria  toxines.  These  changes  are  seen  particularly  in  the  epithelial 
cells  of  the  affected  mucous  membranes,  the  heart  muscle,  the  kidney, 
the  liver,  the  central  and  peripheral  nervous  system,  the  spleen,  and  the 
lymph  glands.  There  are  other  lesions  which  are  the  result  of  the  action 
of  other  organisms,  especially  the  streptococcus  pyogenes  and  the  pneu- 
mococeus,  either  alone,  together,  or  in  conjunction  with  the  diphtheria 
bacillus.  The  most  important  lesions  due  to  these  organisms  are  broncho- 
pneumonia and  nephritis;  but  there  may  be  found  in  the  blood,  and  in 
many  of  the  organs  of  the  body,  the  evidences  of  the  invasion  of  these 
bacteria,  i.  e.,.a  streptococcus  septicaemia,  less  frequently  a  general  pneu- 
mocoecus  infection. 

Distribution  of  the  Diphtheria  Bacillus  in  the  Body. — Unlike  many 
other  pathogenic  organisms,  the  diphtheria  bacillus  is  not  in  most  cases 
widely  distributed  throughout  the  body.  It  is  found  in  great  numbers 
on  the  surface  of  the  affected  mucous  membranes  and  in  the  false  mem- 
brane itself,  particularly  in  its  superficial  portion,  but  it  does  not  invade 
deeply  the  subjacent  structures. 

The  frequency  with  which  the  diphtheria  bacillus  and  other  organ- 
isms are  found  in  the  blood  and  viscera  is  shown  in  a  series  of  209  autop- 
sies studied  by  Councilman,  Mallory,  and  Pearce,  of  Boston,  in  1901. 
The  following  table  shows  the  percentage  of  cases  in  which  the  different 
bacteria  were  found  by  culture : 


Diphtheria  bacillus .  .  . 

Streptococcus 

Staphylococcus  aureus 
Pneumococcus 


Heart's  blood. 


6  per  cent. 
20 
•  2.5     " 

1.5     " 


Liver. 


20  per  cent. 
30 

4 

2.5      " 


Spleen. 


12  per  cent. 
27 

3 

1.5     " 


Kidneys. 


19  per  cent. 
28 

8 

5 


In  this  series,  153  cases  were  pure  diphtheria;  56  were  complicated 
by  measles  or  scarlet  fever  or  both.  The  streptococcus  was  much  oftener 
found  in  the  viscera  in  the  complicated  cases;  otherwise  there  was  little 
difference  in  the  two  groups  of  cases. 

The  Diphtheria  Toxines. — The  wide-spread  effects  seen  in  diphtheria 
are  due  to  the  action  of  certain  substances  called  toxines  which  the  diph- 
theria bacillus  produces  during  its  growth  on  mucous  membranes.  They 
are  very  diffusible,  readily  entering  the  lymphatic  circulation  and  the 
blood,  and  through  these  channels  may  affect  the  entire  body.  In 
susceptible  animals  there  may  be  produced  by  the  injection  of  these 
toxines  all  the  characteristic  lesions  of  diphtheria  except  the  mem- 
brane, as  well  as  the  essential  symptoms  of  the  disease,  even  includ- 


PLATE   XVIII. 


The  Diphtheritic  Membrane. 

A.  Typical  tonsillar  diphtheria. 

B.  Severe  pharyngeal  diphtheria  (fatal  case). 

C.  Pseudo-diphtheria.  The  specimen  is  seen  from  behind,  the  larynx  and  trachea 
having  been  laid  open,  and  shows  an  extensive  membrane  involving  the  epiglottis  and 
the  entire  lower  pharynx,  but  extending  into  the  larynx  only  a  short  distance.  It  is 
also  seen  upon  the  posterior  surface  of  the  uvula  and  soft  palate,  the  tonsils  being  only 
partially  covered.  The  colour  of  the  membrane  is  not  characteristic  of  pseudo-diph- 
theria, as  the  same  appearance  is  often  seen  in  true  diphtheria,  particularly  of  the 
septic  type. 


DIPHTHERIA.  973 

ing  paralysis.  For  the  produclion  of  the  menihranc  living  bacilli  are 
lequired. 

Catarrhal  Diphtheria. — The  routine  practice  of  making  cultures  from 
diseased  throats  has  established  the  fact  that  catarrhal  inflammation  may 
often  be  the  only  result  of  diphtheritic  infection.  Although  to  the  naked 
eye  there  were  only  the  ordinary  changes  of  a  simple  inflammation,  Oertel 
found  the  characteristic  degenerative  changes  in  the  epithelial  cells,  vary- 
ing in  degree  with  the  severity  of  the  process. 

The  Diphtheritic  Membrane. — The  membrane  in  diphtheria  is  most 
frequently  seen  upon  the  mucous  membrane  of  the  tonsils,  soft  palate, 
uvula,  pharynx,  nose,  larynx,  trachea,  and  bronchi ;  less  frequently  upon 
the  mouth,  lips,  oesophagus,  conjunctivae,  middle  ear,  stomach,  and  genital 
organs.  It  may  also  afEect  fresh  wounds,  notably  a  tracheotomy  wound, 
or  any  abraded  cutaneous  surface.  The  gross  appearance  of  the  mem- 
brane varies  greatly  (Plate  XVIII).  It  is  most  frequently  of  a  gray  or 
mouse-colour,  but  it  may  be  pearly  white,  yellow,  green,  and  sometimes 
almost  black.  It  is  composed  of  fibrin,  cells,  granular  matter,  and  bac- 
teria. Its  consistency  varies  with  the  relative  proportions  of  the  differ- 
ent elements.  When  made  up  chiefly  of  fibrin  it  is  firm  and  retains  its 
form,  often  being  discharged  as  a  complete  cast  of  the  nose,  larynx,  or 
trachea.  When  the  amount  of  fibrin  is  small  the  membrane  is  soft, 
friable,  and  sometimes  granular.  It  is  more  closely  adherent  upon  the 
mucous  membranes  covered  with  squamous  epithelium,  as  in  the  pharynx 
and  upper  air  passages,  than  upon  those  covered  with  columnar  and 
ciliated  epithelium,  as  in  the  lower  air  passages. 

The  microscopical  examination  shows  the  fibrin  to  be  sometimes 
granular,  but  usually  in  the  form  of  a  network,  inclosing  in  its  meshes 
small  round  cells  and  epithelial  cells  in  various  stages  of  degeneration. 
On  the  surface  and  in  the  superficial  layer  there  is  usually  found  quite  a 
variety  of  bacteria  including  diphtheria  bacilli.  Beneath  this  is  a  cellu- 
lar layer  containing  little  or  no  fibrin,  in  which  also  the  diphtheria 
bacilli  are  usually  found.  In  the  deepest  parts  of  the  false  membrane 
and  in  the  mucous  membrane  itself  the  bacilli  are  few  in  number  or 
absent. 

Changes  which  are  similar  in  all  the  affected  mucous  membranes,  are 
found  in  the  epithelial  cells  which  undergo  marked  degeneration  with 
fragmentation  of  their  nuclei;  the  mucosa  is  infiltrated  with  leucocytes. 
The  infiltration  with  small  round  cells  is  variable  in  degree  in  the  differ- 
ent mucous  membranes;  in  some  it  extends  deeply  into  the  submucous 
and  even  the  muscular  layers,  while  in  others  it  is  very  superficial. 
Marked  evidences  of  degeneration  are  seen  also  in  the  cells  infiltrating 
the  deeper  layers.  In  places  the  epithelium  is  detached,  in  others  the 
line  between  the  false  membrane  and  the  granular  mucous  membrane 
is  scarcely  distinguishable. 


974  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  Seat  and  the  Distribution  of  the  Membrane. — This  varies  some- 
what with  the  age  of  the  patient,  the  season,  and  the  peculiarity  of  the 
epidemic. 

My  own  records  show  that  the  larynx  is  involved  in  about  forty  per 
cent  of  the  cases  in  children  under  three  years.  In  general  the  statement 
may  be  made  that  the  younger  the  child  the  greater  the  liability  of  the 
disease  to  attack  the  larynx ;  also  when  the  larynx  is  affected,  the  greater 
the  tendency  to  spread  to  the  trachea  and  bronchi.  The  larynx  and 
lower  air  passages  are  rather  more  frequently  attacked  in  winter  than  in 
summer. 

The  tonsils  are  the  most  frequent  and  usually  the  earliest  seat  of  the 
diphtheritic  membrane;  it  may  form  here  a  tough,  leathery  patch,  par- 
tially or  completely  covering  and  very  adherent  to  them;  or  the  disease 
may  affect  only  the  tonsillar  crypts,  so  that  the  gross  lesion  may  resem- 
ble that  of  ordinary  follicular  tonsillitis.  There  is  in  most  cases  only 
moderate  swelling,  but  it  may  be  so  great  that  the  tonsils  are  in  contact. 
The  surrounding  cellular  tissue  is  infiltrated  with  inflammatory  products. 

The  membrane  covering  the  pharynx  and  uvula  is  also  usually  very 
adherent  and  intimately  blended  with  the  mucous  membrane.  The  uvula 
is  swollen  and  cedematous.  Membrane  may  be  seen  only  upon  the  fauces 
and  uvula,  or  the  posterior  and  lateral  pharyngeal  walls  may  be  covered 
down  to  the  level  of  the  cricoid  cartilage,  but  generally  not  below  this 
point.  If  the  posterior  pharyngeal  wall  is  covered,  the  membrane  is  apt 
to  extend  into  the  rhino-pharynx,  and  may  fill  the  entire  pharyngeal 
vault,  covering  the  posterior  portion  of  the  velum  and  extending  into 
the  posterior  nares.  The  adenoid  tissue  of  the  vault  is  frequently  the 
part  most  affected. 

The  nose  may  be  involved  secondarily  to  the  rhino-pharynx,  or  the 
infection  may  be  through  the  anterior  nares ;  if  the  latter,  it  is  not  infre- 
quently the  only  part  involved.  Many  cases  classed  as  nasal  are  really 
rhino-pharyngeal.  The  membrane  in  the  pure  nasal  cases  is  usually 
thick  and  tough  and  often  separates  en  masse.  Both  sides  are  generally 
involved,  but  it  may  be  unilateral. 

The  observations  of  Councilman,  Mallory,  and  Pearce  have  shown 
that  it  is  very  common  for  the  accessory  sinuses  of  the  nose,  especially 
the  antrum  of  Highmore,  to  be  involved  in  fatal  cases.  It  seems  highly 
probable  that  infection  of  these  parts  explains  the  remarkable  persistence 
of  diphtheria  bacilli  in  the  nose  which  is  occasionally  seen. 

The  epiglottis  is  swollen  to  three  or  four  times  its  normal  thickness, 
and  the  aryteno-epiglottic  folds  are  cedematous.  The  anterior  surface 
of  the  epiglottis  is  rarely  covered  by  membrane;  but  its  lateral  borders 
and  posterior  surface,  and  the  aryteno-epiglottic  folds  are  involved  in 
most  of  the  severe  pharyngeal  cases  (Plate  XVIII,  C).  This  lesion  is 
associated  with  pharyngeal  rather  than  with  laryngeal  diphtheria. 


DIPHTHERIA.  975 

The  lesions  which  extend  most  deeply  are  thus  seen  in  the  tonsils, 
uvula,  pharynx,  and  epiglottis.  But  even  here  there  is  very  rarely  deep 
or  extensive  sloughing. 

The  lesions  of  the  larynx,  trachea,  and  bronchi  are  similar  to  the 
above,  although  much  more  superficial.  The  interior  of  the  larynx  may 
be  completely  covered,  the  membrane  coating  the  true  and  false  vocal 
cords  and  lining  the  ventricles  of  the  larynx.  The  membrane  in  the 
larynx  is  not  usually  very  adherent,  and  it  frequently  separates  and  is 
coughed  up  in  large  pieces  or  even  as  a  cast.  That  covering  the  epiglot- 
tis and  the  aryteno-epiglottic  folds  is  very  adherent,  like  that  in  the 
pharynx.  Catarrhal  laryngitis  is  not  an  uncommon  complication  of 
pharyngeal  diphtheria. 

In  a  considerable  number  of  cases  the  membrane  stops  abruptly  at 
the  lower  border  of  the  larynx.  In  the  trachea  it  is  generally  loosely 
attached,  and  often  it  is  found  at  autopsy  entirely  separated  from  the 
mucous  membrane.  It  is  almost  invariably  associated  with  membrane  in 
the  larynx.  Usually  the  membrane  in  the  bronchi  is  continuous  with 
that  in  the  trachea.  Occasionally  I  have  seen  the  trachea  and  larger 
bronchi  passed  over  and  found  membrane  only  in  the  larynx  and  smaller 
bronchi.  As  a  rule,  the  bronchi  of  both  sides  are  affected,  and  to  the 
same  degree.  I  once  saw  a  case  of  laryngeal  diphtheria  in  which  mem- 
brane was  found  only  in  the  bronchi  of  one  lung.  The  above  exceptions 
are  to  be  explained  as  accidents  in  the  mechanical  transportation  of 
bacilli. 

The  extent  of  the  membrane  varies  greatly  in  different  cases.  It 
may  stop  at  the  bifurcation  of  the  trachea  or  at  the  bifurcation  of  the 
primary  bronchi;  but  if  it  goes  beyond  this  point  it  is  likely  to  extend 
to  the  minutest  subdivisions.  Exceptionally  a  very  tough  fibrinous  mem- 
brane forms  in  the  trachea  and  bronchi,  of  sufficient  thickness  and  con- 
sistency to  be  expelled  as  a  cast,  reproducing  almost  the  entire  bronchial 
tree. 

The  inflammation  of  the  mucous  membrane  of  the  larynx,  trachea, 
and  bronchi  is  very  much  less  severe  and  more  superficial  in  character 
than  that  of  the  pharynx,  tonsils,  and  upper  air  passages. 

The  buccal  cavity  is  very  seldom  covered  by  the  membrane;  but  in 
the  worst  cases  of  pharyngeal  disease  it  may  line  the  cheeks,  cover  the 
lips,  gums,  and  more  or  less  of  the  hard  palate,  but  rarely  the  tongue. 
It  usually  occurs  in  patches  rather  than  as  a  continuous  membrane.  In 
one  case  I  saw  the  membrane  on  the  lower  lip,  extending  on  to  the  face, 
though  the  buccal  cavity  was  free.  It  is  not  common  for  the  diphther- 
itic membrane  to  spread  down  the  digestive  tract.  In  127  autopsies 
studied  by  Councilman,  Mallory,  and  Pearce,  in  which  the  extent  of  the 
membrane  was  carefully  noted,  it  was  found  twelve  times  in  the  oesoph- 
agus,  five   times   in   the   stomach,   and   once   in   the    duodenum.     The 


976  THE  SPECIFIC  INFECTIOUS  DISEASES. 

amount  of  membrane  varied  from  small  striations  on  the  folds  of  the 
stomach  or  oesophagus  to  a  complete  covering.  The  accompanying 
changes  consist  in  infiltration,  haemorrhage,  and  cell  degeneration.  In 
the  intestines  there  is  often  found  a  hyperplasia  of  the  lymphoid  elements 
— solitary  follicles  and  Peyer's  patches — with  changes  similar  to  those 
in  the  lymph  nodes  elsewhere  in  the  body,  but  nothing  else  that  is  char- 
acteristic. 

The  writers  just  referred  to  found  otitis,  usually  double,  in  sixty 
per  cent  of  144  autopsies ;  although  in  less  than  one-third  of  the  number 
was  the  complication  recognised  during  life.  Mastoid  disease  is  infre- 
quent. Otitis  is  usually  the  result  of  direct  extension  from  the  pharynx. 
It  may  be  due  to  the  diphtheria  bacillus  alone,  to  the  streptococcus  alone, 
or  to  both  combined ;  occasionally  the  staphylococcus  or  pneumococcus  is 
found.  Conjunctival  diphtheria  is  rare  and  probably  due  to  accidental 
infection  rather  than  extension  through  the  lachr3'mal  duct.  Before  the 
advent  of  antitoxine,  it  almost  invariably  resulted  in  destruction  of  the 
eye ;  but  a  number  of  cases  successfully  treated  have  been  reported.  Diph- 
theria may  attack  any  muco-cutaneous  surface,  especially  the  anus,  pre- 
puce, or  female  genitals ;  any  abraded  cutaneous  surface,  or  recent  wound, 
most  frequently  the  tracheotomy  wound  of  the  neck.  The  diphtheria 
bacilli  have  been  found  in  pure  culture  in  superficial  abscesses. 

Visceral  Lesions. — The  visceral  lesions  ^  of  diphtheria  are  due  partly 
to  the  action  of  the  diphtheria  toxines  and  partly  to  the  invasion  of  the 
body  with  other  organisms,  especially  the  streptococcus.  It  is  to  experi- 
mental diphtheria  that  we  owe  our  most  accurate  knowledge  of  the  for- 
mer changes,  for  in  human  diphtheria  the  large  proportion  of  all  the 
fatal  cases  show  infection  with  other  organisms,  particularly  the  strepto- 
coccus, to  a  less  degree  the  pneumococcus  or  staphylococcus.  The  fre- 
quency with  which  these  bacteria  are  found  at  autopsy  in  different  organs 
has  been  already  stated. 

The  visceral  lesions  of  diphtheria  consist  in  wide-spread  areas  of  cell 
degeneration  similar  to  those  which  have  already  been  described  as  occur- 
ring in  the  epithelial  cells  of  the  affected  mucous  membranes,  together 
with  haemorrhages  due  to  changes  in  the  blood-vessels  and  possibly  in 
the  blood  itself. 

The  lymph  nodes  of  the  cervical  region  are  the  most  constantly  and 
the  most  seriously  affected.  Similar  but  less  marked  changes  are  seen 
in  the  tracheo-bronchial  and  the  mesenteric  groups,  and  in  the  lymph 
nodules  of  the  mucous  membrane  of  the  stomach  and  intestine.  There 
are  degenerative  changes  in  the  cells  of  the  nodes  most  affected,  with 
marked  infiltration  with  leucocytes  and  frequently  small  haemorrhages. 

^  For  an  exhaustive  study  of  the  pathological  anatomy  of  diphtheria,  see  mono- 
graph of  Councilman,  Mallory,  and  Pearce  (Boston,  1901);  being  a  study  of  220  fatal 
cases. 


DIPHTHERIA.  977 

The  cellular  tissue  in  the  neighbourhood  of  the  cervical  nodes  is  often 
extensively  infiltrated  with  cells.  The  process  in  the  lymph  nodes  usu- 
ally terminates  in  resolution,  rarely  in  suppuration. 

The  changes  in  the  spleen  are  quite  constant.  The  organ  is  swollen, 
sometimes  very  much  so,  and  deeply  congested.  Haemorrhages  are  often 
seen  beneath  the  capsule;  the  spleen  pulp  is  soft,  the  follicles  are  large, 
and  cell  degeneration  is  quite  constantly  observed  similar  to  that  which 
takes  place  in  the  lymph  nodes. 

There  are  frequently  small  haemorrhages  beneath  the  capsule  of  the 
liver,  and  sometimes  these  are  seen  throughout  the  organ.  There  are 
found  scattered  through  the  liver,  areas  of  necrotic  hepatic  cells  which 
are  peculiar  to  this  disease;  some  of  these  areas  are  infiltrated  with 
leucocytes. 

The  kidneys  are  involved  in  almost  all  fatal  cases  except  where  death 
occurs  early  from  laryngeal  stenosis,  also  in  nearly  every  severe  case 
which  terminates  in  recovery.  Acute  degeneration  of  the  epithelium 
of  the  tubes  and  the  tufts  is  seen  in  less  severe  cases  and  those  of  shorter 
duration,  and  is  the  direct  result  of  the  action  of  the  toxines.  In  the 
more  severe  and  protracted  cases  there  is  acute  diffuse  nephritis  of  vari- 
able type  and  intensity.  There  is  no  form  of  inflammation  which  is 
peculiar  to  diphtheria ;  in  some  cases  the  interstitial  changes  predominate, 
in  others  the  glomerular  changes.  AVelch  mentions  hyaline  changes  in 
the  glomerular  capillaries  and  small  arteries  as  the  characteristic  feature 
of  the  nephritis  of  diphtheria. 

In  children  dying  suddenly  in  the  early  stage  of  the  disease,  cardiac 
thrombi  are  occasionally  found.  They  may  form  rapidly  only  a  short 
time  before  death,  or  slowly  during  several  days  when  the  circulation 
is  very  feeble.  Portions  of  these  thrombi  may  be  carried  into  the  pul- 
monary or  systemic  circulation,  causing  embolism  in  any  of  the  arteries 
of  the  extremities,  the  lungs,  or  other  viscera.  Even  in  the  early  fatal 
cases  the  heart  muscle  may  be  seriously  affected;  in  the  later  ones  this 
is  almost  constant.  The  changes  consist  in  a  toxic  myocarditis,  the  left 
ventricle  being  most  involved.     (See  Myocarditis.) 

Degeneration  of  the  arteries,  especially  of  the  endothelial  layer,  is 
occasionally  seen,  and  there  may  be  infiltration  of  the  adventitia.  The 
arteries  of  any  of  the  viscera  may  be  the  seat  of  hyaline  degeneration. 

Lesions  of  the  brain  are  rare;  both  haemorrhage  and  embolism  may 
be  met  with.  In  the  spinal  cord  and  membranes  multiple  hasmorrhages 
occasionally  occur.  The  characteristic  lesion,  however,  consists  in  de- 
generative changes  which  are  found  to  some  degree  in  nearly  all  the  more 
severe  cases  which  have  been  examined.  These  affect  the  ganglion  cells 
of  the  anterior  horns,  the  anterior  and  posterior  nerve-roots,  and  some- 
times the  pyramidal  tracts  and  columns  of  Goll.  Some  recent  writers 
are  of  the  opinion  that  the  cord  lesions  are  primary  and  the  degenera- 
63 


978  THE  SPECIFIC   INFECTIOUS   DISEASES. 

tion  of  the  spinal  nerves  secondary.  However,  the  general  opinion  still 
prevails  that  certainly  the  less  severe  cases  of  diphtheritic  paralysis  are 
due  to  peripheral  rather  than  to  central  lesions.  Degenerative  changes 
have  been  found  also  in  the  pneumogastric,  spinal  accessory,  hypoglossal, 
motor-oculi,  and  in  the  cardiac  nerves.  These  nerve  degenerations  pro- 
duced by  the  diphtheria  toxine  constitute  one  of  the  most  striking  lesions 
of  diphtheria.     (See  Multiple  Neuritis.) 

In  infants  and  young  children  broncho-pneumonia  is  found  at  au- 
topsy in  fully  three-fourths  of  the  cases,  and  in  a  large  proportion  of 
these  it  is  the  cause  of  death.  It  is  well-nigh  constant  in  cases  of  diph- 
theritic bronchitis  of  the  finer  tubes,  and  is  usually  present  where  the 
membrane  has  extended  to  the  bifurcation  of  the  trachea.  The  largest 
factor  in  the  production  of  pneumonia  is  the  aspiration  of  diphtheria 
bacilli  and  streptococci  from  the  upper  air  passages;  an  important  part 
is  also  played  by  the  pneumococcus  and  the  influenza  bacillus.  These 
organisms  may  be  present  in  many  combinations. 

With  laryngeal  stenosis,  some  emphysema  is  invariably  present,  and 
usually  it  is  of  the  vesicular  variety.  In  extreme  or  protracted  cases  of 
stenosis  there  may  be  interstitial  emphysema.  Rupture  of  some  of  these 
blebs  may  lead  to  the  escape  of  air  into  the  cellular  tissue  of  the  medi- 
astinum or  of  the  neck,  which  may  result  in  the  production  of  a  general 
emphysema  of  the  subcutaneous  cellular  tissue. 

Blood. — According  to  the  studies  of  Ewing,  Billings,  and  others, 
there  is  found  in  all  severe  cases  of  diphtheria  a  reduction  in  the  number 
of  red  cells  to  the  extent  of  500,000  to  2,000,000.  There  is  a  nearly 
proportionate  reduction  in  the  haemoglobin,  this  amounting  to  from 
twelve  to  twenty-eight  per  cent.  While  the  haemoglobin  falls  coincidently 
with  the  number  of  red  cells,  it  is  regained  much  more  slowly.  Leucocy- 
tosis  is  generally  present,  and  usually  proportionate  to  the  severity  of 
the  attack,  but  is  occasionally  wanting  in  the  most  severe  as  well  as  in 
some  of  the  very  mildest  cases.  The  increase  in  the  leucocytes  is  in  the 
polymorphonuclear  forms.  Engel  has  noted  the  frequent  presence  of 
myelocytes,  especially  in  fatal  cases,  the  proportion  of  these  in  some  in- 
stances reaching  sixteen  per  cent  of  the  white  cells.  In  his  observations, 
every  case  in  which  the  myelocytes  exceeded  two  per  cent,  proved  fatal. 

Symptoms. — The  clinical  picture  of  diphtheria  is  one  which  presents 
wide  variations,  depending  upon  the  principal  location  of  the  disease,  its 
severity,  and  its  complications.  For  practical  purposes  the  following 
seems  the  simplest  grouping  that  can  be  made: 

1.  The  mild  cases,  in  which  there  is  either  no  membrane,  or  the 
amount  of  membrane  is  small  and  limited  to  the  tonsils  or  to  the  nose, 
with  few  or  none  of  the  constitutional  symptoms  which  follow  absorp- 
tion of  the  diphtheria  poison.  These  cases  partake  essentially  of  the 
character  of  a  local  disease. 


DIPHTHERIA.  979 

2.  The  severe  cases  in  which  there  are  marked  evidences  of  consti- 
tutional poisoning  from  diphtheria  toxines.  This  form  is  usually  accom- 
panied by  an  extensive  formation  of  membrane  in  the  pharynx  and 
sometimes  in  the  nose. 

3.  The  laryngeal  cases  in  which  the  larynx  may  be  primarily  affected 
or  in  which  it  is  involved  secondarily  to  the  severe  pharyngeal  form. 

4.  The  malignant  cases.  In  these  cases  the  symptoms  of  inflam- 
mation are  especially  prominent,  not  only  in  the  pharynx  but  sometimes 
in  the  lymph  glands  and  cellular  tissue  of  the  neck,  which  may  be  fol- 
lowed by  suppuration  or  sloughing.  This  form  is  frequently  complicated 
by  broncho-pneumonia  even  without  laryngeal  disease,  and  sometimes  by 
severe  nephritis. 

Cases  without  Membrane. — During  an  epidemic  of  diphtheria  in  a 
family  or  an  institution,  cases  are  frequently  seen  which  present  the 
clinical  evidences  of  only  a  catarrhal  inflammation  of  the  nose  or 
pharynx,  and  yet  cultures  show  the  presence  of  the  diphtheria  bacillus. 
Such  cases  may  be  examples  of  simple  catarrhal  inflammation  with 
the  accidental  presence  of  the  diphtheria  bacillus;  or  the  inflamma- 
tion may  be  caused  by  infection  with  the  diphtheria  bacillus,  but  not 
of  sufficient  intensity  to  lead  to  the  production  of  a  membrane.  The 
latter  is  the  view  of  pathologists,  and  the  one  to  which  clinicians 
must,  it  seems,  inevitably  come.  However,  a  membrane  has  so  long 
been  regarded  as  a  sine  qua  non  of  this  disease  that  the  existence  of 
diphtheria  without  it,  is  something  which  the  clinician  finds  it  hard  to 
grasp. 

Catarrhal  diphtheria  may  be  either  pharyngeal  or  nasal.  In  the 
pharyngeal  cases  there  are  present  the  usual  appearances  belonging  to 
a  catarrhal  inflammation  of  moderate  severity,  often  accompanied  by 
swelling  and  tenderness  of  the  cervical  lymph  glands. 

The  nasal  cases,  in  my  experience,  have  been  most  frequent  in  in- 
fants or  very  young  children.  .  Constitutional  symptoms  may  be  wanting 
or  so  slight  as  to  be  overlooked.  The  only  striking  thing  is  a  persistent 
nasal  discharge  which  may  be  serous  and  frothy,  purulent  or  bloody.  It 
is  usually  copious,  often  excoriating  the  upper  lip  and  sometimes  con- 
tinuing for  three  or  four  weeks  before  any  other  symptoms  are  observed. 
I  have  known  it  to  be  mistaken  for  a  syphilitic  coryza.  Such  cases  can 
be  recognised  with  certainty  only  by  cultures.  Clinical  evidence  of  their 
true  character  is  sometimes  afforded  by  the  appearance  of  visible  mem- 
brane in  the  nose  or  pharynx,  by  the  development  of  croup,  or  by  the 
fact  that  they  cause  diphtheria  in  other  children. 

Catarrhal  diphtheria  is  not  in  itself  serious,  but  it  may  be  followed, 
particularly  in  young  children,  by  laryngeal  diphtheria,  or,  after  it  has 
existed  for  a  time,  pharyngeal  diphtheria  may  develop  in  its  usual  form. 
Cases  like  those  just  described  are  to  be  distinguished  from  others  in 


980  THE  SPECIFIC  INFECTIOUS  DISEASES. 

which  bacilli,  either  of  the  virulent  or  the  non-virulent  variety,  are  found 
without  any  evidence  of  inflammation. 

Cases  with  a  Small  Amount  of  Membrane. — Tonsillar  Diphtheria. — 
The  exudation  is  usually  limited  to  the  tonsils  (Plate  XVIII,  A),  and 
may  partake  of  the  character  of  either  follicular  or  croupous  tonsillitis; 
sometimes  there  is  a  slight  extension  to  the  faucial  pillars  or  to  the 
phar\Tix.  These  cases  are  quite  common,  and  in  some  epidemics  most 
of  those  seen  are  of  this  variety.  They  are  more  frequent  in  older  chil- 
dren and  adults  than  in  infants  and  young  children. 

The  onset  is  accompanied  by  a  little  soreness  of  the  throat ;  the  initial 
temperature  is  from  101°  to  104°  F. ;  but  the  symptoms  are  often  not 
severe  enough  to  keep  the  patient  in  bed.  If  seen  early,  the  throat  shows 
slight  redness,  followed  by  a  gray  film,  and  later  by  a  gray  or  white 
deposit  upon  the  tonsils.  It  may  start  as  a  small  patch  which  enlarges, 
or  as  small,  isolated  spots  which  coalesce  or  remain  separate.  Until  it 
disappears  the  membrane  generally  remains  of  its  original  colour.  It 
is  generally  quite  adherent,  and  can  not  easily  be  removed  with  a  swab; 
usually  it  is  sharply  defined,  but  with  a  somewhat  irregular  outline.  In 
many  cases  the  patch  is  not  larger  than  the  finger  nail.  The  inflam- 
matory changes  in  the  pharynx  are  slight ;  a  faint  red  areola  is  frequently 
present  at  the  border  of  the  patch.  The  lymph  glands  behind  the  jaw 
may  be  slightly  swollen.  There  is  no  nasal  discharge  and  very  little 
increase  in  the  saliva  or  mucus  from  the  pharynx.  Some  constitutional 
symptoms  are  present,  but  they  are  never  severe.  The  temperature  com- 
monly continues  above  the  normal  while  the  membrane  lasts,  its  usual 
range  being  from  100°  to  102°  F.  The  membrane  remains  from  three 
to  seven  days — a  shorter  tin;ie  if  antitoxine  is  used.  It  is  very  often  a 
matter  of  surprise  that  so  small  an  exudate  is  so  persistent.  The  urine 
is  generally  normal.  The  parents  are  loath  to  believe  that  strict  quar- 
antine is  necessary  in  so  mild  an  illness;  and  when  the  membrane  is 
only  upon  the  tonsils,  even  after  the  disease  has  run  its  course,  the 
physician  may  be  led  to  doubt  the  diagnosis  of  diphtheria. 

In  many  cases  one  with  experience  can  usually  make  an  accurate  diag- 
nosis from  the  clinical  symptoms  alone;  but  there  are  many  others  in 
which  the  diagnosis  from  ordinary  tonsillitis  is  impossible,  even  by  the 
most  practised  observers,  except  by  cultures.  When  diphtheria  bacilli 
are  found  in  these  mild  cases  the  question  often  arises  whether  they 
may  not  be  the  non-virulent  form.  Park  tested  forty  such  cases,  and 
found  the  bacilli  to  be  virulent  in  thirty-five  and  non-virulent  in  five. 
In  twenty  of  the  forty  cases  the  clinical  diagnosis  was  follicular  tonsillitis. 

Severe  Cases. — The  clinical  picture  of  diphtheria  is  so  modified  by 
the  use  of  antitoxine  that  those  who  see  it  given  regularly  and  early  can 
have  but  little  conception  of  the  horrors  of  this  disease  when  not  thus 
influenced.     The  onset  in  severe  cases  may  be  gradual,  even  insidious. 


DIPHTHERIA  981 

There  is  then  a  slight  indisposition  for  a  day  or  two,  and  perhaps  some 
soreness  of  the  throat;  the  temperature  may  be  but  little  elevated,  some- 
times less  than  100°  F.  The  symptoms  may  steadily  increase  in  in- 
tensity for  four  or  five  days,  until  the  maximum  is  reached.  At  other 
times  the  disease  begins  abruptly  with  vomiting,  headache,  chilly  sensa- 
tions, and  a  temperature  of  103°  or  104°  F.  Occasionally,  the  first  thing 
to  attract  attention  is  the  swelling  of  the  cervical  lymph  glands,  which 
may  be  so  great  that  mumps  is  suspected.  Tlie  abrupt  onset  is  more  often 
seen  in  young  children  than  in  those  who  are  older. 

The  membrane  upon  the  tonsils  resembles  that  of  tlie  mild  form  pre- 
viously described,  but,  instead  of  remaining  limited  to  them,  it  gradually 
spreads  to  the  fauces,  the  lateral  wall  of  the  pharynx,  the  uvula,  the 
rhino-pharynx,  and  the  posterior  nares.  The  rapidity  with  which  the 
membrane  extends  is  in  direct  proportion  to  the  severity  of  the  attack. 
In  some  cases  it  may  cover  all  tlie  parts  mentioned  in  twenty- four  hours 
from  its  first  appearance;  in  others  this  may  require  several  days.  When 
the  nose  is  first  affected  there  is  an  abundant  discharge  of  serum  and 
mucus,  occasionally  tinged  with  blood,  which  may  continue  some  days 
before  any  membrane  is  visible. 

When  a  severe  case  is  fully  developed  there  is  a  very  abundant  dis- 
charge of  mucus  from  the  mouth  and  nose.  The  tonsils,  the  entire  fau- 
cial  ring,  and  the  pharynx  are  covered  with  membrane  (Plate  XVIII,  B) 
which  is  at  first  gray  and  gradually  becomes  darker,  often  being  of  a 
dirty  olive-green  colour.  Membrane  is  sometimes  seen  upon  the  lips,  or 
in  patches  in  the  mouth.  There  is  obstruction  to  nasal  respiration  from 
the  swelling  of  the  palate,  the  tonsils,  and  the  tissues  of  the  rhino- 
pharynx;  the  mouth  is  half  open,  the  breathing  noisy,  the  tongue  dry, 
and  the  lips  are  fissured  and  bleed  readily.  Occasionally  large  nasal 
hasmorrhages  occur  which  may  necessitate  plugging  the  nares.  Both 
nostrils  are  generally  blocked  by  the  swelling  and  the  false  membrane; 
the  discharge  excoriates  the  upper  lip,  and  frequently  has  a  foetid  odour. 
During  the  second  week  there  may  be  regurgitation  of  fluids  through 
the  nose,  owing  to  paralysis  of  the  palate.  The  lymph  glands  at  the 
angle  of  the  jaw  swell  rapidly;  in  severe  cases  they  are  very  prominent, 
and  there  may  also  be  extensive  infiltration  of  the  cellular  tissue  about 
them. 

The  constitutional  symptoms  usually  increase  steadily  with  the  ex- 
tension of  the  membrane.  In  the  most  severe  cases  the  system  is  over- 
whelmed with  the  poison,  and  all  the  evidences  of  intense  toxaemia  are 
present  by  the  third  day  of  the  disease.  This  is  shown  by  great  muscular 
weakness  and  prostration,  by  a  feeble,  rapid  pulse,  and  a  mental  state 
of  complete  apathy  or  stupor,  sometimes  alternating  with  great  restless- 
ness. It  is  more  frequent  for  the  constitutional  symptoms  to  develop 
gradually,  and  not  to  reach  their  height  before  the  fourth  or  fifth  day. 


982  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  pulse  becomes  rapid,  weak,  and  compressible,  sometimes  irregular; 
and  there  is  a  great  and  steadily  increasing  anaemia.  The  course  of  the 
temperature  is  irregular,  and  bears  no  constant  relation  to  tlie  severity 
of  the  other  symptoms.  Its  usual  range  is  from  101°  to  103°  F.,  but  in 
some  of  the  worst  cases  it  may  never  go  above  101°  F.  It  fluctuates 
irregularly  with  the  development  of  complications,  and  sometimes  with- 
out apparent  cause.  By  the  second  or  third  day  the  urine  regularly 
shows  the  presence  of  albumin,  and  by  the  end  of  the  first  week  the  quan- 
tity is  often  large.  Granular  and  hyaline  casts,  and  occasionally  blood 
in  small  quantities,  are  also  found.  The  amount  of  urine  secreted  is 
not  noticeably  diminished,  and  dropsy  is  rare.  There  is  complete 
anorexia,  and  often  vomiting  and  diarrhoea  are  present;  in  some  of  the 
cases  they  are  prominent.  Nervous  symptoms  are  seen  in  all  the  very 
severe  cases.  There  may  be  dulness  and  apathy,  but  more  frequently, 
owing  to  the  discomfort  arising  from  local  symptoms,  there  is  extreme 
restlessness  and  excitement,  sometimes  followed  by  delirium. 

At  any  time  during  the  first  week,  but  not  often  after  that  time, 
symptoms  may  arise  indicating  that  the  disease  has  extended  to  the 
larynx.  The  first  signs  of  laryngeal  invasion  usually  appear  from  the 
second  to  the  fifth  day  of  the  disease.  These  are  at  first  hoarseness,  a 
crourpy  cough,  and  slight  dyspnoea.  In  the  severe  cases  these  symptoms 
steadily  increase  until  all  the  signs  of  laryngeal  stenosis  are  present. 

The  local  process  in  the  pharynx  seems  to  be  a  self-limited  one,  even 
when  no  antitoxine  is  used.  It  usually  reaches  its  height  by  the  fifth  or 
sixth  day,  and  after  that  the  appearances  do  not  change  materially  for 
two  or  three  days.  From  the  seventh  to  the  tenth  day,  in  favourable 
cases,  the  diphtheritic  membrane  begins  to  loosen  and  separate  from  its 
attachment.  It  hangs  loosely  from  the  palate  or  uvula,  and  can  often  be 
pulled  away  in  large  masses.  The  detachment  is  frequently  rapid,  and 
in  two  or  three  days  from  the  time  when  the  first  improvement  is  seen, 
the  tonsils  and  pharynx  may  be  almost  free  from  membrane.  The  mu- 
cous surface  left  behind  is  of  a  bright-red  colour  and  bleeds  easily.  The 
separation  of  the  membrane  in  the  nose  and  rhino-pharynx  takes  place 
more  slowly.  From  the  former  it  may  disintegrate  gradually  or  come 
away  en  masse.  With  the  disappearance  of  the  membrane  the  local  symp- 
toms abate  rapidly — the  discharge  ceases,  the  swelling  of  the  lymph 
glands  subsides,  deglutition  becomes  easy  and  natural,  and  nasal  breath- 
ing is  re-established.  When  antitoxine  is  given  the  local  process  passes 
through  similar  stages,  but  much  more  rapidly. 

Simultaneously  with  these  changes  in  the  throat  the  constitutional 
symptoms  improve,  but  much  more  slowly.  Convalescence  is  often  pro- 
tracted. The  anaemia  and  muscular  weakness,  and  most  of  all  the  feeble 
heart  action  may  persist  for  weeks. 

Instead  of  the  usual  course  just  described,  the  diphtheritic  mem- 


DIPHTHERIA.  983 

brane  may  persist  for  two  or  three  weeks.  In  rare  cases  relapses  occur, 
the  membrane  forming  again  after  it  has  entirely  or  partially  disappeared. 

The  early  course  of  the  disease  in  the  fatal  cases  often  does  not  dif- 
fer from  that  of  the  severe  cases  which  end  in  recovery,  except  in  the 
malignant  form,  which  kills  in  twenty-four  or  forty-eight  hours,  and 
which  is  rare.  In  very  young  children  death  is  most  frequently  due 
to  broncho-pneumonia,  usually  accompanying  diphtheria  of  the  larynx 
and  bronchi.  It  may  also  be  due  to  progressive  asthenia  the  result  of 
diphtheritic  toxaemia,  or  to  heart  failure,  which  may  come  early  or  late; 
rarely  it  is  due  to  nephritis. 

Laryngeal  Diphtheria. — In  cases  of  primary  laryngeal  diphtheria 
there  are  wanting  most  of  the  characteristic  clinical  features  which  dis- 
tinguish diphtheria  of  the  pharynx.  There  are  two  reasons  for  this: 
one  is  the  relatively  rapid  course  of  the-  disease,  often  producing  death 
from  local  causes  before  the  constitutional  symptoms  resulting  from  the 
absorption  of  the  toxine  have  developed ;  the  second  reason  is,  that  absorp- 
tion of  the  poison  by  the  laryngeal  mucous  membrane  is  very  feeble  as 
compared  with  that  which  takes  place  from  the  pharynx.  Hence  it 
follows  that  glandular  enlargements,  albuminuria  and  astlienic  symp- 
toms are  generally  wanting ;  also,  that  in  the  cases  which  come  to  autopsy 
early,  the  parenchymatous  degenerations  of  the  heart,  kidney,  and  other 
organs  are  seldom  found,  but  instead  only  such  lesions  as  are  connected 
with  the  laryngeal  disease.  The  feeble  contagion  is  due  to  the  fact  that 
the  course  is  much  shorter,  and  that  the  discharge  from  the  nose  and 
mouth  is  slight,  or  absent  altogether. 

In  its  onset,  diphtheria  of  the  larynx  is  indistinguishable  from 
catarrhal  inflammation.  It  is  usually  somewhat  less  abrupt,  and  ap- 
parently not  quite  so  severe  for  the  first  twelve  hours  or  even  for  a  longer 
time.  There  are  present  the  same  hoarse  cough  and  voice,  with  slight 
stridor,  gradually  increasing.  The  constitutional  symptoms  are  usually 
not  quite  so  marked,  the  temperature  ranging  from  99°  to  101°  F.  The 
pulse  is  accelerated,  but  not  weak  or  intermittent.  It  is. the  progress  of 
the  disease  which  indicates  its  character,  usually  during  the  first  twenty- 
four  hours.  A  child  beginning  in  the  morning  with  such  symptoms  as 
have  been  described,  may  by  evening  show  a  decided  change  for  the 
worse,  or  the  symptoms  may  increase  with  great  rapidity  during  the 
night.  At  first  the  voice  is  hoarse;  later  it  is  entirely  lost.  Dyspnoea 
in  the  beginning  is  scarcely  noticeable,  but  steadily  increases  hour  by 
hour.  Sometimes  from  the  first  sign  of  hoarseness  to  such  extreme 
dyspnoea  as  to  necessitate  intubation  may  be  but  a  few  hours.  During 
the  second  twenty-four  hours  all  the  symptoms  are  usually  well  developed. 
The  respiration  is  often  somewhat  accelerated,  but  it  may  be  slower 
than  normal.  The  face  is  pale  and  anxious.  The  alae  nasi  dilate  with 
each  inspiration.     The  loud,  "  sawing,"  stridulous  breathing  is  present. 


984  THE  SPECIFIC  INFECTIOUS   DISEASES. 

indicating  obstruction  both  to  inspiration  and  expiration.  As  the 
dyspnoea  increases,  all  the  accessory  muscles  of  respiration  are  brought 
into  action.  There  is  now  with  every  inspiration  deep  recession  of  the 
suprasternal  fossa,  the  supraclavicular  regions,  and  the  epigastrium.  The 
child  tosses  uneasily  from  side  to  side  in  his  cril),  at  times  struggling 
violently  to  get  more  air  into  the  lungs.  The  pulse  grows  rapid  and 
Weaker.  There  is  slight  blueness  of  the  finger  nails  and  the  lips;  the 
face  is  usually  pale;  but  later  this  too  may  be  cyanotic.  The  skin  is 
covered  with  clammy  perspiration.  On  auscultating  the  chest,  very  rude 
respiratory  sounds  are  heard,  but  no  vesicular  murmur.  As  the  symp- 
toms increase  in  severity  the  temperature  usually  rises  gradually,  in  some 
very  severe  cases  at  the  rate  of  a  degree  an  hour,  until  shortly  before  death 
it  reaches  104°  or  even  106°  F.  Late  in  the  disease  the  intellect  becomes 
dull,  the  violent  struggles  for  air  cease,  and  the  child  passes  into  a  con- 
dition of  semi-stupor  which  gradually  deepens  until  death  occurs,  which 
may  be  preceded  by  convulsions. 

Such  is  the  usual  course  of  the  disease  when  unrelieved  by  treatment. 
Its  progress  is  most  rapid  in  infants,  in  whom  death  usually  takes  place 
in  from  thirty-six  to  forty-eight  hours  from  the  first  symptoms.  In  older 
children  the  course  is  rather  slower,  and  the  attack  may  last  from  two 
days  to  a  week,  death  occurring  more  frequently  from  bronchial  croup  or 
pneumonia.  They  are  indicated  by  continued  high  temperature,  rapid 
respiration,  cyanosis,  and  increased  prostration. 

The  course  of  the  disease  is  not  always  so  regular.  Occasionally  for  a 
week  or  more  the  symptoms  are  precisely  like  those  of  catarrhal  laryngitis 
of  moderate  severity — hoarseness,  larjTigeal  cough,  little  or  no  fever,  and 
slight  or  occasional  dyspnoea.  Then  there  may  be  the  sudden  develop- 
ment of  very  severe  symptoms,  and  death  in  a  few  hours.  Great  im- 
provement may  follow  the  dislodgment  of  the  membrane  by  vomiting  or 
coughing,  although  in  most  cases  it  forms  again. 

The  issue  of  every  case  of  diphtheritic  laryngitis  is  doubtful.  The 
prognosis  is  worse  in  infants  and  very  young  children  than  in  those  over 
three  years  of  age.  Before  the  days  of  antitoxine  the  mortality  of  cases 
not  operated  upon  was  from  eighty  to  ninety  per  cent.  Even  with  mod- 
ern methods  of  treatment  the  outlook  in  infants  is  bad;  fully  forty  per 
cent  die. 

It  may  be  difficult  in  a  given  case  to  decide  whether  the  dyspnoea  is 
due  to  laryngeal  inflammation,  and  whether  this  inflammation  is  catar- 
rhal or  diphtheritic.  The  dyspnoea  of  retro-pharyngeal  abscess,  of  for- 
eign bodies  in  the  larynx  or  trachea,  or  of  broncho-pneumonia,  may  be 
mistaken  for  that  due  to  laryngitis.  But  in  none  of  these  conditions 
should  there  be  any  doubt  if  a  careful  examination  is  made  and  a  history 
obtained.  Retro-pharjTigeal  abscess  may  be  recognised  by  digital  ex- 
amination of  the  pharynx ;  broncho-pneumonia  by  the  signs  in  the  lungs. 


DIPHTHERIA.  985 

the  difference  in  the  character  of  the  dyspnoea,  and  especially  by  the 
absence  of  the  noisy  stridor;  in  the  case  of  foreign  bodies,  whether  they 
enter  through  the  mouth  or  consist  of  ulcerating  caseous  glands  which 
have  ruptured  into  the  trachea,  the  dyspncea  comes  suddenly,  and  is  not 
accompanied  by  fever.  The  main  points  by  which  catarrhal  laryngitis 
is  distinguished  from  the  diphtheritic  form  have  been  considered  under 
the  former  disease.  In  brief,  diphtheritic  inflammation  may  be  assumed 
if  there  is  severe,  constant,  and  increasing  dj^spnoca  with  aphonia. 

Malignant  Diphtheria. — The  symptoms  are  usually  severe  from  the 
outset.  The  exudation  in  these  cases  may  be  of  a  yellow,  dirty-gray, 
or  olive  colour,  sometimes  being  almost  black  from  the  presence  of  blood. 
The  membrane  is  usually  extensive,  covering  the  entire  pharynx,  often 
extending  to  the  nose  and  the  middle  ear,  and  occasionally  spreading  to 
the  buccal  cavity.  There  is  great  swelling  of  the  tonsils  and  uvula,  and 
it  is  often  impossible  to  obtain  a  view  of  the  pharynx.  Sometimes  the 
inflammation  is  of  a  necrotic  character,  and  tliere  may  be  extensive 
sloughing  of  the  tonsils,  the  uvula,  or  the  soft  palate.  The  nasal  discharge 
is  generally  abundant,  and  often  very  offensive.  There  is  marked  swelling 
of  the  cervical  lymph  glands,  and  frequently  extensive  infiltration  of  the 
cellular  tissue  of  the  neck,  so  that  the  head  is  thrown  back  to  relieve  the 
pressure  upon  the  larynx  and  tracliea.  The  swelling  sometimes  forms 
a  distinct  collar,  reaching  from  ear  to  ear  and  filling  out  the  whole  space 
beneath  the  jaw.  The  pressure  upon  the  jugular  veins  leads  to  congestion 
and  swelling  of  the  face  and  congestion  of  the  brain. 

The  temperature  is  usually  high;  it  follows  no  regular  course,  but 
generally  fluctuates  widely  from  102°  to  106°  F.  In  some  cases,  how- 
ever, it  may  never  be  above  101°  F.  In  the  form  characterised  by  very 
high  temperature  there  is  sometimes  found  a  general  streptococcus  or 
pneumococcus  infection,  usually  the  former.  The  pulse  is  weak,  rapid, 
and  compressible.  The  peripheral  circulation  is  poor,  the  extremities  are 
often  cold,  there  is  extreme  muscular  prostration,  and  both  vomiting  and 
diarrhoea  are  frequent.  There  may  be  excitement,  restlessness,  and  active 
delirium,  or  dulness,  apathy,  and  stupor.  Nephritis  is  very  frequent  and 
is  often  severe ;  the  urine  contains  a  large  amount  of  albumin  and  casts  of 
all  varieties,  but  rarely  blood.  In  a  large  proportion  of  the  children  under 
three  years  old  broncho-pneumonia  develops.  Severe  symptoms  con- 
tinue for  from  two  days  to  a  week;  the  patient  may  die  from  the  sud- 
den invasion  of  the  larynx,  or  there  may  be  suppression  of  urine  and 
uraemic  convulsions;  but  more  frequently  the  cause  of  death  is  asthenia 
or  broncho-pneumonia.  Death  usually  occurs  while  the  local  disease  is 
at  its  height.  Occasionally  it  comes  later  from  heart  failure,  after  the 
signs  of  local  improvement  have  begun. 

Those  who  manage  to  escape  the  dangers  of  the  acute  period  have 
still   others  to  encounter.     Among  the  latter  may  be   mentioned,  ex- 


986  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tensive  sloughing  in  the  throat  or  of  the  cellular  tissue  of  the  neck, 
which  may  be  followed  by  severe  or  even  fatal  haemorrhage,  diffuse  sup- 
puration of  the  same  region,  late  nephritis,  pneumonia,  or  pleurisy,  and 
finally  paralysis  of  the  heart  or  respiration. 

Complications  and  Sequelae. — Most  of  the  complications  of  diph- 
theria have  already  been  mentioned  either  under  the  head  of  Lesions  or 
Symptoms.     It  only  remains  to  consider  their  clinical  association. 

Otitis  occurs  particularly  in  the  rhino-pharyngeal  cases,  and  is  some- 
times due  to  the  diphtheria  bacillus  alone,  but  more  often  to  mixed  in- 
fection. The  type  of  inflammation  is  often  a  severe  one,  and  it  may  be 
accompanied  by  necrotic  changes  in  the  drum  membrane  which  resem- 
ble those  of  scarlet  fever. 

Broncho-pneumonia  is  the  most  frequent  complication  in  young  chil- 
dren. It  occurs  especially  in  laryngeal  cases,  and  in  those  of  a  severe 
type  whether  the  larynx  is  involved  or  not.  Other  pulmonary  compli- 
cations are  infrequent.  Pleurisy  with  a  serous  effusion  may  occur  in 
connection  with  severe  nephritis,  and  emp3'ema  in  septic  cases.  Emphy- 
sema is  a  complication  of  laryngeal  diphtheria;  it  is  nearly  always 
vesicular,  rarely  interstitial.  It  may  l)eeome  general,  extending  into 
the  'cellular  tissue  of  the  neck  and  afterward  that  of  the  entire  body. 
Pericarditis,  endocarditis,  and  meningitis  are  all  very  rare  and  are  seen 
chiefly  in  septic  cases  of  the  most  severe  type.  Myocarditis  is  much 
more  frequent,  and  is  present  to  a  greater  or  less  degree  in  nearly  all 
severe  cases,  although  in  but  a  small  proportion  of  these  does  it  give 
rise  to  distinct  symptoms.  It  is  closely  connected  pathologically  with 
degeneration  of  the  cardiac  nerves,  and  it  may  be  a  cause  of  sudden 
death  at  any  time  during  the  acute  period  of  the  disease  or  during  con- 
valescence. 

Thrombosis  and  embolism  are  among  the  less  frequent  complica- 
tions. If  cerebral,  they  may  cause  hemiplegia,  aphasia,  and  sometimes 
convulsions;  if  peripheral,  they  usually  affect  one  of  the  lower  extrem- 
ities, where  they  may  cause  sudden  pain,  numbness,  and  coldness  of  the 
limb,  followed  by  partial  paralysis,  oedema,  and  sometimes  even  by  gan- 
grene. Thrombosis  of  the  pulmonary  artery  or  of  the  heart  may  be  a 
cause  of  sudden  death ;  or  this  may  occur  more  gradually  with  dyspnoea 
and  praecordial  distress,  with  pallor  or  cyanosis.  Both  thrombosis  and 
embolism  are  associated  with  a  very  feeble  action  of  the  heart,  and  gen- 
erally they  are  preceded  by  degenerative  changes  in  its  muscular  walls. 

Haemorrhages  are  usually  nasal,  and  while  in  most  cases  they  are  not 
serious,  they  may  necessitate  plugging  of  the  posterior  nares.  Bleeding 
from  any  other  mucous  membrane  may  occur,  but  it  is  rare  except  from 
the  mouth.  Subcutaneous  haemorrhages  are  infrequent,  and  are  evi- 
dence of  a  very  high  degree  of  diphtheritic  toxsemia.  They  usually 
occur  as  small  petechial  spots,  but  are  sometimes  extensive.     They  may 


DIPHTHERIA.  987 

be  seen  upon  almost  any  part  of  the  body,  most  frequently  upon  the 
abdomen  and  lower  extremities;  but  the  most  extensive  extravasation 
I  have  ever  seen  was  in  the  neck,  reaching  from  the  clavicle  almost 
to  the  ear  and  covering  nearly  one  lateral  half  of  the  neck. 

Albumin  is  present  in  the  urine  of  almost  every  case  of  moderate 
severity,  usually  depending  upon  acute  degeneration  of  the  kidneys. 
Acute  nephritis  is  most  frequently  seen  in  severe  cases.  It  then  usually 
develops  at  the  height  of  the  local  disease,  but  may  come  during  con- 
valescence. Albumin  and  casts  are  found  in  the  urine,  but  rarely  is 
there  dropsy  or  signs  of  uraemia.  Less  frequently  a  more  severe  form 
of  inflammation  occurs,  with  dropsy,  scanty  urine,  or  even  suppression, 
vomiting,  and  all  the  usual  symptoms  of  acute  uraemia.  This  complica- 
tion may  be  a  cause  of  death. 

Functional  disturbances  of  the  stomach  are  present  in  most  of  the 
severe  cases,  but  lesions  of  the  mucous  membrane  are  rare.  While  diar- 
rhoea is  often  seen  without  intestinal  lesions,  the  latter  are  of  frequent 
occurrence.  The  most  characteristic  form  of  inflammation  is  a  follicular 
ileo-colitis,  which,  however,  seldom  goes  on  to  ulceration.  It  is  ex- 
tremely rare  that  the  membranous  form  is  seen,  and  then  it  is  almost 
always  associated  with  the  presence  of  other  organisms  than  the  diph- 
theria bacillus. 

Diphtheria  is  usually  followed  by  a  severe  and  often  persistent  anae- 
mia which  may  continue  for  weeks.  Pneumonia,  nephritis,  and  cardiac 
disease  may  first  show  themselves  during  convalescence,  and  so  be  ranked 
as  sequelas.  The  most  important  sequel  of  diphtheria,  however,  is  post- 
diphtheritic paralysis,  already  discussed  in  the  chapter  on  Multiple 
Neuritis. 

Pneumo gastric  Paralysis. — Some  cases  of  diphtheria,  especially  those 
which  receive  no  antitoxine  or  when  the  antitoxine  is  administered  late  or 
in  too  small  amount,  present  a  group  of  symptoms  which  have  been 
referred  to  degeneration  of  the  pneumogastric  nerves.  The  evidence, 
however,  is  by  no  means  conclusive  that  this  is  the  true  explanation  of 
the  clinical  picture,  which  is  a  familiar  one. 

These  symptoms  may  come  on  at  any  time  in  the  course  of  the  dis- 
ease, but  seldom  earlier  than  the  end  of  the  second  week.  By  this 
time  the  throat  has  usually  cleared  off  entirely,  and  the  patient  is  con- 
sidered convalescent.  The  symptoms  relate  to  the  stomach,  the  heart, 
and  the  respiration.  Usually  the  first  thing  to  attract  notice  is  that  the 
patient  refuses  food  and  vomits  occasionally,  afterward  persistently, 
without  apparent  cause.  If  the  pulse  is  carefully  observed  it  is  found 
to  be  much  slower  than  previously,  being  only  80  or  90  when  it  was 
formerly  120  or  more.  It  is  also  weaker,  compressible,  and  often  some- 
what irregular.  The  face  is  pale  or  slightly  cyanotic,  and  moderate 
dyspnoea  may  be  noticed.     There  are  frequent  attacks  of  severe  abdom- 


988  THE  SPECIFIC  INFECTIOUS  DISEASES. 

inal  pain  which  comes  in  paroxysms,  and  is  usually  referred  to  the 
epigastrium.  These  symptoms  in  most  cases  gradually  increase  in  sever- 
ity for  two  or  three  days,  but  sometimes  develop  with  such  intensity  that 
death  occurs  within  twelve  or  twenty-four  hours.  The  later  symptoms 
are  a  continuance  of  the  abdominal  pain  and  vomiting;  there  is  a  feel- 
ing of  great  precordial  oppression  and  distress  accompanied  by  dysp- 
noea; the  respiration  is  shallow  and  often  rapid;  the  face  is  either  pale 
or  cyanotic;  the  extremities,  cold;  the  pulse,  slow,  irregular,  and  inter- 
mittent, becoming  rapid  on  the  slightest  exertion.  The  heart  sounds 
are  weak,  the  muscular  quality  is  absent,  and  the  rhythm  much  disturbed. 
There  may  be  no  murmurs.  There  is  great  restlessness,  but  the  mind 
is  entirely  clear.  Death  usually  results  from  heart  failure,  which  may 
come  quite  suddenly,  often  from  so  slight  exertion  as  turning  over  in 
bed  or  attempting  to  take  food. 

Not  all  the  cases  are  so  severe.  In  the  milder  forms  there  is  some 
palpitation,  an  irregular  pulse,  slight  dyspnoea,  and  occasional  sjTicopal 
attacks,  but  of  no  great  severity.  Such  symptoms  may  come  and  go 
for  several  days  and  then  disappear;  but  more  frequently  they  prove  to 
be  the  beginning  of  the  more  serious  form  of  the  complication.  The 
time  of  occurrence  of  these  symptoms  varies  considerably.  It  may  be 
as  late  as  the  third  or  fourth  week.  The  late  cases  are  generally 
associated  with  some  other  form  of  post-diplitheritic  paralysis. 

Sudden  heart  failure  may  be  seen  late  in  diphtheria  quite  apart  from 
the  symptoms  just  described.  It  may  occur  with  few  or  no  premonitory 
symptoms;  as  when  a  child  falls  dead  after  walking  across  a  room,  or 
suddenly  sitting  up  in  bed,  or  from  some  other  muscular  effort,  or  pos- 
sibly as  a  consequence  of  passion  or  excitement.  I  knew  of  one  little 
girl  who  was  considered  well  enough  to  go  coasting  and  who  died  sud- 
denly after  the  effort. 

The  explanation  of  heart  failure  during  or  after  diphtheria  is  there- 
fore not  always  the  same.  When  it  occurs  at  the  height  of  the  disease 
it  is  sometimes  due  to  cardiac  thrombosis,  probably  always  associated 
with  changes  in  the  muscular  walls.  When  it  occurs  late  and  follows 
some  sudden  muscular  effort  or  excitement  without  premonitory  symp- 
toms of  any  sort,  it  is  probably  the  result  of  changes  in  the  muscular 
walls — a  toxic  myocarditis. 

Diagnosis. — The  diagnosis  of  diphtheria  rests  upon  two  kinds  of  evi- 
dence— clinical  and  bacteriological.  In  mild  cases  and  in  the  early  stage 
only  bacteriological  evidence  can  be  relied  upon.  However,  the  clinical 
manifestations  of  the  disease  are  important  and  should  not  be  ignored. 
It  is  in  most  cases  possible  to  say  from  clinical  symptoms  that  a  case 
is  one  of  diphtheria ;  but  it  is  never  possible  to  say  from  symptoms  alone 
that  a  case  is  not  diphtheria.  Cultures,  therefore,  are  of  the  greatest 
assistance,  and  should  if  possible  be  made  in  every  case.    They  are  nee- 


DIPHTHERIA.  989 

essary  in  the  mild  cases  in  order  that  a  correct  diagnosis  may  be  made 
and  proper  quarantine  regulations  enforced ;  otherwise  a  case  might  be 
dismissed  as  simple  tonsillitis  and  no  precautions  taken. 

Tlie  mere  presence  of  diphtheria  bacilli  in  the  throat  does  not  prove 
that  a  person  has  diphtheria  any  more  than  the  presence  of  the  pneumo- 
coccus  in  his  saliva  proves  that  he  has  pneumonia ;  but  when  diphtheria 
bacilli  are  associated  with  clinical  evidences  of  inflammation  of  the 
throat  or  nose  the  diagnosis  may  be  regarded  as  established.  Again,  the 
case  may  be  one  of  diphtheria  and  the  bacilli  not  found  at  the  first 
examination,  although  found  subsequently.  In  using  antitoxine  one 
must,  in  perhaps  the  majority  of  cases,  be  guided  by  clinical  symptoms 
alone,  not  waiting  for  the  result  of  the  bacteriological  examination.  It 
is  therefore  important  that  both  methods  of  diagnosis  should  be  em- 
ployed. 

1.  The  Clinical  Diagxosis. — Not  much  importance  can  be  attached 
to  the  mode  of  onset;  for  diphtheria  may  begin  in  many  different  ways. 
The  presence  of  a  nasal  discharge,  especially  if  abundant,  ichorous 
and  tinged  with  blood,  the  early  development  of  the  symptoms  of  croup, 
the  rapid  enlargement  of  the  cervical  lymph  glands,  and  the  early  ap- 
pearance of  albumin  in  the  urine — all  point  strongly  to  diphtheria. 
Later  symptoms  which  are  especially  diagnostic  are  marked  anaemia, 
progressive  asthenia,  intense  toxaemia  often  with  a  low  temperature,  very 
feeble  pulse  which  is  sometimes  slow,  sometimes  rapid,  sudden  attacks 
of  syncope,  nasal  haemorrhages,  nasal  regurgitation  from  paralysis  of 
the  soft  palate,  contagion,  and,  finally,  the  development  of  paralysis  of 
the  muscles  of  the  throat,  eye,  or  extremities,  with  paralysis  of  the  heart 
or  respiration. 

The  membrane  of  diphtheria  generally  appears  first  upon  the  tonsils, 
usually  as  a  gray  film  which  gradually  becomes  more  dense  and  white, 
and  often  has  the  look  of  being  plastered  on.  The  colour  of  older  mem- 
brane is  gray,  greenish-yellow,  brown,  sometimes  black.  Beginning  as 
a  small  patch,  it  soon  covers  the  tonsils.  It  frequently  affects  one  tonsil 
twenty-four  or  thirty-six  hours  before  the  other,  and  occasionally  it  is 
confined  to  one  side.  In  exceptional  cases  it  begins  in  the  crypts  of  the 
tonsil  and  appears  as  isolated  dots,  which  may  coalesce  to  form  a  con- 
tinuous patch  like  that  already  described,  or  it  may  remain  isolated  like 
the  exudate  of  an  ordinary  follicular  tonsillitis.  More  important  is 
the  fact  that  the  membrane  spreads  from  the  original  seat,  and  also  the 
manner  of  its  spreading.  If  it  extends  beyond  the  tonsils  to  the  walls 
of  the  pharynx,  the  faucial  pillars,  and  the  uvula,  it  is  almost  surely 
diphtheria.  The  same  is  true  of  doubtful  patches  on  the  tonsils  or  fauces 
followed  by  symptoms  of  croup.  The  rapidity  of  the  spreading  varies 
much  in  the  different  cases,  depending  upon  the  intensity  of  the  infec- 
tion; but  the  gradual  extension,  as  shown  by  observations  made  at  in- 


990  THE  SPECIFIC   INFECTIOUS  DISEASES. 

tervals  of  six  or  eight  hours,  usually  settles  the  diagnosis  in  the  primary 
eases.  However,  if  the  throat  symptoms  complicate  measles  or  scarlet 
fever  the  above  rules  do  not  apply.  Most  of  the  membranous  inflam- 
mations of  the  throat  seen  in  these  diseases  are  not  due  to  diphtheria. 
This  is  particularly  true  of  those  which  occur  at  the  height  of  the  pri- 
mary disease.  Those  which  develop  at  a  later  period  are  often  due  to 
diphtheria. 

Primary  membranous  inflammation  of  the  larynx  may  always  be 
safely  regarded  as  diphtheria;  but  if  there  is  no  visible  membrane,  the 
diagnosis  is  rendered  positive  only  by  a  bacteriological  examination. 
This  may  be  true  of  many  nasal  cases  where  the  only  symptoms  are  a 
discharge  of  the  character  previously  described.  Such  cases  may  con- 
tinue for  weeks  with  no  symptoms  other  than  the  discharge,  especially 
in  infants. 

It  is  seldom  difficult  to  distinguish  diphtheria  from  any  other  dis- 
ease; but  the  exudation  upon  the  pharynx  or  tonsils  may  be  confounded 
with  thrush  or  ulcero-membranous  angina.  The  appearance  of  the  ton- 
sils on  the  second  or  third  day  after  tonsillotomy  has  been  performed, 
may  easily  be  mistaken  for  diphtheria  by  one  who  is  unfamiliar  with  the 
appearance  of  the  post-operative  wound. 

Diphtheria  of  the  mouth  may  be  mistaken  for  herpetic  or  ulcerative 
stomatitis ;  but,  as  a  rule,  it  is  seen  only  in  the  worst  cases  of  pharyngeal 
diphtheria.  Diphtheria  of  the  mouth  alone  is  so  rare  that  it  may  be 
ignored. 

It  is  sometimes  difficult  to  distinguish  cases  of  scarlet  fever  in  which 
the  throat  symptoms  are  severe  and  appear  early,  from  cases  of  primary 
diphtheria.  In  many  of  these  cases  the  eruption  appears  late,  and  is 
not  characteristic.  Much  importance  is  to  be  attached,  as  pointing 
toward  scarlet  fever,  to  a  prevailing  epidemic,  a  history  of  exposure,  a 
sudden  onset  with  severe  sjnnptoms,  vomiting,  prostration,  very  high 
temperature,  and  to  a  very  active  inflammation  in  the  pharynx.  In  all 
cases  with  a  sudden  onset,  in  which  from  the  throat  symptoms  one  is 
inclined  to  make  a  diagnosis  of  diphtheria,  the  possibility  of  scarlet 
fever  should  not  be  forgotten,  and  one  should  never  omit  to  examine 
the  patient  thoroughly  for  an  eruption. 

2.  The  Bacteriological  Diagnosis. — The  Technique. — In  many 
cases  an  immediate  diagnosis  may  be  reached  by  the  examination  of  a 
cover-glass  smear  from  the  throat.  This  method,  although  often  valu- 
able, is  not  adapted  for  general  use,  as  bacilli  directly  from  the  throat 
are  much  less  typical  than  those  from  cultures,  and  the  chances  of  con- 
tamination are  much  increased.  Furthermore,  the  mouth  often  contains 
other  bacilli  which  somewhat  resemble  the  diphtheria  bacillus. 

In  taking  a  culture  from  the  throat,  the  tongue  should  be  depressed 
and  the  tonsils,  pharynx,  or  other  seat  of  visible  membrane  rubbed  firmly 


DIPHTHERIA.  991 

with  a  swab,  which  is  then  rubbed  over  the  surface  of  the  culture-medium 
in  the  tube  or  on  the  plate.  In  laryngeal  cases  the  culture  should  be 
taken  from  the  posterior  wall  of  the  pharynx,  and  in  nasal  cases  from 
the  nostril.  The  tube  or  plate  is  then  placed  in  an  inculjator  for  eight 
to  twelve  hours,  at  the  end  of  which  time  the  colonies  may  l)e  examined. 
Examination,  in  the  great  majority  of  cases,  shows  cither  a  great  num- 
ber of  diphtheria  bacilli  and  a  few  cocci,  or  only  cocci  in  pairs  or  short 
chains ;  exceptionally,  the  cocci  and  bacilli  may  be  present  in  nearly  equal 
numbers.  A  definite  opinion  should  not  be  given  without  examining 
several  colonies. 

The  Reliance  to  be  Placed  upon  Bacteriological  Diagnosis. — The  diph- 
theria bacillus  will  almost  invariably  be  found,  if  there  is  visible  mem- 
brane in  the  pharynx,  if  no  antiseptics  have  been  applied  shortly  before 
using  the  swab,  and  if  the  culture  has  been  made  with  sufficient  care  to 
avoid  contamination. 

The  diphtheria  bacillus  sometimes  disappears  early;  hence  cultures 
made  while  the  membrane  is  loosening  may  be  negative.  If  the  mem- 
brane has  disappeared,  or  if  none  has  been  present,  it  is  not  infrequently 
necessary  to  go  into  the  tonsillar  crypts  with  a  probe  or  spoon  to  dis- 
cover bacilli.  It  is  therefore  important  in  all  cases  to  consider  the  dura- 
tion of  the  disease  before  drawing  a  conclusion  from  a  negative  culture. 
If  the  case  is  one  of  laryngeal  disease  without  pharyngeal  exudation, 
an  early  culture  is  negative  in  nearly  half  the  cases;  although  a  little 
later  bacilli  may  be  coughed  up  and  found  in  the  pharynx  in  abundance. 
A  single  negative  culture  should  never  be  taken  as  conclusive. 

For  diagnostic  purposes,  all  bacilli  present  in  suspicious  throats,  hav- 
ing the  morphological  and  cultural  characteristics  of  diphtheria  bacilli, 
are  to  be  regarded  as  virulent. 

Non-virulent  Bacilli  Resembling  the  Diphtheria  Bacillus. — There 
may  be  found  in  throats  a  form  which  corresponds  in  every  other  charac- 
teristic with  the  diphtheria  bacillus,  but  which  lacks  virulence,  as  shown 
by  animal  tests.  Also,  another  form,  which,  though  in  many  particulars 
resembling  the  diphtheria  bacillus,  differs  from  it  in  being  shorter, 
plumper,  and  more  uniform  in  size,  and  in  producing  an  alkali  in  broth 
cultures;  to  this  the  term  pseudo-diphtheria  bacillus  has  been  given.  It 
is  more  frequently  seen  than  the  form  just  described  and  like  it  is  non- 
virulent.  Both  these  forms  are  rare  in  throats  where  a  suspicion  of  diph- 
theria exists. 

The  Presence  of  Virulent  Bacilli  in  the  Throats  of  Healthy  Persons. 
— That  virulent  bacilli  may  be  harboured  for  an  indefinite  period  in  the 
throat  or  nose  of  a  healthy  person  is  proved  by  many  observations.  The 
New  York  Health  Department  made  observations  upon  forty-eight  chil- 
dren in  fourteen  families  in  which  one  or  more  cases  of  diphtheria  had 
occurred,  and  where  no  attempt  at  isolation  had  been  made.     In  one- 


992  THE  SPECIFIC   INFECTIOUS   DISEASES. 

half  these  cases  bacilli  were  found,  and  animal  tests  showed  them  to  be 
virulent  in  every  one  of  six  cases  tested,  although  four  of  the  children 
did  not  develop  diphtheria.  Of  the  entire  number,  forty  per  cent  subse- 
quently developed  diphtheria.  My  own  experience  in  two  institutions 
where  diphtheria  has  been  endemic,  fully  confirms  the  observation  that 
bacilli  of  all  degrees  of  virulence  are  very  frequently  found  in  the  noses 
or  throats  of  such  exposed  children,  although  a  large  proportion  of  them 
never  develop  the  disease.  Outside  of  institutions  and  infected  tene- 
ment houses,  however,  such  a  condition  is  extremely  rare. 

Prognosis. — Many  possibilities  exist,  and  even  the  mildest  case  must 
be  regarded  as  serious  and  carefully  watched,  since  one  can  never  know 
when  unfavourable  symptoms  may  develop. 

The  factors  to  be  considered  in  the  prognosis  of  any  given  case  are: 
the  age  and  previous  condition  of  the  patient;  the  extent  of  the  mem- 
brane and  the  rapidity  with  which  it  is  spreading;  the  degree  of  diph- 
theritic toxaemia  as  shown  by  the  condition  of  the  pulse  and  the  nervous 
symptoms;  whether  or  not  the  membrane  has  invaded  the  larynx;  and 
the  presence  or  absence  of  complications,  especially  nephritis  and  bron- 
cho-pneumonia;  but  of  more  importance  than  any  or  all  these  things  is 
whether  antitoxine  is  used  and  when  it  is  administered. 

The  following  figures  are  from  the  Report  of  the  Health  Depart- 
ment of  Chicago  of  cases  treated  from  October  5,  1895,  to  February  28, 
1899 : 

Died. 

Injected  1st  day 355  1 

"        2d  day 1,018  17 

3d  day 1,509  57 

4th  day 720  82 

later 469  119 


Mortality. 

0.27  per 

cent. 

1.67 

3.77 

11.39 

25.37 

0.77 

Totals 4,071   270 

In  all  these  cases  the  diagnosis  of  diphtheria  was  confirmed  by 
cultures. 

Diphtheria  mortality  is  highest  during  the  first  two  years  of  life, 
from  its  strong  tendency  to  invade  the  larynx  and  lower  air  passages, 
and  from  the  frequency  with  which  broncho-pneumonia  occurs  as  a  com- 
plication. Those  whose  experience  with  this  disease  does  not  antedate 
the  introduction  of  antitoxine  can  scarcely  appreciate  the  results  previ- 
ously obtained.  Of  eighty-five  consecutive  cases  under  twenty-six 
months  of  age  observed  in  the  New  York  Infant  Asylum,  in  a  period 
extending  over  two  years,  the  mortality  was  sixty-eight  per  cent ;  in  over 
two-thirds  of  the  fatal  cases  the  disease  involved  the  larynx.  In  diph- 
theria hospitals,  where  most  of  the  mild  cases  included  in  the  above 
statistics  would  probably  not  have  been  admitted,  the  mortality  in 
children   under  two  years   formerly  varied   from   sixty   to   eighty  per 


DIPHTHERIA.  993 

cent;  in  private  practice  it  ranged  for  this  age  from  thirty  to  sixty 
per  cent. 

It  can  not  be  too  often  emphasised  that  the  danger  from  diphtheria 
is  not  over  when  the  throat  has  cleared.  The  most  frequent  causes  of 
death  after  this  time  are  broncho-pneumonia  and  cardiac  paralysis. 

Prophylaxis. — In  no  infectious  disease,  smallpox  alone  excepted,  can 
so  much  be  accomplished  in  the  way  of  prevention  as  in  diphtheria. 

Public  funerals  of  children  dying  from  diphtheria  should  invariably 
be  prohibited.  Schools  should  be  closed  whenever  the  disease  is  epi- 
demic. Children  from  families  where  diphtheria  exists  should  not  be 
allowed  to  attend  school,  nor  mingle  in  any  way  with  other  children, 
for  the  reasons  that  they  may,  while  healthy,  be  the  carriers  of  the  dis- 
ease; and,  what  is  even  more  important,  that  they  may  be  themselves 
suffering  from  diphtheria  in  an  early  stage  or  in  a  mild  form. 

In  every  large  city,  hospitals  for  diphtheria  patients  should  be  estab- 
lished, not  only  for  the  poor,  but  with  private  rooms  for  cases  develop- 
ing in  hotels  or  other  places  where  isolation  is  impossible.  Every  city 
should  be  provided  with  a  steam  disinfecting  plant,  where  carpets,  blan- 
kets, bedding,  etc.,  can  be  sent  from  the  sick-room  for  disinfection. 

Quarantine. — Not  only  every  undoubted  case  of  diphtheria,  but  every 
suspected  case,  should  be  immediately  isolated.  Quarantine  for  the  lat- 
ter should  continue  until  the  diagnosis  is  settled  either  by  a  bacterio- 
logical examination  or  by  the  course  of  the  disease.  Positive  and  sus- 
pected cases  should  not  be  isolated  together.  The  quarantine  in  every 
instance  must  be  complete.  If  possible,  cultures  should  be  taken  from 
the  throats  of  all  exposed  children.  Those  containing  diphtheria  bacilli 
should  be  quarantined  like  cases  of  diphtheria,  for  they  may  be  equally 
dangerous ;  they  should  use  gargles  and  sprays,  and  the  nose  and  throat 
should  be  closely  watched. 

Bacteriology  has  furnished  some  very  definite  data  from  which  the 
necessary  duration  of  the  period  of  quarantine  may  be  determined.  In 
this  the  physician  is  to  be  guided  by  the  time  that  the  bacilli  remain  in 
the  throat,  for  the  patient  is  to  be  considered  as  dangerous  while  they 
persist.  This  point  was  investigated  by  the  New  York  Health  Depart- 
ment in  605  cases:  In  304  of  these  the  bacilli  had  disappeared  by  the 
third  day  after  the  membrane  was  gone;  and  in  301  they  persisted  for  a 
longer  time — in  176,  for  seven  days;  in  64,  for  twelve  days;  in  36,  for 
fifteen  days;  in  12,  for  twenty-one  days;  in  4,  for  twenty-eight  days;  in 
4,  for  thirty-five  days ;  and  in  2,  for  sixty-three  days.  Many  of  the  cases 
in  which  the  bacilli  have  persisted  for  an  unusual  time  have  been  those 
of  nasal  diphtheria;  in  some  of  these  it  is  doubtless  owing  to  the  fact 
that  the  nasal  sinuses,  especially  the  antrum,  have  been  invaded.  While 
it  is  unquestionably  true  that  in  a  certain  number  of  cases  these  per- 
sistent bacilli  are  non-vinilent,  the  opposite  has  been  frequently  shown. 
64 


994  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Of  15  cases  in  which  the  virulence  was  tested,  virulent  bacilli  were  found 
in  9  at  periods  varying  from  eight  to  twenty-five  days  after  the  mem- 
brane was  gone. 

Treatment  of  Suspected  Cases. — During  an  epidemic  of  diphtheria, 
especially  in  an  institution,  every  sore  throat  and  nasal  discharge  should 
be  looked  upon  with  suspicion,  and  isolated  pending  the  result  of  a  bac- 
teriological examination,  even  though  no  membrane  is  present.  If  there 
are  patches  on  the  tonsils  or  any  other  visible  membrane,  the  case  should 
be  treated  as  true  diphtheria,  in  order  that  no  time  may  be  lost.  If  the 
bacteriological  examination  shows  the  disease  not  to  be  true  diphtheria, 
the  patient  may  be  released  from  quarantine  in  two  or  three  days,  pro- 
vided the  throat  symptoms  disappear.  It  is,  of  course,  important  that 
the  conditions  laid  down  with  reference  to  bacteriological  diagnosis  shall 
have  been  fulfilled.  Should  symptoms  continue,  however,  a  second  cul- 
ture should  be  taken. 

Immunisation  of  Persons  Exposed. — When  a  case  of  diphtheria  occurs 
in  a  family  or  an  institution,  every  child  that  has  been  exposed  should 
receive  an  immunising  dose  of  antitoxine.  This  rule  is  not  followed  in 
practice  as  regularly  as  it  ought  to  be.  There  is  no  doubt  that  for  a 
limited  time — from  two  to  three  weeks — ^the  serum  confers  almost  com- 
plete protection. 

One  need  not  hesitate  to  immunise  persons  of  any  age  and  in  almost 
every  condition,  even  newly-born  infants  and  pregnant  women. 

The  dose  for  immunisation  is  from  500  to  1,000  units,  the  former 
being  that  required  for  an  infant,  and  the  latter  for  older  children.  If 
the  exposure  is  continuous,  as  in  an  institution,  the  dose  should  be  re- 
peated every  three  or  four  weeks.  A  nurse  in  charge  of  a  diphtheria 
case  should  receive  1,000  units. 

Diphtheria  so  often  complicates  scarlet  fever  and  measles,  particu- 
larly in  institutions  and  in  hospitals  for  contagious  diseases,  that  special 
consideration  should  be  given  to  such  patients.  It  is  practically  impos- 
sible by  cultures  to  separate  with  absolute  certainty  all  cases  in  which 
diphtheritic  infection  is  present,  from  others;  the  only  safe  rule  is  to 
immunise  every  child  admitted  to  a  scarlet-fever  or  measles  hospital, 
and  in  institution  epidemics  of  either  of  these  diseases  to  immunise 
every  child  attacked. 

Nurses  and  Physicians. — As  diphtheria  is  contracted,  not  from  the 
breath  of  the  patient  or  the  air  of  the  room,  but  by  receiving  the  bacilli 
into  the  mouth  or  air  passages,  all  possible  means  should  be  taken  to 
destroy  the  bacilli  discharged,  and  to  secure  absolute  cleanliness  in  every- 
thing about  the  sick-room.  When  it  can  possibly  be  avoided,  nurses 
should  not  be  allowed  to  eat  or  sleep  in  the  sick-room,  and  an  antiseptic 
gargle  should  be  used.  .  The  hands  should  be  kept  clean,  and  only  such 
dresses  worn  as  can  be  readily  washed  and  disinfected.     It  is  the  nurse 


DIPHTHERIA.  995 

who  is  most  likely  to  contract  the  disease,  on  account  of  the  continued 
exposure. 

The  physician  should  take  the  same  precautions  as  in  scarlet  fever. 
A  pocket  tongue-depressor  should  not  be  used  for  the  throat,  but  a 
wooden  depressor  or  a  spoon  kept  in  a  solution  of  carbolic  acid. 

The  Sick-room. — The  carpets,  hangings,  upholstered  furniture,  every- 
thing in  fact  not  necessary  for  the  patient's  welfare,  should  be  removed. 
The  room  should  be  a  large  one,  well  ventilated,  and  fresh  air  should  be 
allowed  in  abundance.  The  floor  should  be  washed  once  a  day  with  a 
solution  of  bichloride,  1  to  2,000,  and  dusted  often  with  cloths  moistened 
in  the  same  solution.  All  handkerchiefs,  bed-linen,  and  clothing  re- 
moved from  the  patient  should  be  treated  as  in  a  case  of  scarlet  fever. 
Pieces  of  membrane  and  other  matters  discharged  from  the  patient 
should  be  burned.  Old  muslin  or  absorbent  cotton  should  be  used  to 
cleanse  the  nose  and  mouth  of  the  patient  and  burned  immediately.  All 
vessels  for  the  reception  of  expectoration  or  other  discharges  sliould  con- 
tain bicliloride,  1  to  2,000.  The  bed-linen  should  be  very  frequently 
changed,  and  everything  kept  scrupulously  clean.  In  the  room  should  be 
a  large  bowl  of  carbolic  acid,  1  to  40,  or  some  similar  solution  for  cleans- 
ing the  hands,  and  a  tray  of  the  carbolic  solution  for  spoons,  syringes,  or 
other  things  used  in  the  treatment  of  the  patient.  All  spoons,  cups,  or 
other  dishes  used  by  the  patient  should  be  carefully  sterilised  by  boiling. 
No  milk  or  other  food  should  be  allowed  to  stand  about  the  room.  There 
is  no  objection  to  the  hanging  of  sheets  moistened  in  carbolic,  bichloride, 
or  other  disinfectant  solutions  before  the  door,  but  neither  this  nor 
hanging  them  about  in  the  sick-room  is  to  be  regarded  as  having  any 
value  in  disinfecting  the  air  of  the  room.  They  create  a  false  sense  of 
security,  and  often  lead  to  the  neglect  of  thorough  cleanliness. 

Disinfection  of  apartments  after  an  attack  should  be  done  as  after 
scarlet  fever. 

Treatment. — General  Measures. — It  is  important  in  every  case  that 
there  should  be  plenty  of  fresh  air  in  the  room  throughout  the  attack. 
Hospital  patients  should  never  have  less  than  1,000  cubic  feet  of  air  space, 
and  if  possible  1,200  should  be  allowed.  Even  in  mild  cases  the  patient 
should  be  kept  in  bed  throughout  the  entire  attack,  and  in  severe  cases 
this  should  be  continued  for  some  time  during  convalescence. 

Nursing  infants  may  be  fed  on  breast-milk  obtained  by  a  breast- 
pump,  but  should  not  be  put  to  the  mother's  breast.  The  feeding  of 
older  children  should  be  managed  very  much  as  in  other  cases  of  severe 
illness.  Milk  is  the  main  reliance;  it  should  usually  be  diluted.  The 
greatest  difficulty  in  feeding  is  seen  in  the  latter  part  of  the  disease,  when 
the  patients  are  septic  and  have  a  strong  aversion  to  food,  when  vomit- 
ing is  easily  excited  and  when  swallowing  is  difficult  on  account  of  the 
swelling  and  pain.    It  is  then  that  gavage  is  most  valuable.    This  is  much 


996  THE  SPECIFIC   INFECTIOUS  DISEASES. 

more  successful  with  children  under  three  years  old  than  is  rectal  feed- 
ing.   In  older  children  the  tube  may  be  passed  through  the  nose. 

Stimulants. — In  most  cases  they  are  not  needed  until  the  third  or 
fourth  day,  and  in  some  they  may  not  be  required  at  all.  The  indica- 
tions for  stimulants  are  marked  prostration,  a  feeble  pulse,  and  a  weak 
first  sound  of  the  heart.  Of  alcohol,  half  an  ounce  of  whisky  or  brandy 
in  twenty-four  hours  is  enough  to  begin  with,  for  a  child  four  years 
old.  This  should  be  diluted  with  at  least  eight  parts  of  water.  In 
very  severe  cases  two  or  three  times  as  much  may  be  given ;  but  more 
than  this,  except  for  a  short  period,  is  seldom  wise.  More  reliance  is  to 
be  placed  upon  the  other  circulatory  stimulants,  especially  caffein,  cam- 
phor, and  digitalis,  which  are  given  for  the  same  indications  as  in  other 
acute  diseases.  In  cases  of  threatened  cardiac  paralysis  occurring  late 
in  the  disease  or  during  convalescence,  morphine  should  be  used  hypo- 
dermically.  Full  doses  must  be  given  and  repeated  every  two  to  four 
hours,  so  that  the  child  may  be  kept  under  its  influence. 

Except  for  stimulation  or  the  control  of  special  symptoms  such  as 
vomiting  or  diarrhoea,  all  internal  medication  should  be  omitted ;  for 
there  is  yet  wanting  proof  that  drugs  influence  the  course  or  the  result 
of  the  disease. 

Local  Treatment. — Since  the  introduction  of  antitoxine,  opinion  has 
undergone  a  decided  change  with  reference  to  local  treatment.  While 
it  should  not  be  entirely  abandoned,  still  it  is  of  secondary  importance; 
and  under  conditions  when  it  can  be  carried  out  only  witli  great  diffi- 
culty and  the  use  of  force  it  is  often  wise  not  to  attempt  it  regularly. 

The  purpose  of  local  treatment,  it  is  now  generally  agreed,  should  be 
cleanliness,  and  not  the  destruction  of  bacilli.  Cleanliness  of  the  nose, 
mouth,  and  pharynx  is  important,  inasmuch  as  one  of  the  chief  dangers 
of  the  disease  is  the  aspiration  of  bacteria  contained  in  the  abundant 
secretions  of  these  parts,  into  the  larynx  and  bronchi.  Our  aim  should 
therefore  be  to  keep  the  parts  as  clean  as  possible  without  too  severely 
taxing  the  strength  of  the  child. 

For  cleansing  the  nose  and  pharynx  only  syringing  can  be  depended 
upon.  Nasal  syringing  is  indicated  when  there  is  much  nasal  discharge, 
whether  membrane  is  visible  in  the  anterior  nares  or  not.  In  septic 
cases  with  a  profuse  foetid  discharge  it  may  be  necessary  to  syringe  the 
nose,  no  matter  how  strongly  the  child  resists.  Whether  it  shall  be 
done,  will  depend  upon  the  condition  of  the  patient's  strength  and  his 
pulse.  The  purpose  in  syringing  is  not  so  much  to  clear  the  nose,  from 
which  absorption  is  slow  and  imperfect,  as  to  flush  the  rhino-pharynx, 
from  which  absorption  is  always  very  active.  Only  bland  solutions 
should  be  employed,  such  as  a  saline  solution,  one  per  cent,  or  a  boric- 
acid  solution,  one-  to  four-per-cent  strength.  For  some  cases,  the  piston 
syringe  may  be  used;  but  for  most  a  fountain  syringe  possesses  man- 


DIPHTHERIA.  997 

if  est  advantages,  and  it  is  rather  more  convenient  for  hospital  pur- 
poses. Irrigation  of  the  pharynx  is  best  done  with  the  fountain  syringe, 
and  is  of  especial  value  where  there  is  much  swelling  or  abundant  dis- 
charge. All  solutions  should  be  used  as  warm  as  can  be  borne,  and  in 
sufficient  quantity  to  irrigate  the  parts  thoroughly,  a  few  such  irrigations 
being  much  better  than  a  great  many  partial  ones.  By  a  skilful  nurse 
syringing  can  in  most  cases  be  done  with  comparatively  little  disturbance 
to  the  child. 

Slight  nasal  haemorrhages  may  necessitate  less  frequent  syringing, 
and  a  free  haemorrhage  may  require  it  to  be  discontinued.  Astringent 
solutions  of  alum  and  adrenalin  are  often  beneficial  in  such  cases,  but 
they  must  be  used  carefully.  In  children  who  are  old  enough  gargles 
should  be  used.  A  solution  of  boric  acid,  or  Dobell's  or  Seller's  solution 
much  diluted,  may  be  employed. 

In  eases  with  a  moderate  nasal  discharge  it  is  usually  sufficient  to 
syringe  three  or  four  times  a  day;  but  in  severe  septic  cases,  with  very 
abundant  discharge,  syringing  should  be  repeated  as  often  as  every  two 
hours  during  the  day  and  every  four  hours  at  night. 

External  applications  to  the  throat  have  practically  no  effect  upon 
the  disease,  but  are  often  useful  to  relieve  pain  and  tension  in  the 
swollen  lymph-glands.  Poultices  should  not  be  employed.  As  a  con- 
tinuous application,  only  cold  is  to  be  advised,  generally  by  means  of  an 
ice-bag  well  protected  to  prevent  wetting  the  clothing. 

The  treatment  of  cardiac  and  other  forms  of  post-diphtheritic  paral- 
ysis has  been  considered  in  the  chapter  on  Multiple  Neuritis. 

The  Senim  Treatment. — This  has  been  the  outcome  of  a  long  series 
of  experiments  in  which  many  men  have  had  a  share ;  but  it  is  to  Behr- 
ing  pre-eminently  that  the  credit  belongs  for  the  development  of  the 
principles  of  serum-therapy. 

Antitoxine  is  produced  by  the  cells  of  the  body  under  the  stimulus 
of  the  diphtheria  toxine.  It  is  intimately  combined  with  the  globulin 
of  the  blood,  and  is  itself  possibly  a  globulin.  It  directly  neutralises  the 
toxine  produced  by  the  diphtheria  bacillus,  and  also  has  some  effect  upon 
the  bacilli  themselves,  the  nature  of  which  is  not  understood.  It  in- 
duces a  condition  in  the  blood  which  inhibits  the  growth  of  the  bacilli, 
and  thus  arrests  the  membranous  inflammation  which  they  excite. 

Properly  prepared,  it  will  keep  without  deterioration  for  from  three 
to  six  months;  but  after  one  year  it  loses  somewhat  its  antitoxic  prop- 
erties. It  should  be  kept  in  a  cool,  dark  place,  and  after  a  bottle  has 
been  opened  it  should  be  used  within  a  few  days.  Antitoxine  is  now 
prepared  in  a  dry  form,  which  is  to  be  preferred  only  when  it  must  be 
kept  for  a  very  long  time. 

The  strength  of  the  serum  is  measured  in  antitoxine  units,  the  unit 
being  an  arbitrary  one,  viz.,  the  amount  of  antitoxine  which  will  protect 


998  THE  SPECIFIC  INFECTIOUS  DISEASES. 

a  guinea-pig  weighing  250  to  300  grammes  against  one  hundred  times  the 
fatal  dose  of  diphtheria  toxine.  The  improvements  in  the  production  of 
the  serum  have  thus  far  consisted  in  increasing  its  strength.  Behring's 
serum  first  used  contained  but  one  unit  in  each  cubic  centimetre.  At 
present  there  can  be  obtained  sera  containing  1,000  antitoxine  units  in 
each  cubic  centimetre.  This  concentration  is  of  immense  advantage  and 
has  to  a  large  degree  done  away  with  the  unpleasant  symptoms. 

Method  of  Administration  and  Dosage. — Before  making  the  injection, 
the  skin  should  be  thoroughly  cleansed  with  alcohol;  the  needle  should 
invariably  be  boiled  and  the  whole  syringe  either  boiled  or  rinsed  with 
alcohol.  The  seat  of  injection  is  not  a  matter  of  great  importance;  my 
own  preference  is  for  the  cellular  tissue  of  the  abdomen  or  the  muscles 
of  the  buttock.  Absorption  from  the  cellular  tissue  is  slower  than  from 
the  muscles.  For  very  rapid  effect,  intravenous  injections  should  be 
employed.  After  the  injection  is  made  the  puncture  should  be  covered 
by  adhesive  plaster. 

It  is  desirable  to  give  enough  antitoxine  to  neutralise  the  diphtheria 
toxine  present  in  the  blood,  but  no  amount  can  neutralise  the  toxine 
which  has  already  become  fixed  to  the  cells,  except  to  a  very  slight  degree. 
What  can  be  accomplished  is  to  supply  the  blood  with  sufficient  antitoxine 
to  neutralise  new  toxine  as  fast  as  it  is  produced.  Convinced  now  of  the 
essential  harmlessness  of  the  serum,  the  tendency  everywhere  has  been 
to  use  larger  and  larger  doses.  For  a  child  over  two  years  old  an  initial 
dose  for  a  severe  attack,  including  all  laryngeal  cases,  should  not  be  less 
than  7,000  or  8,000  units,  repeated  in  from  six  to  eight  hours,  provided 
no  improvement  is  seen.  Children  under  two  years  should  receive  from 
5,000  to  6,000  units.  Cases  of  exceptional  severity,  in  older  children, 
should  receive  from  10,000  to  15,000  units,  to  be  repeated  in  from  six 
to  eight  hours  if  the  progress  of  the  disease  is  unfavourable.  Mild  cases 
should  receive  from  3,000  to  5,000  units  as  an  initial  dose,  a  second 
being  rarely  required. 

In  cases  receiving  antitoxine  late,  even  though  the  symptoms  may 
not  seem  particularly  severe,  the  dose  should  be  increased  in  proportion 
to  the  length  of  the  illness — i.  e.,  if  three  days  ill,  three  times  the  or- 
dinary dose  should  be  given. 

Only  serum  from  a  trustworthy  manufacturer  should  ever  be  used. 
The  most  concentrated  serum  which  can  be  obtained  should  be  se- 
lected. 

All  experience  shows  that  the  results  are  greatly  modified  by  the 
time  of  its  administration.  The  serum  can  not  undo  the  serious  damage 
already  done  to  the  cells  of  the  body,  and  this  at  the  time  of  injection 
may  be  so  great  that  death  will  result.  In  very  mild  cases,  with  older 
children,  one  may  wait  for  the  result  of  a  bacteriological  examination, 
but  never  in  a  severe  case  and  never  in  a  young  child.    In  the  group  of 


DIPHTHERIA.  999 

severe  cases  should  be  placed  every  one  which  at  the  first  visit  shows  a 
pharyngeal  exudate  covering  more  than  the  tonsils,  also  all  cases  with 
symptoms  of  laryngeal  invasion,  and  all  with  an  exudate  on  the  pharynx 
and  a  profuse  nasal  discharge.  If  in  a  doubtful  case  twelve  hours'  ob- 
servation shows  that  the  membrane  has  spread  from  its  original  seat,  no 
further  delay  is  admissible.  In  human  diphtheria  marked  benefit  usually 
follows  injections  made  as  late  as  the  third  day ;  but  after  this  time  the 
value  of  the  serum  diminishes  very  rapidly,  and  although  striking  ex- 
amples of  benefit  are  sometimes  seen  after  later  injections,  they  can  not 
be  depended  upon.  In  very  severe  or  in  malignant  cases  so  much  harm 
may  be  done  during  the  first  twenty-four  hours  of  the  attack  that  the 
subsequent  use  of  antitoxine  is  without  avail. 

The  effect  upon  the  diphtheritic  membrane  is  usually  noticeable 
within  twenty-four  and  often  in  twelve  hours;  it  first  stops  spreading, 
and  soon  begins  to  soften  and  loosen.  The  swelling  of  the  mucous  mem- 
brane subsides  and  the  local  disease  abates,  very  much  as  when  the  dis- 
ease runs  its  usual  course.  The  striking  thing  after  the  use  of  antitoxine 
is  the  rapidity  with  which  these  changes  take  place,  and  the  abrupt  tran- 
sition from  an  advancing  to  a  retrograde  process.  The  subsidence  of 
the  inflammatory  conditions  in  the  larynx  and  trachea  is  quite  as  marked 
as  in  the  pharynx.  The  symptoms  of  stenosis,  even  when  severe,  often 
diminish  in  a  few  hours,  making  operation  unnecessary  in  a  very  large 
number  of  cases  when  previously  it  seemed  inevitable.  The  membrane 
loosens  rapidly  in  the  larynx  and  trachea,  sometimes  necessitating  the 
frequent  removal  of  the  intubation  tube,  when  operation  has  been  per- 
formed. Improvement  is  also  shown  by  the  cessation  of  the  nasal  dis- 
charge, the  re-establishment  of  nasal  respiration,  and  the  diminution  in 
the  swelling  of  the  glands  of  the  neck. 

The  effect  upon  the  constitutional  symptoms  is  not  less  striking.  In 
favourable  cases  there  is  seen,  often  in  twelve  hours,  a  fall  in  tempera- 
ture and  improvement  in  the  pulse  and  in  the  nervous  symptoms. 

The  Limitations  of  Antitoxine. — It  is  important  that  these  should 
always  be  kept  in  mind.  The  serum  must  be  given  early,  for  if  given 
late  it  can  not  undo  the  mischief  already  done  by  the  diphtheria  toxine. 
Cases  of  great  severity  often  pass  the  period  when  recovery  is  possible, 
before  the  antitoxine  is  given.  This  period  may  in  some  cases  be  four 
days,  in  others  it  may  be  less  than  twenty-four  hours.  The  tissues  most 
susceptible  to  the  diphtheria  toxine  are  probably  those  of  the  nervous 
system,  the  heart,  and  the  kidneys;  and  the  consequences  of  its  action 
may  be  seen  in  the  production  of  nephritis,  in  heart  failure  at  the  height 
of  the  disease,  or  in  later  paralysis  of  the  heart,  respiration,  or  the  volun- 
tary muscles,  in  spite  of  the  fact  that  antitoxine  is  given  at  a  period  early 
enough  to  avert  death  from  local  disease  in  the  larynx  or  bronchi. 
Against  the  phlegmonous   inflammation  of  the  throat  or  the  cellular 


1000  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tissue  of  the  neck,  broncho-pneumonia,  and  nephritis,  antitoxine  is  pow- 
erless* and  just  in  proportion  to  the  severity  of  these  inflammations  are 
negative  results  seen. 

Eruptions  and  Other  Unpleasant  Effects. — Some  transient,  local 
oedema  usually  follows  the  injection  and  a  slight  rise  of  temperature  is 
very  frequently  observed.  In  a  few  hours  there  may  be  seen  a  general 
erythema;  this,  however,  is  rare  and  usually  of  short  duration.  The 
most  important  eruptions  are  seen  between  the  eighth  and  fourteenth 
days.  They  follow  from  ten  to  twenty  per  cent  of  the  injections  made, 
and  appear  to  be  quite  independent  of  the  amount  of  serum  used.  The 
exact  cause  is  not  known.  The  most  common  eruption  is  urticaria.  This 
is  often  intense,  very  annoying,  and  may  nearly  cover  the  body.  It  may 
be  accompanied  by  a  slight  rise  of  temperature;  it  usually  lasts  for  two 
or  three  days;  however,  it  is  rarely  severe  for  more  than  twenty-four 
hours.  Various  forms  of  erythema  are  occasionally  met  with.  In  two 
or  three  instances  I  have  seen  haemorrhagic  eruptions,  generally  in  the 
neighbourhood  of  the  large  joints,  and  always  in  children  suffering 
from  extreme  malnutrition.  In  a  few  cases  a  moderate  swelling  of  some 
of  the  joints  has  been  observed,  and  very  exceptionally  a  transient  albu- 
minuria. One  occasionally  meets  with  patients  who  seem  unusually 
susceptible  to  serum  injections,  and  in  whom  even  small  immunising 
doses  cause  headache,  muscular  pains,  and  general  malaise,  so  that  they 
feel  quite  wretched  for  several  days.  All  of  the  above  symptoms  except 
the  urticaria  are  rare,  and  should  not  for  an  instant  deter  one  from  using 
antitoxine  when  indicated. 

Real  and  Alleged  Dangers  from  Antitoxine  Injections. — In  a  few  in- 
stances sudden  death  has  followed  antitoxine  injections,  but  the  evidence 
that  antitoxine  was  the  cause  of  death  has  not  always  been  conclusive. 
In  some  of  these  patients  the  autopsy  has  revealed  a  status  lymphaticus 
not  before  suspected.  In  this  condition  the  shock  of  so  slight  a  thing 
as  a  needle  puncture  may  produce  death.  There  are  other  cases  which 
do  not  admit  of  this  explanation.  Almost  all  have  occurred  in  patients 
during  adolescence  or  adult  life.  So  many  of  these  patients  have  been 
asthmatics  that  the  association  can  hardly  be  an  accidental  one ;  and  curi- 
ously some  of  these  patients  have  had  the  form  of  asthma  excited  by  con- 
tact with  horses.  The  sj-mptoms  usually  come  on  within  a  few  minutes 
after  the  injection,  and  occur  quite  independently  of  the  dose  given. 
Several  have  followed  small  immunising  doses  given  to  apparently 
healthy  persons.  The  most  striking  symptoms  are  a  rapidly  developing 
dyspnoea  with  cyanosis  and  great  prostration.  In  the  most  severe  cases 
death  may  follow  in  a  few  minutes  from  suffocation ;  in  those  less  severe, 
a  gradual  recovery  takes  place  with  no  permanent  after-effects.  The 
most  effective  treatment  is  atropine,  hypodermically,  in  full  doses,  com- 
bined with  artificial  respiration. 


DIPHTHERIA. 


1001 


That  so  very  few  reported  instances  of  serious  harmful  results  have 
occurred  among  the  great  numbers  of  injections  which  have  been 
made^  is  sufficient  to  establish  the  fact  that  the  serum  itself  is,  in 
the  vast  majority  of  instances,  quite  harmless.  Certainly  in  children 
one  should  not  hesitate  one  moment  in  regard  to  its  use.  In  an 
asthmatic  patient,  if  antitoxine  is  given,  atropine  should  be  injected 
simultaneously. 

Results  with  Antitoxine  Treatment. — Since  1895  the  serum  has  been 
tested  on  such  an  extensive  scale  as  the  prevalence  of  diphtheria  all  over 
the  world  has  made  possible,  with  results  so  imiformly  good  that  it  seems 
quite  unnecessary  any  longer  to  cite  statistics  in  proof  of  the  value  of 
this  remedy.  No  tables  of  figures  are  so  convincing  to  an  individual  as 
personal  experience,  and  by  this  argument  one  by  one  the  opponents  of 
antitoxine  have  been  converted. 

The  beneficial  effects  of  the  remedy  may  be  summed  up  in  the  follow- 
ing statements:  (1)  The  percentage  mortality  from  diphtheria  in  hos- 
pitals both  in  Europe  and  in  America  has  been  reduced  to  a  little  more 
than  one-third  the  previous  figures;  (8)  the  proportion  of  cases  now 
requiring  operation  for  laryngeal  stenosis  has  been  reduced  to  about 
one-half;  (3)  the  mortality  after  tracheotomy  has  been  reduced  to  one- 
half,  and  that  after  intubation  to  about  one-third  the  former  figures; 
(4)  but  even  more  convincing  is  the  effect  of  the  serum  treatment  upon 
the  actual  diphtheria  mortality  of  cities  and  countries  where  it  has 
been  used. 

In  the  first  of  the  subjoined  tables  is  given  for  a  period  of  years  the 
actual  number  of  reported  deaths  from  diphtheria  and  membranous 
croup,  irrespective  of  the  growth  in  population;  in  the  second  one  the 
number  of  deaths  in  each  10,000  of  population.  These  figures  can  not 
be  open  to  the  question  which  is  sometimes  raised  concerning  percentage 
mortality  statistics. 

Table    Showing  Annual  Deaths  from  Diphtheria  and  Croup, 
before  and  since  the  Use  of  Antitoxine. 


London .... 

Berlin 

Paria 

New  York . . 

(Manhattan  and 
Bronx) 

Chicago .... 

Boston 

Philadelphia 
Brooklyn. .  . 
Denver.  .  .  . 
Germany. .  . 
(266  tnwns  over 
1.5,000) 

N.  Y.  State. 
Mass 


1887  1888  1889  1890  1891  1892  1893  1894  1895  1896  1897  1898  1899  1900 


1,579 
1,392 
1,585 
3,056 

1,405 

410 

858 

1,453 

68 

10,970 

6,490 
1,628 


1,812  2,075 

1,195  1,210 

1,729!  1,706 

2,553  2,291 

l,297f  1,509 

589  683 

523  727 


1,885 

120 

10,142 

6,710 
1,831 


1,467 

109 

11,919 


5,930 
2,214 


1,877 
1,601 
1,659 
1,783 

1,261 
462 
748 

1,283 

277 

11,915 

4,954 
1,626 


1,174 
1,106 
1,361 
1,970 


1,358 

285 

1,362 

1,180 

175 

10,484 

4,844 
1,218 


2,182 
1,342 
1,403 
2,106 


1,548 

481 

1,707 

1,137 

89 

12,365 


5,970 
1,455 


3,484 
1,637 
1,206 
2,558 

1,476 

546 

1,238 

878 

106 

16,557 

5,942 
1,394 


2,86112,479 
1,416'  987 
1,009  435 
2,8701,976 


1,460 

878 

1,452 

1,660 

71 

13,790 


1,632 
654 
1,398 
1,454 
40 
7,611 


6,6165,696 
1,8011,784 


2,7932,328 
559!  546 
444  268 

1,703  1,591 


1,098 
572 
1,201 
1,310 
19 
6,262 

4,640 
1,677 


774 
456 

1,514 

998 

43 

5,208 


4,115 
1,426 


1,842 
664 
256 
843 

680 
185 

1,154 

745 

34 

5,220 


2,612 
706 


2,041  1,558 

655  563 

336  291 

960  1,121 


917 
304 
997 
744 
31 
5,111 

2,786 
11,047 


797 
537 

1,064 

673 

14 

4,685 


3,306 

2 1,475 


'  Cases  reported  1899,  7,134. 


*  Cases  reported  1900,  12,641. 


1002  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Table  Showing   Average   Annual   Deaths  from   Diphtheria   and   Croup 
per   10,000   of  Population. 


London,  before  antitoxine,  1887-'93,  4.8 

Berlin,  "  "         10.2 

Paris,  "  "           6.5 

New  York,  "  "         14.5 

Chicago,  "  "         13.1 

Denver,  "  "         12.9 

Philadelphia,  "  •1890-'94,  11.9 


since  antitoxine  1896-1900,  4.7 
3.7 
1.3 

"  "  6.3 

5.0 
1.7 

"  "  9.6 


Some  explanation  of  these  figures  is  necessary  that  they  may  be  fully 
appreciated.  The  great  reduction  in  the  death-rate  is  seen  only  in  those 
cities  and  countries  where  the  serum  treatment  has  been  Avidely  employed. 
Nowhere  in  Europe  is  this  true  to  the  same  degree  as  in  Paris,  Berlin, 
and  Germany  generally;  and  probably  nowhere  in  Europe  was  it  so 
little  used  and  so  slow  in  gaining  favour  as  in  London.  In  our  American 
cities  the  effect  of  the  serum  treatment  upon  municipal  mortality  figures 
has  been  directly  proportionate  to  the  extent  to  which  the  health  depart- 
ments have  believed  in  its  efficacy  and  encouraged  its  use  by  furnishing  it 
free  to  the  poor,  and  sending  their  own  inspectors  to  administer  it.  This 
is  true  particularly  of  New  York  and  Chicago;  in  Philadelphia,  on  the 
contrary,  the  authorities  for  a  long  time  were  openly  opposed  to  the 
serum  treatment. 

Convalescence. — After  a  severe  attack  of  diphtheria  convalescence  is 
always  slow  on  account  of  the  anaemia  and  the  depressing  effects  of  the 
disease.  Patients  should  invariably  be  kept  in  bed  for  at  least  a  week 
after  the  throat  has  cleared,  and  longer  if  any  tendency  to  cardiac  weak- 
ness is  seen.  The  pulse  should  be  carefully  watched,  and  irregularity, 
intermission,  dicrotism,  or  a  weak  first  sound  of  the  heart,  should  make 
one  apprehensive.  An  abnormally  slow  pulse  is  generally  more  serious 
than  one  which  is  rapid.  Under  such  circumstances  the  patient  should 
be  kept  recumbent  and  absolutely  quiet,  since  sudden  and  even  fatal 
syncope  may  be  the  result  of  a  violation  of  these  rules. 

The  extreme  degree  of  anaemia  requires  that  iron  be  given  for  a 
considerable  time  during  convalescence,  to  be  followed  by  cod-liver  oil 
and  other  tonics. 

Great  difficulty  is  occasionally  experienced  in  getting  rid  of  the 
bacilli  in  the  throat.  The  tonsillar  crypts,  the  adenoid  tissue  of  the 
rhino-phar3'nx,  and  the  nasal  sinuses  are  the  places  where  the  bacilli  are 
most  likely  to  remain.  Inasmuch  as  it  is  now  generally  made  a  condition 
of  release  from  quarantine  that  the  throat  shall  have  been  shown  by 
cultures  to  be  free  from  bacilli,  this  becomes  a  matter  of  much  im- 
portance. The  most  efficient  means  appears  to  be  to  syringe  the  nose 
gently  three  or  four  times  daily  with  a  solution  of  bichloride,  1  to  10,000, 
to  which  one-eighth  glycerin  has  been  added,  and  to  use  the  same  solution 


INTUBATION. 


1003 


as  a  gargle.    For  children  under  four  years  old  a  simple  salt  solution,  or 
a  dilute  Dobell's  solution,  should  be  substituted  and  the  gargle  omitted. 

Laryngeal  Diphtheria. — Emetics,  inhalations  of  steam,  and  solvents 
for  the  membrane,  although  they  all  sometimes  give  relief,  are  not  to  be 
relied  upon. 

Opinions  will  always  differ  as  to  the  time  when  operative  inter- 
ference is  called  for.  One  should  never  wait  for  general  cyanosis,  for 
often  this  does  not  occur  until  just  before  death.  It  is  better  to  operate 
too  early  than  too  late.  If,  in  spite  of  other  measures,  the  dyspnoea  in- 
creases steadily,  operation  should  not  be  deferred  longer.  Intubation  has 
almost  universally  superseded  tracheotomy  as  a  primary  operation  for 
the  relief  of  membranous  laryngitis.  Tracheotomy  is  still  needed  at 
times  for  the  cases,  very  few  in  number,  in  which  intubation  fails  to 
give  relief  on  account  of  the  position  of  the  membrane  or  some  other 
complication. 

Intubation. 

Intubation  is  the  introduction  of  a  tube  through  the  mouth  into  the 
larynx  for  the  relief  of  laryngeal  dyspnoea.  For  the  operation,  as  now 
performed,  the  world  is  indebted  to  the  late  Dr.  Joseph  O'Dwyer,  of 
New  York. 


Fig.  199. — O'Dwyer's  Intubation  Set. 


A  set  of  O'Dwyer's  instruments  (Fig.  199)  consists  of  seven  tubes,  an 
introductor,  an  extractor,  a  mouth-gag,  and  a  gauge.  The  tubes  are  made 
of  hard  rubber  and  lined  with  gold-plated   metal.      So   carefully   did 


1004  THE  SPECIFIC  INFECTIOUS  DISEASES. 

O'Dwyer  perfect  his  instruments  that  nothing  of  importance  has  been 
added  by  others.  It  is  interesting  to  note  that  nearly  all  the  modifica- 
tions which  have  been  suggested  since  his  first  publication  had  already 
been  tried  by  him  and  discarded.  No  one  thing  is  more  essential  to 
success  with  intubation  than  properly  constructed  instruments.  The 
operation  is  not  difficult,  if  one  has  had  practice  on  the  cadaver.  With- 
out this  it  should  not  be  attempted.  The  tube  is  selected  according  to 
the  age  of  the  patient,  this  being  indicated  on  the  gauge.  A  very  large 
child  will  often  require  a  tube  of  larger  size  than  its  age  would  call  for. 

Introduction  of  the  Tube. — Either  one  of  two  positions  may  be  em- 
ployed, the  choice  depending  upon  the  preference  of  the  operator.  For- 
merly the  usual  method  was  to  have  the  child  seated  upon  the  lap  of  a 
nurse  while  his  head  was  steadied  by  a  second  assistant  standing  behind. 
In  the  other  position  the  child  lies  upon  his  back  upon  a  table,  his  head 
being  steadied  by  an  assistant.  In  both  positions  the  arms  should  be 
pinioned  to  the  sides  by  a  sheet.  In  the  recumbent  position  the  child 
can  be  held  more  firmly;  it  has  also  the  advantage  of  dispensing  with 
one  assistant,  and  in  an  emergency  with  both  of  them.  The  tube  is 
attached  to  the  introductor,  and  the  gag  is  inserted  into  the  left  angle 
of  the  mouth  and  opened  as  widely  as  possible.  The  slipping  of  the  gag 
and  laceration  of  the  mouth  may  be  prevented  by  using  a  piece  of  rubber 
tubing  to  cover  each  arm  of  the  gag  where  it  comes  in  contact  with  the 
gum.  The  attempts  at  introduction  must  be  made  quickly,  for  during 
them  respiration  is  practically  arrested.  Several  short  attempts  are 
always  better  than  a  single  prolonged  one.  Very  little  force  is  ordinarily 
required  in  introducing  the  tube,  that  used  in  passing  a  catheter  being 
a  good  general  guide.  In  cases  of  subglottic  stenosis,  however,  quite  a 
little  force  may  be  necessary. 

The  index  finger  of  the  left  hand  is  used  as  a  guide  in  introduction. 
This  is  passed  well  back  into  the'phar}'nx,  then  brought  forward  until  a 
hard  nodule — the  upper  border  of  the  cricoid  cartilage — is  encountered. 
This  is  the  best  of  all  landmarks,  since  the  soft  parts  are  often  distorted 
by  swelling.  Directly  in  front  of  the  cricoid  cartilage  may  be  felt  the 
epiglottis  and  the  opening  of  the  larynx,  which  are  readily  recognised 
after  the  touch  has  become  somewhat  educated.  The  epiglottis  is  drawn 
forward  and  the  tube  is  passed  along  the  palmar  surface  of  the  left  index 
finger,  by  which  it  is  guided  into  the  larynx;  it  is  then  pushed  off  the 
introductor  by  a  thumb-piece  attached  to  its  handle.  When  it  is  certain 
that  the  tube  is  in  position,  and  the  patient  breathes  properly,  the  loop 
of  silk  attached  to  the  head  of  the  tube  is  cut  off  and  pulled  through, 
the  removal  of  the  tube  being  prevented  by  placing  the  left  forefinger 
upon  its  head.  The  silk  is  not  usually  left  attached  unless  there  is  evi- 
dence of  loose  membrane  below  the  tube.  It  may  be  desirable  to  leave 
the  silk  attached  in  case  no  one  can  be  within  reach  who  is  able  to  remove 


INTUBATION.  1005 

the  tube  should  it  become  obstructed.  The  child's  arms  and  hands  should 
then  be  secured  to  prevent  him  from  seizing  it  himself.  When  not  re- 
moved the  silk  is  fastened  to  the  cheek  by  a  piece  of  adhesive  plaster. 
The  tube  is  known  to  be  in  place,  first,  by  the  hissing  breathing  sounds, 
somewhat  similar  to  what  is  heard  when  the  trachea  is  opened ;  secondly, 
by  a  severe  paroxysm  of  coughing,  which  is  usually  excited  by  a  tube  in 
the  larynx;  thirdly,  by  the  relief  of  the  dyspnoea.  If  this  relief  is  not 
very  apparent  the  physician  may  still  be  in  doubt  as  to  whether  the  tube 
is  in  the  larynx  or  the  oesophagus.  If  in  the  former,  it  can  not  be  pushed 
down  by  the  finger  without  depressing  the  larynx  with  it;  and  by  in- 
troducing the  finger  into  the  pharynx,  the  posterior  wall  of  the  larynx 
can  be  felt  between  the  finger  and  the  tube.  The  most  common  mistake 
made  is  to  pass  the  tube  into  the  oesophagus.  This  sometimes  happens 
because  the  position  of  the  child's  head  is  improper — too  far  forward  or 
too  far  backward — but  more  often  because  the  operator  has  not  been  quite 
sure  of  his  landmarks.  If  this  has  occurred,  there  is  no  relief  to  the 
dyspnoea,  no  hissing  sound,  and  the  tube  can  be  pushed  down  indefinitely. 
When  this  condition  is  recognised,  the  tube  is  withdrawn  by  the  loop  of 
silk  and  after  a  few  moments  a  second  attempt  made. 

False  passages  in  the  larynx  are  most  frequently  made  by  employing 
too  much  force  or  because  the  operator  has  worked  at  the  angle  of  the 
mouth  instead  of  keeping  in  the  median  line.  The  tube  usually  goes 
into  one  of  the  ventricles,  and  may  be  pushed  quite  through  the  larynx 
into  the  cellular  tissue.  This  is  not  likely  to  happen  unless  undue  force 
has  been  used.  The  production  of  a  false  passage  is  recognised  by  the 
fact  that,  although  the  tip  of  the  tube  can  be  felt  to  enter  the  larynx, 
it  does  not  descend,  but  projects  above  the  epiglottis. 

False  membrane  which  has  become  loosened  is  sometimes  crowded 
down  by  the  tube  and  obstructs  the  larynx  just  below  it.  This  i»  one  of 
the  most  serious  accidents  that  may  occur,  but  fortunately  it  is  not  a 
frequent  one.  It  is  more  likely  to  happen  when  the  disease  has  existed 
for  several  days  than  in  recent  cases.  The  tube  may  be  in  place  in  the 
larynx  as  shown  by  all  the  signs  above  mentioned,  except  relief  of  the 
asphyxia.  In  such  a  case  the  immediate  withdrawal  of  the  tube  is  neces- 
sary, it  being  often  followed  by  the  discharge  of  masses  of  loose  mem- 
brane. This  is  aided  by  the  administration  of  half  a  teaspoonful  of  pure 
whisky  or  brandy  to  excite  a  strong  cough.  Artificial  respiration  may  be 
required,  and  if  there  is  no  relief  by  any  of  these  means  tracheotomy  is 
indicated.  Asphyxia  is  sometimes  produced  by  prolonged  and  injudicious 
attempts  at  intubation. 

After-treatment. — So  far  as  the  tube  itself  is  concerned  no  treat- 
ment is  required.  The  original  disease  is  to  be  treated  as  before.  The 
operation  has  removed  only  one  danger  from  the  patient,  viz.,  that  of 
asphyxia  from  mechanical  obstruction  of  the  larynx.    A  good  expulsive 


1006  THE  SPECIFIC   INFECTIOUS  DISEASES. 

cough  should  occur  after  the  tube  is  in  place.  This  is  necessary  to  clear 
the  tube  of  mucus,  as  the  pharynx  and  larynx  are  generally  filled  with 
it  as  a  result  of  the  manipulation. 

The  child  should  not  be  allowed  to  lie  upon  his  face,  nor  should  he 
be  held  over  the  nurse's  shoulder  face  downward,  for  in  either  position 
a  slight  cough  is  enough  to  expel  the  tube.  Xursing  infants  may  some- 
times continue  at  the  breast  after  the  operation ;  ordinarily  they  have  but 
little  difficulty  in  swallowing.  Older  children  often  experience  consider- 
able trouble  in  taking  liquids.  This  may  be  overcome  by  the  device  sug- 
gested by  Casselberry,  of  having  the  patient's  head  lower  than  his  body 
while  he  drinks.  When  fluids  cause  excessive  coughing  or  at  other  times 
when  they  can  be  taken  only  with  the  greatest  difficulty,  they  may  be 
given  through  a  nasal  tube  or  one  passed  through  the  mouth.  Semi- 
solid articles,  such  as  condensed  milk,  wine  jelly,  com  starch,  ice  cream, 
or  scrambled  eggs,  may  be  well  taken  when  fluids  are  not.  Feeding  is 
always  easier  after  the  first  day  or  two,  and  patients  who  wear  a  tube 
for  chronic  disease  soon  experience  no  trouble  whatever,  showing  that  the 
difficulty  depends  more  upon  the  inability  to  co-ordinate  the  movements  of 
the  muscles  of  deglutition  when  the  tube  is  in  place  than  upon  mechanical 
causes,  for  the  head  of  the  tube  is  effectually  covered  by  the  epiglottis. 

It  sometimes  happens  that  the  tube  is  coughed  out  soon  after  its 
introduction,  because  too  small  a  size  has  been  used.  In  some  cases  this 
occurs  repeatedly.  It  happened  in  a  case  of  my  own  twenty-eight  times 
during  four  days.  Such  cases  are  probably  due  to  paralysis  of  the  laryn- 
geal muscles.  The  dyspnoea  does  not  usually  return  for  two  or  three 
hours  after  the  tube  has  been  coughed  out,  but  may  come  back  at  once. 
It  may  happen  that  the  tube  is  coughed  up  and  not  seen  by  the  nurse, 
or  it  may  be  coughed  up  and  swallowed  by  the  child.  When  called  be- 
cause of  dyspnoea  after  operation,  the  physician  should  make  a  digital 
examination  of  the  pharynx  to  be  sure  that  the  tube  is  still  in  place. 
Swallowing  the  tube  generally  causes  no  harm  to  the  child,  for  tubes  have 
repeatedly  passed  through  the  intestines. 

The  entrance  of  food  into  the  bronchi  through  the  tube  is  a  danger 
that  does  not  exist,  and  broncho-pneumonia  following  intubation  does 
not  depend  upon  the  entrance  of  food  into  the  bronchi. 

Deep  ulceration  at  the  head  of  the  tube  very  rarely  occurs,  provided 
properly  made  tubes  are  employed,  but  superficial  ulceration  almost  in- 
variably is  produced  at  the  base  of  the  epiglottis  and  in  the  trachea  at 
the  lower  end  of  the  tube.  Deep  ulcers  extending  to  the  tracheal  rings 
may  occur  in  ill-conditioned  children,  usually  in  connection  with  other 
complications  serious  enough  to  cause  death. 

Spontaneous  descent  of  the  tube  into  the  larynx  is  almost  impossible, 
and  it  can  not  be  crowded  down  without  using  considerable  force  and 
severely  lacerating  the  larynx. 


INTUBATION,  1007 

Sudden  blocking  of  the  lower  end  of  the  tube  by  membrane  loosened 
from  the  trachea  or  bronchi  occasionally  occurs.  The  usual  result  of 
this  is  the  immediate  expulsion  of  the  tube  by  coughing,  the  discharge 
of  the  loose  membrane  following.  This  condition  is  one  of  the  safety 
valves  of  tlie  operation.  One  of  the  strong  points  in  favour  of  intuba- 
tion is  that  the  forcible  cough  which  the  patient  is  able  to  make  on 
account  of  the  narrow  opening  of  the  tube,  often  enables  him  to  expel 
large  accumulations  of  mucus,  and  even  membrane,  more  readily  than 
through  a  much  larger  tracheal  opening. 

The  period  for  which  the  tube  is  required  varies  much  in  different 
cases.  It  is  the  experience  of  practically  all  operators  that  it  has  been 
materially  shortened  by  the  use  of  antitoxine.  The  average  time  of  wear- 
ing the  tube  is  about  five  days,  and  in  many  it  can  be  dispensed  with  in 
two  or  three  days.  Should  the  tube  be  coughed  out  at  any  time,  its 
introduction  should  be  delayed  until  dyspnoea  returns. 

Removal  of  the  Tube — Extubation. — This  is  rather  more  difficult  than 
its  introduction.  The  general  arrangement  of  the  patient  and  assistants 
is  the  same  as  for  introduction.  The  left  index  finger  is  placed  upon 
the  head  of  the  tube,  which  is  steadied  externally  by  the  thumb  of  the 
same  hand.  The  beak  of  the  extractor  is  introduced  within  the  opening 
of  the  tube,  its  jaws  are  then  separated  by  pressure  upon  the  lever  at  the 
handle,  and  the  instrument  withdrawn,  very  slight  force  being  required. 

The  tube  is  first  removed  tentativel}'^,  the  physician  waiting  to  see  if 
dyspnoea  returns.  It  is  well  to  give  a  full  dose  of  morphine  an  hour 
before  the  removal  of  the  tube,  since  this  operation  is  almost  invariably 
followed  by  a  marked  degree  of  laryngeal  spasm  which  lasts  for  ten  or 
fifteen  minutes.  To  avoid  the  production  of  vomiting  and  the  entrance 
of  food  into  the  larynx,  food  should  not  be  given  for  two  hours  previ- 
ously. If  dyspnoea  does  not  return  in  the  course  of  three  or  four  hours, 
the  probabilities  are  that  the  tube  will  no  longer  be  required.  It  is  excep- 
tional that  the  patient  has  great  difficulty  in  dispensing  with  the  tube, 
as  so  often  happens  after  tracheotomy. 

The  only  objection  of  much  force  urged  against  intubation  is  that 
asphyxia  may  be  produced  by  crowding  down  loose  membrane  into  the 
larynx.  This  is  an  infrequent  accident;  should  it  happen,  and  the 
asphyxia  not  be  relieved  by  removing  the  tube  and  inserting  another, 
tracheotomy  may  be  performed. 

There  is  always  some  degree  of  hoarseness  following  intubation,  but 
in  the  majority  of  cases  it  disappears  within  a  week,  occasionally  it  con- 
tinues as  long  as  three  or  four  weeks,  but  it  is  very  rarely  if  ever  perma- 
nent. The  duration  of  the  aphonia  seems  to  have  little  relation  to  the 
length  of  time  the  tube  is  worn  unless  this  is  many  weeks. 

Experience  has  clearly  proved  that  intubation  relieves  the  dyspnoea 
due  to  laryngeal  stenosis  promptly,  efficiently,  and  certainly ;  it  does  this 


1008  THE  SPECIFIC  INFECTIOUS  DISEASES. 

without  many  of  the  dangers  and  objectionable  features  of  tracheotomy, 
while  at  the  same  time  it  does  not  deprive  the  patient  of  any  essential 
advantage  which  tracheotomy  affords. 

Retained  Intubation  Tubes — Prolonged  Intubation. — Difficulty  is  ex- 
perienced in  dispensing  with  the  intubation  tube  much  less  frequently 
than  with  the  cannula  after  tracheotomy;  yet  when  this  condition  occurs 
it  is  the  cause  of  much  concern  and  even  danger.  Trouble  of  this  sort 
is  seen  in  about  one  per  cent  of  the  cases  of  intubation.  In  the  majority 
of  these  the  patient  is  able  to  do  without  the  tube  in  a  few  weeks,  and 
such  cases  require  very  close  attention,  but  no  special  treatment  other 
than  the  substitution  at  times  of  a  special  O'Dwyer  tube  with  an  extra 
large  "  retaining  swell."  But  occasionally  there  are  met  with  cases  in 
which  every  effort  to  dispense  with  the  tube  proves  futile.  Although 
the  children  breathe  well  with  the  tube  in  place,  still  if  it  is  removed 
or  expelled  by  coughing,  in  a  short  time,  varying  from  a  few  minutes  to 
several  days,  the  dyspnoea  returns  with  such  severity  that  the  tube  must 
be  replaced  to  prevent  asphyxia.  Inasmuch  as  these  patients  sometimes 
expel  the  tube  several  times  a  day,  surgeons  have  often  resorted  to  trache- 
otomy to  avert  the  danger  of  suffocation,  which  might  easily  occur  if  no 
one  were  at  hand  who  could  replace  the  tube.  This  operation,  however, 
gives  only  temporary  relief.  Many  of  these,  children,  after  wearing 
tubes  of  one  sort  or  another  for  years,  ultimately  die  from  some  accident 
connected  with  the  tube  or  from  pneumonia. 

The  causes  and  the  exact  pathological  condition  underlying  this  dif- 
ficulty are  subjects  regarding  which  there  has  been  much  difference  of 
opinion.  The  cause  of  the  returning  dyspnoea  is  probably  subglottic 
swelling  and  oedema  which  occur  in  tissues  which  are  the  seat  of  chronic 
inflammation  as  soon  as  the  pressure  of  the  tube  is  removed.  In  a  few 
cases  a  cicatricial  condition,  the  result  of  previous  ulceration,  has  been 
found ;  but  it  is  doubtful  if  granulations,  so  frequent  a  cause  of  retained 
cannula  after  tracheotomy,  play  a  part.  The  chronic  inflammation  of  the 
mucous  and  submucous  tissues  of  the  subglottic  region  of  the  larynx 
which  produces  the  symptoms,  is  aggravated  by  a  faulty  tube  or  a  clumsy 
operation,  but  it  may  occur  under  the  most  favourable  conditions. 

For  the  relief  of  this  condition,  O'Dwyer  advised  in  recent  cases  the 
application  of  astringents  by  means  of  an  intubation  tube  coated  with 
gelatine  with  which  some  astringent  was  combined.  For  those  patients 
who  cough  out  the  tube  frequently,  tracheotomy  is  at  times  a  necessity 
to  prevent  sudden  death.  But  this  does  not  affect  the  original  condition, 
for  the  same  difficulty  exists  in  doing  without  the  tracheal  cannula.  The 
operations  of  lar)Tigotomy,  curetting,  etc.,  have  been  such  signal  failures 
as  to  discourage  one  from  repeating  them. 

The  most  successful  method  of  treatment  thus  far  proposed  is  that 
of  Rogers,  which  consists  in  increasing  intra-laryngeal  pressure  by  the 


TYPHOID   FEVER.  1009 

insertion  of  larger  and  larger  intubation  tubes.  This  is  not  to  be  adopted 
until  long  after  all  acute  symptoms  have  subsided.  The  first  tube  used 
is  as  large  a  one  as  can  be  introduced  without  force ;  after  a  few  weeks, 
the  next  larger  size,  and  after  a  longer  interval,  possibly  a  still  larger 
one.  When  the  very  large  tube  has  been  worn  for  several  weeks  one  is 
usually  able  to  dispense  with  all  tubes. 

True  cicatricial  stenosis  may  best  be  relieved  by  opening  the  trachea 
and  dilating  from  below,  and  afterward  inserting  an  intubation  tube. 
When  there  is  complete  destruction  of  the  cricoid  cartilage,  as  sometimes 
occurs,  tracheotomy  is  the  only  remedy,  but  this  is  only  palliative,  as 
the  tube  must  be  worn  permanently. 


CHAPTEE    IX. 
TYPHOID  FEVER. 

Typhoid  fever  is  an  acute  infectious  disease  due  to  a  specific  germ 
— Eberth's  bacillus.  It  may  affect  the  foetus  in  utero,  or  the  newly- 
born  child,  and  it  is  seen  in  infancy  and  throughout  childhood. 

Fcetal  Typlioid. — Morse  has  collected  the  evidence  bearing  upon  foetal 
infection,  from  which  the  following  conclusions  seem  warranted:  Infec- 
tion of  the  child  from  the  mother  is  a  frequent  but  not  an  invariable  oc- 
currence. The  bacilli  may  pass  directly  from  the  maternal  into  the  foetal 
circulation.  The  fcetal  form  of  the  disease  is  a  general  blood-infection, 
since  the  intestines  are  not  functionally  active.  The  most  common 
result  is  death  of  the  foetus  and  consequent  abortion;  but  the  child  may 
be  born  alive  still  suffering  from  infection,  and  die  in  a  short  time  be- 
cause of  its  feeble  resistance. 

Infantile  Typhoid. — Much  difference  of  opinion  exists  regarding  the 
frequency  with  which  typhoid  fever  occurs  in  infancy.  Some  clinicians 
hold  the  opinion  that  the  disease  is  of  very  common  occurrence,  but  is 
often  unrecognised  because  of  the  absence  of  many  of  the  symptoms 
which  are  characteristic  at  a  later  age.  They  regard  every  protracted 
fever  not  malarial  and  not  dependent  upon  a  local  inflammation  as  pre- 
sumably typhoid.  The  symptoms  from  which  we  may  regard  the  ques- 
tion of  typhoid  as  established  will  be  considered  under  Diagnosis.  I  have 
seen  but  two  undoubted  cases  of  typhoid  under  two  years  of  age,  and  I 
believe  it  to  be  rare,  at  least  in  New  York.  No  case  recognised  as 
typhoid  occurred  in  a  child  under  two  years  of  age  during  my  eight  years' 
service  in  the  New  York  Infant  Asylum,  where  about  10,000  cases  of  acute 
illness  were  treated  and  over  700  autopsies  made.  No  case  has  been  recog- 
nised as  typhoid,  either  in  the  wards  or  the  post-mortem  room  of  the  New 
York  Foundling  Hospital  during  the  past  twenty-five  years.  Tvphoid 
65 


1010  THE  SPECIFIC  INFECTIOUS  DISEASES. 

has  been  seen  by  Murchison  at  six  months  and  by  Ogle  at  four  and  a  half 
months,  the  diagnosis  being  in  both  instances  confirmed  by  autopsy ;  also 
by  Griffith  at  seven  months  and  by  Taylor  at  eight  months,  with  fairly 
typical  symptoms.  It  is  during  epidemics  that  most  of  the  infantile  cases 
are  seen;  sporadic  instances  of  infantile  typhoid  should  always  be  re- 
garded with  suspicion,  and  I  believe  that  most  cases  so  diagnosticated  are 
questionable.  Even  in  epidemics  it  is  surprising  that  so  few  infants  are 
attacked.  In  that  of  Montclair,  N^.  J.,  in  1894,  of  115  eases,  only  3  were 
under  two  years ;  in  that  of  Stamford,  Conn.,  in  1895,  of  406  cases  only 
4  were  under  two  years. 

Typhoid  in  childhood  is  by  no  means  rare,  but  it  is  not  until  after 
the  fifth  year  that  it  can  be  said  to  occur  frequently.  The  following 
figures,  embracing  groups  of  cases  reported  by  eight  writers,  represent  the 
relative  frequency  with  which  the  disease  is  seen  at  the  different  ages: 
Of  970  cases,  eight  per  cent  occurred  under  five  years,  forty-two  per  cent 
between  five  and  ten  years,  and  fifty  per  cent  between  ten  and  fifteen 
years. 

Typhoid  fever  is  almost  invariably  contracted  by  drinking  water  or 
milk  which  contains  the  germs  of  the  disease.  The  infrequency  of 
typhoid  in  infants  is  explained,  in  part  at  least,  by  the  fact  that  most 
of  the  water  and  a  large  part  of 'the  milk  taken  are  previously  boiled, 
or  heated  in  some  manner. 

Lesions. — Typhoid  in  young  children  is  so  seldom  fatal  that  oppor- 
tunities for  a  study  of  the  lesions  have  been  limited.  In  a  general  way 
they  resemble  thoSe  of  adults  except  in  severity.  In  a  considerable  num- 
ber of  the  cases  the  pathological  process  in  the  intestines  does  not  go  on 
to  ulceration ;  and  when  ulcers  form  they  are  seldom  large  or  deep,  and 
perforation  is  very  rare.  Montmollin  gives  the  following  facts  concern- 
ing twenty-three  autopsies,  most  of  them,  however,  being  in  children 
over  eight  years  old :  ulcers  were  present  in  seventeen  cases ;  they  were 
situated  in  the  lower  ileum  in  sixteen,  and  in  ten  they  were  only  there; 
in  the  ascending  colon  in  nine,  and  only  there  in  one  case;  perforation 
occurred  in  three  cases,  in  every  instance  in  the  lower  ileum.  Autopsies 
made  upon  infants  may  show  even  less  severe  intestinal  lesions  than  those 
mentioned.  In  fact,  some  cases  in  which  the  clinical  diagnosis  was 
beyond  question,  have  shown  only  moderate  redness  and  swelling  of 
Peyer's  patches,  the  solitary  follicles  and  the  mesenteric  lymph  nodes — 
lesions  which  are  exceedingly  frequent  in  cases  of  simple  diarrhoea.  In  a 
doubtful  case  such  post-mortem  findings  do  not  establish  the  diagnosis 
of  typhoid.  Indeed,  they  prove  nothing  unless  cultures  from  the  intes- 
tinal contents,  the  mesenteric  glands,  or  other  organs,  show  the  typhoid 
bacillus.  Enlargement  of  the  spleen  is  practically  constant.  The  de- 
generative changes  in  the  heart,  the  kidneys,  and  the  liver  are  much 
less  frequent  and  generally  less  severe  than  in  adults. 


TYPHOID   FEVER.  1011 

Symptoms. — The  peculiar  features  of  typhoid  in  early  life  are  seen 
only  in  children  under  ten  years  old ;  for  after  this  time  the  disease  does 
not  differ  essentially  from  the  adult  type.  In  hrief,  the  typhoid  of  early 
childhood  may  be  described  as  a  fever  characterised  more  often  by  nerv- 
ous symptoms  than  by  intestinal  symptoms. 

Onset. — A  sudden  onset  with  well-marked  symptoms — fever,  pros- 
tration, vomiting,  etc. — is  not  uncommon;  in  fact,  it  is  quite  as  fre- 
quently seen  as  the  insidious  beginning,  with  lassitude,  headache,  coated 
tongue,  anorexia,  and  gradual  rise  in  temperature.  In  cases  developing 
abruptly  it  often  appears  as  if  an  acute  indigestion  had  been  the  means 
of  precipitating  the  attack.  The  most  frequent  initial  symptom  is  vomit- 
ing; a  chill  is  rare.  Epistaxis  occurs  as  an  early  symptom  rather  less 
frequently  than  in  adults. 

Condition  of  the  Bowels. — There  is  no  constant  relation  between  the 
severity  of  the  intestinal  lesions  and  the  condition  of  the  bowels.  Tak- 
ing large  groups  of  cases  together,  diarrhoea  is  present  in  about  half  the 
total  number.  It  is  rarely  profuse,  from  two  to  four  discharges  a  day 
being  the  average.  The  appearance  of  the  stools  is  seldom  character- 
istic; they  are  usually  thin  and  fluid,  often  containing  mucus.  Consti- 
pation may  be  present  at  the  beginning  only,  or  throughout  the  attack. 
Tympanites  is  generally  moderate,  and  is  often  entirely  absent;  it  usu- 
ally accompanies  constipation.  Marked  iliac  tenderness  and  gurgling 
are  infrequent. 

Spleen. — By  the  end  of  the  first  week  this  is  almost  invariably  found 
to  be  enlarged  to  a  sufficient  degree  to  be  recognised  by  palpation.  Usu- 
ally the  spleen  extends  but  an  inch  or  an  inch  and  a  half  below  the  ribs, 
but  at  times  it  may  be  three  inches  or  more ;  persistent  enlargement 
always  indicates  that  the  disease  is  not  at  an  end  even  though  the  tem- 
perature has  reached  the  normal,  and  a  relapse  should  be  expected. 

Eruption. — It  is  the  experience  of  nearly  all  Avho  have  seen  much  of 
typhoid  in  children  that  the  eruption  is  less  constant,  less  abundant, 
and  less  characteristic  than  in  adults.  The  typical  eruption  consists  of 
small,  scattered,  rose-coloured  spots,  which  appear  chiefly  or  solely  upon 
the  abdomen  at  the  beginning  of  the  second  week.  They  come  in  suc- 
cessive crops,  each  one  of  which  generally  lasts  three  days,  the  whole 
duration  of  the  eruption  being  about  ten  days. 

Prostration,  Emaciation,  etc. — As  a  rule  the  prostration  is  quite  suffi- 
cient to  keep  a  child  in  bed  after  the  first  few  days.  The  general  weak- 
ness after  this  time  is  in  direct  proportion  to  the  height  of  the  tempera- 
ture. Loss  of  flesh  is  steady  and  usually  marked;  and  in  a  prolonged 
attack  there  may  be  extreme  emaciation. 

Temperature. — In  the  cases  with  a  gradual  onset,  the  typical  tem- 
perature curve  is  one  which  rises  steadily  for  from  two  to  seven  days, 
fluctuates  within  the  limits  of  one  to  three  degrees  during  the  second 


1012 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


week,  and  steadily  declines  during  the  third  week,  reaching  the  normal 
on  the  average  at  the  end  of  the  third  week.  In  cases  with  an  abrupt 
onset,  the  temperature  rises  at  once  to  from  102.5°  to  105°  F.,  but  sub- 
sequently may  run  the  same  course  as  in  the  first  group. 

The  following  are  the  most  important  variations  from  the  tempera- 
ture curve  of  adults :  The  initial  rise  is  much  more  frequently  rapid ; 

during  the  second  week  the 
remittent  character  is  less 
marked,  this  probably  de- 
pending upon  the  fact  that 
ulceration  is  less  frequent 
and  less  extensive ;  the  aver- 
age duration  is  shorter.  In 
young  children  the  propor- 
tion of  cases  in  which  the 
fever  lasts  only  from  eight 
to  fourteen  days  is  quite 
large  (Fig.  200).  After 
the  age  of  ten  years  the 
type  of  the  fever  is  much 
like  that  seen  in  adults. 
The  maximum  temperature 
in  the  mild  cases  is  103°  or  101°  F. ;  in  the  severe  ones  it  often  reaches 
105°  or  106°  F.,  but  rarely  goes  above  this  point.  The  range  is  usually 
higher  than  in  adult  cases  of  the  same  severity.  At  the  beginning  of 
convalescence  a  subnormal  temperature  is  very  frequent,  and  by  many 
writers  is  considered  to  be  the  rule.  A  secondary  rise  is  most  frequently 
due  to  errors  in  diet,  but  may  occur  from  the  development  of  complica- 
tions. A  sudden  fall  indicates  either  perforation  or  intestinal  haemorrhage. 


DAY 

10*° 

108° 

|1M 

K  101° 

im 

99° 

98° 
97° 

1 

2 

3 

t 

5 

C 

7 

8 

9 

10 

u 

12 

IS 

k 

T\ 

J 

' 

/^ 

"-^ 

1 

V 

,   j 

\ 

\J 

1 

^ 

/ 

V 

1 

V 

1/ 

V 

\^ 

^ 

^ 

Fig.  200.  —  Typhoid  Fever  of  Short  Duration 
IN  A  Child  Thirteen  Months  Old.  Spleen 
enlarged ;  eruption  typical ;  no  diarrhcEa  and  only 
moderate  abdominal  distention.  There  were  two 
other  cases  in  the  family,  all  being  due  to  the 
same  cause — infected  milk.     (After  Northrup.) 


0A1 

f           8      «    10   11   IS   IS  u\li   18    17   18   1*20naZ3S4ttS«»i8»»ZlS233   3t3S3eS7383940   414243 

b 

1 

z 

i 

104°    <....-..      /I    .      -                                                                                                            ,     /                1 

Z^zix^u:                         ^Ji^jz^ 

Z'             I     -,             -t^^^^jt^  \ri_^_i. 

Z'             \      /             fy-^^u      \    \  aA 

^             i     ir-                            ^^iflrr 

2             A  r^\-  ^^^                      ttt.^^-, 

«°             ^^       V     t'^                         r     ^7t=^ 

I'                      \          3^                                                           L^^ 

. 

Fig.  201. — Typhoid  Fever  with  Relapse.  Child  two  and  a  half  years  old;  early  tem- 
perature high  and  symptoms  typical;  natural  fall  on  fourteenth  day;  rise  on  seven- 
teenth day  apparently  due  to  otitis;  relapse  on  twenty-fourth  day,  with  fresh  eruption 
and  return  of  splenic  swelling  which  had  disappeared.  Temperature  was  subnormal 
at  the  end  both  of  primary  and  secondary  fever. 


Relapses  were  present  in  8 . 4  per  cent  of  533  cases  collected  by  Morse. 
They  follow  about  the  same  course  as  in  adults  (Fig.  201). 


TYPHOID  FEVER.  1013 

Nervous  Symptoms. — As  a  rule,  these  are  more  prominent  in  severe 
cases  than  the  intestinal  symptoms,  and  are  directly  proportionate  to  the 
height  of  the  temperature.  The  extreme  nervous  symptoms  belonging 
to  the  typhoid  state  in  adults  are  rare  in  childhood,  except  in  patients 
over  ten  years  old.  Headache  and  mild  delirium  at  night  are  very  fre- 
quent, the  former  being  seen  in  the  majority  of  cases.  Young  children 
are  usually  dull,  apathetic,  and  often  in  a  state  of  semi-stupor.  Oc- 
casionally the  disease  may  closely  simulate  meningitis.  The  nervous 
symptoms  are  usually  most  severe  in  the  second,  or  early  in  the  third 
week,  and  subside  as  the  temperature  declines. 

Pulse. — This  is  increased  in  frequency,  but  not  to  the  degree  that 
is  seen  in  most  diseases  of  childhood  with  a  similar  elevation  of  temper- 
ature. The  force  and  rhythm  of  the  pulse  are  usually  good,  irregularity 
and  dicrotism  being  rare  in  children  as  compared  with  adults. 

Urine. — A  small  amount  of  albumin  is  found  in  the  urine  of  most 
of  the  severe  cases  at  the  height  of  the  disease,  and  is  due  to  acute  renal 
degeneration;  but  a  marked  degree  of  nephritis  is  infrequent.  In  from 
one-fourth  to  one-third  of  the  cases  typhoid  bacilli  are  found  in  the 
urine,  generally  in  pure  culture.  They  usually  appear  in  the  latter  part 
of  the  disease,  the  second  or  third  week,  and  may  continue  for  months 
or  even  years.  They  are  sometimes  accompanied  by  evidence  of  cystitis 
or  nephritis.  Their  number  is  in  some  cases  so  large  as  to  render  the 
urine  turbid;  in  others  they  give  no  indication  of  their  presence.  Ehr- 
lich's  diazo  reaction  is  usually  present  at  the  height  of  the  fever. 

Blood. — The  characteristic  blood  picture  in  typhoid  is  a  low  leucocyte 
count,  generally  under  10,000,  accompanied  usually  by  a  slightly  increased 
proportion  of  lymphocytes.  Blood  cultures,  with  great  uniformity,  show 
the  bacilli  even  in  the  first  week  of  the  disease. 

Intestinal  Hcemorrhage. — Of  946  collected  cases,  mainly  from  hospital 
reports,  intestinal  haemorrhage  occurred  in  thirty,  or  about  three  per 
cent;  the  majority  of  these  were  in  children  over  ten  years  old.  Of 
twenty-four  collected  cases  of  haemorrhage  in  children,  ten  terminated 
fatally.  The  youngest  case  of  this  nature  which  has  come  under  my  own 
notice  was  in  a  child  of  four  and  a  half  years. 

Intestinal  Perforation. — This  is  even  more  rare  than  haemorrhage. 
In  1,028  collected  cases,  this  accident  occurred  but  twelve  times,  or  in 
1 . 1  per  cent.  Perforation  is  indicated  by  a  sudden  fall  in  the  tem- 
perature, with  collapse;  usually  there  is  vomiting  and  the  rapid  devel- 
opment of  tympanites. 

Complications  and  Sequelae. — The  complications  of  typhoid  in  early 
life  are  infrequent  and  usually  mild.  Bronchitis  is  present  in  most  of 
the  severe  cases.  Pneumonia  has  been  noted  in  nine  per  cent  of  the  cases 
reported  by  various  authors.  Both  serous  and  purulent  effusions  into 
the  chest  are  occasionally  seen,  and  sometimes  abscess  of  the  lung. 


1014  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Complications  referable  to  the  nervous  system  are  not  very  frequent, 
but  are  of  much  interest.  Meningitis  is  extremely  rare.  Morse  has 
collected  twenty-one  cases  of  aphasia,  in  two  of  which  it  was  clearly  due 
to  embolism ;  in  the  remainder,  however,  it  apparently  was  not  dependent 
upon  any  organic  lesion.  In  two-thirds  of  the  cases  it  came  on  during 
convalescence,  and  in  nearly  all  complete  recovery  occurred  after  an 
average  duration  of  three  weeks.  Aphasia  usually  followed  a  severe  type 
of  the  disease,  and  in  most  of  the  cases  was  not  accompanied  by  any  other 
paralysis  or  by  mental  disturbance.  Insanity  is  a  rare  sequel  of  typhoid 
in  children,  the  usual  type  being  acute  mania.  Adams  (Washington) 
has  reported  two  examples  of  this,  both  terminating  in  recovery.  Chorea 
is  seen  rather  oftener  than  after  the  other  infectious  diseases. 

Otitis  is  not  an  infrequent  complication,  occurring  much  oftener  than 
in  adults.  It  is  principally  seen  in  young  children  and  during  the  cold 
season.  Among  the  less  frequent  complications  may  be  mentioned :  paro- 
titis, which  is  usually  suppurative  and  is  seen  in  septic  cases;  abscess 
of  the  liver,  examples  of  which  have  been  reported  by  Bokai,  Asch,  and 
others;  gangrenous  inflammation  of  the  mouth  or  genitals;  pericarditis, 
endocarditis,  and  peritonitis,  suppurative  inflammations  of  joints,  mul- 
tiple abscesses  and  furunculosis.  Tuberculosis  of  the  lungs  or  bones  not 
infrequently  follows  typhoid. 

Diag;nosis. — The  diagnostic  symptoms  of  typhoid  are  the  Widal  blood 
reaction,  the  discovery  of  the  bacilli  in  the  blood,  urine  or  faeces,  the  erup- 
tion, the  course  of  the  temperature,  the  enlargement  of  the  spleen  and  the 
abdominal  symptoms — diarrhoea,  tympanites,  intestinal  haemorrhage,  and 
perforation. 

The  Widal  reaction  is  present  at  some  period  in  from  ninety-five  to 
ninety-eight  per  cent  of  the  cases,  and  thus  becomes  the  most  valuable 
single  symptom  for  diagnosis.  It  is  seldom  obtained  before  the  seventh 
day  and  frequently  not  until  the  tenth;  it  may  not  be  present  until 
convalescence  or  a  relapse.  Repeated  tests  should  always  be  made  if 
the  first  reaction  is  negative  or  doubtful;  and  the  tests  should  be  made 
by  an  experienced  pathologist.  The  reaction  is  therefore  of  mucli  less 
value  for  an  early  than  for  an  exact  diagnosis.  A  positive  reaction  may 
be  present  if  the  patient  has  previously  had  typhoid,  something  much  less 
likely  to  be  the  case  with  children  than  with  adults ;  in  rare  instances  it 
has  been  obtained  in  other  diseases  or  in  health  when  no  history  of 
previous  typhoid  existed.  Both  these  conditions,  however,  are  very  ex- 
ceptional, and  a  positive  reaction  may  as  a  rule  be  taken  to  establish 
the  diagnosis. 

Typhoid  bacilli,  according  to  the  observations  of  Park,  may  be 
demonstrated  in  the  stools  by  culture  in  a  large  proportion  of  the  cases. 
They  are  found  in  the  urine,  usually  in  the  latter  part  of  the  disease, 
in  about  one-third  the  cases.     Their  discovery  in  either  of  these  discharges 


TYPHOID  FEVER.  1015 

is  conclusive  evidence  of  previous  or  existing  typhoid.  An  examination 
of  both  urine  and  faeces  should,  if  possible,  be  made  in  all  doubtful  cases. 

The  course  of  the  temperature  is  an  important  aid  to  diagnosis,  but 
alone  is  not  to  be  depended  upon.  The  characteristic  feature  is  a  fever 
which  continues  for  two,  three,  or  four  weeks,  and  subsides  spontaneously. 
The  variations  from  the  adult  type  have  already  been  mentioned,  also 
the  frequency  of  the  eruption,  the  enlargement  of  the  spleen,  and  the 
abdominal  symptoms.  We  are  not  warranted,  I  think,  in  making  the 
diagnosis  of  typhoid,  if  repeated  tests  fail  to  show  the  Widal  reaction  or 
if  the  eruption  and  splenic  enlargement  are  absent,  and  no  bacilli  can 
be  demonstrated  in  the  discharges,  no  matter  what  the  course  of  the 
temperature  may  be. 

One  should  hesitate  to  make  the  diagnosis  of  typhoid  in  a  child 
under  two  years  old,  unless  the  disease  is  epidemic.  The  great  majority 
of  sporadic  cases  reported  as  occurring  in  infancy  are  probably  not 
typhoid.  After  the  fifth  year  the  disease  is  inore  frequent,  and  its  symp- 
toms in  general  resemble  those  of  adults,  except  in  severity. 

A  differential  diagnosis  is  to  be  made  from  malarial  fever,  ileo-colitis, 
meningitis,  tuberculosis,  and  from  other  ill-defined  continuous  fevers  of 
unknown  origin.  From  malarial  fever  the  diagnosis  is  to  be  made  by 
the  temperature  curve,  the  organisms  in  the  blood,  and  the  effect  of 
quinine.  In  most  of  the  cases  of  malaria  the  temperature  will  be  found 
to  touch  the  normal  at  some  time  in  the  twenty-four  hours.  The  admin- 
istration of  full  doses  of  quinine  is  a  diagnostic  test  of  much  practical 
importance;  an  irregular  or  remittent  fever  which  yields  promptly  to 
quinine  is  most  certainly  not  typhoid. 

Ileo-colitis  and  typhoid  fever  are  not  often  confounded.  The  former 
is  chiefly  seen  in  the  first  three  years  of  life,  a  time  when  typhoid  is  rare. 
The  intestinal  symptoms  of  ileo-colitis  are  marked  even  though  the  tem- 
perature is  not  high,  and  they  are  altogether  more  severe  than  is  usual 
in  typhoid;  while  enlargement  of  the  spleen,  tympanites,  and  the  erup- 
tion are  not  present. 

The  cerebral  symptoms  of  typhoid  may  be  difficult  to  distinguish  from 
meningitis,  unless  one  has  watched  their  development.  Irregular  respira- 
tion, a  slow,  irregular  pulse,  localised  paralysis  and  complete  coma  are 
seldom,  if  ever,  seen  in  typhoid,  and  a  retracted  abdomen  very  rarely, 
while  the  enlarged  spleen  and  the  peculiar  eruption  are  not  seen  in  men- 
ingitis. In  typhoid  with  pronounced  nervous  symptoms  the  temperature 
is  usually  higher  than  in  meningitis. 

General  tuberculosis  very  often  resembles  typhoid  so  closely  that  a 
differential  diagnosis  is  almost  impossible  until  local  signs  'of  tuber- 
culosis have  appeared,  usually  in  the  lungs. 

Prognosis. — Of  2,623  cases  in  children,  collected  from  the  reports  of 
twelve  different  writers,  the  mortality  was  5 . 4  per  cent.    These  are,  how- 


1016  THE  SPECIFIC  INFECTIOUS  DISEASES. 

ever,  almost  all  taken  from  hospital  reports,  where  as  a  rule  the  mildest 
cases  are  not  brought  for  treatment.  The  mortality  of  the  disease  in 
children  over  three  years  old  probably  does  not  exceed  three  or  four  per 
cent.  Death  seldom  occurs  from  the  disease  itself,  but  usually  from  some 
accident  or  complication,  the  most  frequent  being  pneumonia  and  intes- 
tinal haemorrhage  or  perforation.  Griffith's  collection  of  cases  occurring 
in  infancy  indicates  a  much  higher  mortality  for  this  period.  The  death- 
rate  for  the  first  year  reached  nearly  fifty  per  cent. 

Treatment. — The  usually  low  mortality  of  this  disease  shows  how 
successful  all  methods  of  treatment  are  likely  to  be  considered.  In  the 
great  majority  of  cases  very  little  active  treatment  is  required.  Every 
patient  with  typhoid  should  be  put  to  bed  and  kept  there  during  the 
febrile  period,  and  a  few  days  beyond  it,  no  matter  how  mild  the  attack 
may  be.  The  diet  should  consist  of  sterilised  milk  or  animal  broths, 
cereal  gruels  and  very  soft  eggs.  These  articles  should  be  given  regularly 
every  three  hours,  but  not  pushed  beyond  the  desire  of  the  patient.  Milk 
may  be  diluted  or  partially  peptonised,  and  kumyss  or  matzoon  may  be 
substituted  for  it  if  the  stomach  is  irritable.  Plenty  of  water  should  be 
given.    Solid  food  should  not  be  allowed  until  the  temperature  is  normal. 

Both  the  urine  and  faeces  should  be  immediately  and  thoroughly  dis- 
infected by  a  solution  of  carbolic  1 :  20.  If  the  movements  are  in  a 
chamber  or  a  bed-pan  they  should  be  covered  with  this  solution  for  at 
least  six  hours  before  they  are  thrown  into  the  water-closet.  If  napkins 
or  diapers  are  used,  they  should  be  soaked  in  some  effective  antiseptic 
solution  for  twelve  hours  and  then  thoroughly  boiled.  Sheets  stained 
by  discharges  should  be  treated  in  the  same  way,  and  all  bed-linen  should 
be  boiled  for  two  hours  apart  from  the  washing  of  the  family.  The 
efficiency  of  hexamethylenamine  (urotropin)  in  removing  typhoid  bacilli 
from  the  urine  seems  now  to  be  well  established.  It  should  be  given  at 
the  close  of  the  attack  in  doses  of  three  to  five  grains,  three  times  a  day, 
and  continued  for  a  week  or  ten  days. 

Diarrhoea  calls  for  treatment  only  when  the  movements  exceed  four 
or  five  in  twenty-four  hours.  If  no  more  than  this  number  are  present, 
they  should  not  be  interfered  with.  Opium  and  bismuth  are  undoubt- 
edly the  best  means  for  controlling  excessive  diarrhoea,  but  care  should 
be  taken  that  they  are  not  pushed  to  the  degree  of  inducing  con- 
stipation. 

Constipation  early  in  the  disease  may  be  relieved  by  calomel,  followed 
by  the  salines,  or  castor  oil,  but  all  active  purgation  should  be  avoided. 
Later  in  the  disease  daily  irrigation  of  the  colon  with  tepid  water  is 
better  than  anything  else.  On  the  whole,  constipation  is  more  trouble- 
some to  overcome  than  diarrhoea. 

Tympanites  is  rarely  severe  enough  to  require  treatment;  it  may  be 
relieved  by  turpentine  stupes,  by  a  glycerin  suppository,  or  a  small 


TUBERCULOSIS.  1017 

glycerin  injection  (one  teaspoonful  of  glycerin  to  two  ounces  of  water), 
or,  better  still,  by  the  use  of  the  rectal  tube. 

Whenever  the  temperature  remains  above  104°  F.,  antipyretic  meas- 
ures are  indicated.  In  mild  cases  cold  or  tepid  sponging  is  generally 
sufficient.  In  those  which  do  not  yield  to  such  measures,  baths  may  be 
employed.  Not  all  children  bear  baths  well,  and  considerable  discretion 
should  be  used  in  employing  them.  One  should  be  guided  quite  as  much 
by  the  effect  upon  the  pulse  and  the  nervous  system  as  by  the  tempera- 
ture. The  best  method  is  usually  the  graduated  bath;  the  child  is  placed 
in  the  tub  with  the  water  at  a  temperature  of  95°  or  100°  F. ;  this  is 
gradually  lowered  to  95°,  90°,  or  even  85°  F.,  but  seldom  lower.  The 
body  should  be  actively  rubbed  while  the  child  is  in  the  bath,  to  prevent 
shock  and  cardiac  depression.  The  cold  pack  may  be  substituted  for  the 
bath  where  circumstances  make  the  latter  impracticable.  The  bath  or 
pack  should  be  repeated  in  an  average  case  in  from  three  to  six  hours. 

The  milder  nervous  symptoms — headache,  restlessness,  sleeplessness, 
etc. — may  be  relieved  by  an  occasional  dose  of  phenacetine,  either  alone 
or  in  combination  with  the  bromides,  or  by  cold  or  tepid  sponging;  the 
more  severe  ones  usually  occur  with  high  temperature,  and  are  best  con- 
trolled by  the  cold  bath. 

Stimulants  in  most  of  the  cases  are  not  called  for.  They  are  to  be 
given  according  to  the  indications  afforded  by  the  pulse,  the  first  sound 
of  the  heart,  and  the  child's  general  condition.  They  are  seldom  needed 
earlier  than  the  end  of  the  second  week.  Intestinal  haemorrhage  calls 
for  absolute  quiet,  morphine  hypodermically,  and  an  ice-coil  to  the  ab- 
domen, nothing  being  given  by  mouth  except  stimulants,  turpentine,  and 
possibly  opium.  Intestinal  perforation  is  successfully  treated  only  by 
early  laparotomy. 

CHAPTER    X. 
TUBEliCULOSIS. 

Tuberculosis  is  an  infectious  communicable  disease,  due  to  the 
bacillus  tuberculosis  of  Koch.  It  may  be  local  or  general,  and  may  in- 
volve any  organ  and  almost  any  structure  in  the  body. 

Etiology. — Age  and  Frequency. — No  age  is  exempt  from  tuberculosis. 
It  was  formerly  believed  that  the  disease  was  rare  in  infancy,  but  recent 
observations  have  shown  the  opposite  to  be  the  case. 

Statistics  taken  chiefly  from  three  New  York  institutions  where  only 
infants  and  young  children  are  received  give  the  following  figures  for 
383  cases  of  tuberculosis,  the  diagnosis  being  confirmed  by  autopsy  in 
nearly  every  instance:  In  the  first  year  there  were  160  cases,  and  of 
these  67  were  under  six  months,  10  of  which  were  under  three  months 


1018 


THE   SPECIFIC   INFECTIOUS  DISEASES. 


of  age.  The  frequency  of  tuberculosis  appears  to  increase  steadily  as 
age  advances,  as  shown  by  the  following  table,  in  which  results  found 
at  autopsy  are  compared  with  those  obtained  by  means  of  v.  Pirquet's 
skin  reaction.     Both  series  are  from  Vienna. 


Age. 


I.    Hamburger:  Autopsies. 


No.  of 
Cases. 


Percentage  of 
Tuberculosis. 


II.  V.  Pirquet:  Skin  Tests. 


No.  of 
Tests. 


Percentage  of 
Reactions. 


Under  3  months  . . 
3  to  6 

6  to  12 

2d  year 

3d  and  4th  years  , 
5th  and  6th  years 

7  to  10  years 

11  to  14    "     

Over  14    "    


105 

73 

140 

179 

175 

67 

65 

44 


4  per  cent 
18 
23 
40 
60 
56 
63 
70 


147 

64 

67 

88 

127 

101 

182 

100 

112 


0  per  cent 

5 
16 
24 
37 
53 
57 
68 
90 


848 


40  per  cent 


41  per  cent 


From  the  facts  at  hand  it  would  seem  that  the  percentage  of  children 
with  tuberculosis  is  much  greater  in  Europe  than  in  this  country.  The 
following  table  gives  figures  for  three  institutions  with  which  I  am 
connected  in  New  York,  as  compared  with  data  taken  from  Vienna  and 
Munich. 

Frequency  of  Tuberculosis  as  Shown  by  Autopsies. 


Institutigx. 

Age  of  Patients. 

No.  of 
Autopsies 

No.showing 
Tuber- 
culosis. 

Percentage  of 
Tuberculosis. 

N.  Y.  Infant  Asylum.  . 

Babies'  Hospital 

N.Y.  Foundling  Hosp. . 

MuUer — Munich 

Hamburger — Vienna. . . 
«                  It 

Nearly  all  under  2  J^  years. 
"       "     3 
"      3 

Children  of  all  ages 

All  ages  up  to  14  years.  .  .  . 
(  Including  only  children  } 
}      of  2  years  and  under .  ) 

726 
1,000 
1,000 

500 

848 

497 

56 
168 
136 
200 
335 

120 

8.0  per  cent 
16.8       " 
13.6       " 
40.0       " 
40.0       " 

24.4       " 

These  percentages  are  not  to  be  taken  to  represent  tlie  occurrence 
of  tuberculosis  in  the  community  generally,  but  only  its  frequency  in 
the  class  which  furnishes  hospital  and  institution  inmates.  Nor  are 
these  figures  to  be  interpreted  as  showing  the  percentage  of  active  tuber- 
culosis. In  the  cases  showing  tuberculosis  at  autopsy  nearly  one-third 
of  the  number  died  from  other  diseases,  tuberculosis  being  latent  and 
its  existence  being  discovered  only  post  mortem.  Likewise  in  nearly 
one-fifth  the  cases  giving  positive  skin  reactions  there  were  no  evidences 
of  active  tuberculosis. 

Predisposing  Causes. — These  include  all  the  conditions  which  bring 
about  a  diminished  resistance  of  the  body  to  tuberculous  infection.    This 


TUBERCULOSIS.  1019 

susceptibility  may  be  inherited,  as  when  parents  have  suffered  from  tu- 
berculosis or  other  constitutional  disease,  syphilis,  alcoholism,  etc.  It 
may  be  due  to  the  fact  that  children  have  been  reared  in  crowded  city 
tenements,  in  institutions,  or  under  other  unfavourable  surroundings. 
A  local  predisposition  may  be  afforded  by  any  pathological  condition 
of  the  organs  or  mucous  membranes  exposed  to  infection.  Thus,  adenoid 
growths  of  the  pharynx  or  large  tonsils  may  favour  the  development 
of  cervical  adenitis,  and  frequent  attacks  of  bronchitis  may  precede  pul- 
monary tuberculosis.  Certain  infectious  diseases,  particularly  measles, 
whooping-cough,  and  influenza,  greatly  increase  a  child's  susceptibility 
to  tuberculosis,  and  these  may  also  cause  a  latent  tuberculosis  to  develop 
into  an  active  process.  General  or  pulmonary  tuberculosis  is  therefore 
often  seen  as  a  sequel  to  the  diseases  mentioned,  the  latent  focus  for 
which  has  been  tuberculous  bronchial  glands. 

Modes  of  Infection. — Intra-uterine  infection,  although  rare,  has  been 
established  by  the  report  of  at  least  seven  complete  and  well-authenti- 
cated cases.  Tuberculosis  of  the  placenta  is  more  frequent.  In  most  of 
the  cases  of  congenital  tuberculosis  the  mother  has  been  suffering  from 
the  disease  in  an  advanced  form,  and  the  child  is  either  still-born  or 
dies  soon  after  birth.  Besides  tuberculosis  of  the  placenta,  tubercle 
bacilli  are  found  in  the  organs  of  the  child,  and,  when  life  is  prolonged, 
there  are  generalised  lesions  showing  infection  through  the  blood. 
Cheesy  nodules  have  been  observed  in  the  umbilical  cord.  Intra-uterine 
infection  is  highly  probable  in  many  of  the  children  born  of  tuberculous 
mothers,  who  develop  the  disease  during  the  first  few  months  of  life,  al- 
though they  may  show  no  evidence  of  it  at  birth.  Among  my  own  cases 
there  was  one  only  twenty  days  old.  The  child  was  born  prematurely  of  a 
mother  suffering  from  advanced  tuberculosis.  Besides  other  lesions,  the 
autopsy  showed,  in  the  case  of  the  mother,  tuberculosis  of  the  endo- 
metrium. 

Tuberculosis  may  be  communicated  by  direct  inoculation,  as  in  the 
case  of  a  bite  from  a  person  suffering  from  the  disease,  several  instances 
of  which  are  on  record.  The  rite  of  circumcision  performed  by  a  rabbi 
suffering  from  tuberculosis  is  also  known  to  have  caused  the  disease. 
One  of  the  most  striking  instances  of  direct  infection  is  that  reported  by 
Eeich.^  In  a  town  of  about  1,300  inhabitants,  the  obstetric  practice  was 
divided  between  two  midwives.  Within  fourteen  months  no  less  than 
ten  infants,  who  had  been  delivered  by  one  of  these  women,  died  of 
tuberculous  meningitis.  In  none  of  these  families  was  there  a  history 
of  tuberculosis.  This  midwife  was  found  to  be  suffering  from  pulmonary 
tuberculosis,  and  died  from  that  disease.  It  was  her  custom  to  remove 
the  mucus  from  the  mouth  of  the  newly-born  infants  by  direct  mouth- 

^  Berliner  klinische  Wochenschrift,  No.  37,  1878 


1020  THE  SPECIFIC  INFECTIOUS  DISEASES. 

to-inouth  aspiration,  and  then  to  establish  respiration  by  blowing  into 
the  nose.  In  the  practice  of  the  other  midwife,  who  was  healthy,  no 
cases  of  tuberculosis  occurred,  although  she  treated  the  newly-born  in- 
fants in  the  same  fashion. 

I  believe  that  altogether  the  most  frequent  means  by  which  children 
acquire  tuberculosis  is  from  association  with  persons  suffering  from  pul- 
monary tuberculosis.  Some  of  these  are  persons  in  the  active  stage  of 
the  disease ;  many  are  supposed  to  have  been  cured ;  in  others  the  disease 
has  not  yet  developed  so  as  to  he  recognised.  Bacilli  may  be  directly 
conveyed  by  kissing.  Dried  sputum  containing  bacilli  may  become  a 
part  of  the  dust  of  the  room ;  it  may  be  inhaled  or  it  may  be  introduced 
into  the  mouths  of  children  by  hands,  toys,  or  other  objects.  The  source 
of  infection  is  usually  one  or  other  parent  or  some  member  of  the  house- 
hold— a  nurse,  caretaker,  servant,  or  a  frequent  visitor.  A  history  of 
such  exposure  was  definitely  traced  in  forty-four  per  cent  of  101  con- 
secutive cases  of  tuberculosis  in  young  children  which  were  investigated 
at  the  Babies'  Hospital.  These  figures  do  not  represent  the  proportion 
of  the  cases  in  which  the  disease  is  so  contracted.  I  believe  there  is  a 
v^ry  much  larger  number  in  which  this  connection  can  not  be  traced. 
Doubtless  exposure  antedates  symptoms  by  a  number  of  weeks,  at  least, 
often  by  several  months.  In  instances  where  it  could  be  pretty  accu- 
rately ascertained,  the  interval  between  exposure  and  development  of 
sjonptoms  was  from  four  to  twelve  weeks. 

Infection  may  take  place  from  beds,  rooms,  sleeping  cars,  or  any 
apartments  previously  occupied  by  tuberculous  patients;  from  dishes  or 
spoons,  from  glasses  at  public  drinking  places;  also  from  the  milk  of 
tuberculous  cows  ^  or  from  meat.  My  own  observations  lead  me  to  the 
conclusion  that  only  a  very  small  proportion  of  children  contract  tuber- 
culosis in  these  indirect  ways.  Infection  through  milk  I  believe  to  be 
relatively  rare.  (See  chapter  upon  Milk.)  Unless  the  disease  in  an 
animal  is  far  advanced  or  the  udder  is  involved,  the  number  of  bacilli 


^  In  this  connection  the  following  incident  is  interesting  as  bearing  upon  the  other 
side  of  the  question:  Near  a  large  American  city  was  a  fancy  stock  farm  of  registered 
Jersey  cows,  which  supplied  milk  for  table  use  and  infant  feeding  to  a  large  number 
of  families  in  the  wealthiest  part  of  the  city,  for  a  period  of  over  ten  years.  At  the 
end  of  that  time  the  tuberculin  test  was  used  for  the  first  time,  and  45  per  cent  of 
these  cows  were  found  to  be  tuberculous,  and  were  killed  by  order  of  the  State  Board 
of  Health.  The  diagnosis  was  confirmed  by  autopsies  upon  the  animals  in  every 
instance.  An  investigation  was  instituted  among  the  children  who  had  been  fed 
upon  this  milk,  but  in  only  one  case  of  many  hundreds  could  it  be  learned  that  tuber- 
culosis had  developed,  and  in  this  instance  it  was  by  no  means  established  that  the 
milk  had  been  the  source  of  infection.  It  should  be  stated  that  this  was  before  the 
days  of  sterilising  milk  for  infant  feeding.  Besides  the  families  who  took  the  milk 
in  the  manner  mentioned,  the  employees  at  the  farm  were  accustomed  to  drink  the 
skimmed  milk  in  large  quantities  daily  as  a  beverage  in  the  place  of  water.  Many  of 
them  continued  to  do  this  for  years,  and  yet  not  one  of  them  developed  tuberculosis. 


TUBERCULOSIS.  1021 

present  in  the  milk  of  a  tuberculous  cow  is  small  and  the  chances  of 
infecting  a  child  are  slight.  Those  which  enter  may  ])e  destroyed  in  the 
stomach  or  pass  through  the  intestinal  tract  without  doing  harm.  Bacilli 
entering  through  the  respiratory  tract  unfortunately  have  no  such  ready 
means  of  exit.  Infection  from  the  meat  of  tuberculous  animals  is  a  pos- 
sibility, but  hardly  more.  Bollinger's  experiments  in  feeding  animals 
with  the  expressed  juice  of  such  meat  gave  negative  results. 

Types  of  Bacilli. — Important  information  in  regard  to  the  source  of 
infection  is  obtained  from  a  study  of  the  type  of  organism  present  in  the 
different  varieties  of  tuberculosis.  Of  137  cases  of  tuberculosis  in  chil- 
dren investigated  by  Park  and  Krumwiede  in  the  Research  Laboratory 
of  the  New  York  Health  Department  the  following  results  were  ob- 
tained :  The  human  type  was  found  in  107  cases ;  of  w^hich  13  were  pul- 
monary; 29,  glandular;  2,  abdominal;  33,  meningeal;  16  in  bones  and 
joints;  1,  genito-urinary ;  and  13  were  generalised.  The  bovine  type 
was  found  in  30  cases;  of  which  none  were  pulmonary;  20,  glandular; 
5,  abdominal ;  1,  meningeal ;  none,  bones  and  joints  alone ;  4,  generalised. 

Paths  of  Infection  of  the  Tubercle  Bacillus. — ^Tubercle  bacilli  may 
gain  entrance  to  the  body  through  the  respiratory  or  the  alimentary 
tract  or  the  skin,  the  last,  however,  being  so  rare  that  it  needs  only  to 
be  mentioned.  In  infancy  and  early  childhood,  infection  I  believe  to  be 
most  frequent  through  the  respiratory  tract.  The  situation  of  the  pri- 
mary lesions  strongly  supports  this  view.  Bacilli  taken  in  with  the 
inspired  air  may  lodge  upon  the  adenoid  tissue  of  the  naso-pharynx  and 
enter  the  body  through  the  blood  or  the  lymph  stream.  Such  infection 
is  favoured  by  pathological  conditions  of  these  structures.  Bacilli  which 
pass  the  upper  respiratory  tract  may  not  be  arrested  until  the  smaller 
bronchi  are  reached.  Both  clinical  experience  and  animal  experiments 
indicate  that  the  bacilli  may  pass  through  a  mucous  membrane  without 
inducing  in  it  a  tuberculous  disease,  but  that  penetration  is  much  easier 
if  the  mucous  membrane  is  the  seat  of  a  catarrhal  inflammation,  or  if 
the  epithelium  has  been  injured.  The  bacilli  are  usually  taken  up  by 
the  lymphatics  from  the  surface  of  the  mucous  membrane  upon  which 
they  have  lodged,  and  are  carried  to  the  nearest  lymph  nodes,  where 
they  may  excite  a  tuberculous  inflammation,  but  where  they  may  be 
permanently  arrested.  The  great  majority  of  children  who  suffer  from 
tuberculosis  of  the  cervical  lymph  nodes  escape  general  tuberculous  in- 
fection. 

In  autopsies  both  upon  children  and  adults  dying  from  various  non- 
tuberculous  diseases  it  is  not  infrequent  to  find  tuberculosis  limited  to 
the  bronchial  lymph  nodes. 

Arriving  at  the  lymph  node,  the  bacilli  light  up  a  tuberculous  in- 
flammation of  varying  degrees  of  intensity,  depending  upon  their  number 
and  upon  local  conditions.     This  inflammation  may  pass  through  the 


1022  THE  SPECIFIC  INFECTIOUS  DISEASES. 

usual  changes  of  tuberculous  glands — congestion,  swelling,  cell  prolifera- 
tion, and  caseation ;  or  the  process  may  be  arrested  at  any  point,  and  the 
products  of  inflammation  become  encapsulated  by  a  proliferation  of 
fibrous  tissue,  in  which  condition  they  may  remain  latent  in  the  body 
for  an  indefinite  number  of  years — possibly  for  a  lifetime.  This  occurs 
in  many  children,  and  is  consistent  with  every  outward  sign  of  health; 
but  it  is  a  smouldering  ember  which  at  any  time  may  be  fanned  into 
flame  under  the  stimulus  of  an  inflammation  excited  by  some  other 
cause. 

In  infants  and  young  children  there  is  a  strong  tendency  for  the 
bacilli  to  lodge  first  in  the  bronchial  lymph  nodes,  probably  on  account 
of  the  favourable  conditions  for  entrance  existing  in  the  bronchi  and 
lungs.  In  those  who  are  delicate  and  have  but  little  resistance,  the 
process  in  the  lymph  nodes  is  likely  to  go  on  to  caseation  and  softening, 
and,  secondary  to  this  process  in  the  glands,  the  lung  may  become  in- 
fected. The  manner  of  the  extension  of  the  disease  to  the  lung  is  not 
always  easy  to  trace;  but  in  many  instances  it  has  been  shown  to  be  the 
result  of  the  softening  of  one  of  these  small  tuberculous  lymph  nodes, 
which  then  ulcerates  through  the  wall  of  one  of  the  small  bronchi  or  a 
blood-vessel,  in  this  way  distributing  its  bacilli  through  the  lung. 

Although  this  is  the  course  usually  taken  by  bacilli  when  they  are 
inhaled,  it  is  not  always  the  case.  Lesions  in  the  lungs  are  occasionally 
found  where  the  lymph  nodes  are  not  involved ;  and  there  are  other  cases 
in  which  advanced  changes  exist  in  the  lung,  while  only  the  earlier  ones 
are  seen  in  the  lymph  nodes.  In  these  cases,  which  perhaps  are  to  be 
considered  as  exceptional,  the  tuberculous  process  probably  begins  in 
the  walls  of  the  small  bronchi,  the  alveoli,  or  in  the  connective-tissue 
septa. 

For  bacilli  which  may  find  their  way  into  the  mouth  the  tonsils  may 
be  a  portal  of  entry.  Those  which  pass  to  the  stomach  rarely  cause 
lesions  of  the  gastric  mucous  membrane,  or  through  it  reach  the  lym- 
phatic circulation.  In  the  intestines,  however,  more  favourable  condi- 
tions exist.  It  is  possible  for  the  bacilli  to  reach  the  mesenteric  lymph 
nodes  without  causing  a  lesion  of  the  intestinal  mucous  membrane,  and 
experiments  upon  animals  have  shown  that  from  the  intestine  they  may 
even  reach  the  bronchial  lymph  nodes;  but  in  the  human  subject  I  be- 
lieve both  to  be  exceedingly  rare.  By  careful  search  I  have  seldom 
failed  to  find  intestinal  ulceration  when  the  mesenteric  lymph  nodes 
were  manifestly  tuberculous. 

Lesions. — In  the  following  table  are  given  the  lesions  found  in  255 
autopsies,  of  which  I  have  notes.  These  represent  the  lesions  of  infancy 
and  early  childhood,  seventy  per  cent  of  these  children  being  two  years 
old  or  under.  For  comparison  there  are  given  statistics  of  131  autopsies 
from  the  Pendlebury  Hospital,  Manchester,  England.     Few  of  the  chil- 


TUBERCULOSIS. 


1023 


dren  in  this  series  were  under  three  3^ears  old.  The  greater  frequency 
of  abdominal  tuberculosis,  especially  tuberculous  peritonitis,  will  be 
noted.  This  difference  obtains  in  nearly  all  the  English  statistics  of  the 
disease. 


Frequency  of  the  Different  Visceral  Lesions 

of  Tuberculosis. 

Organs. 

Personal  cases; 

255  autopsies  (chiefly  under 

three  years). 

Pendlebury  Hospital  Reports; 

131  autopsies  (chiefly  over 

three  years). 

Lungs 

235 

93 

208 

85 

178 

191 

88 

7 

110 

118 

22 

10 

1 

5 

4 

4 

92.1  per  cent 

36.5 

81.5 

33.3 

69.8 

74.9 

30.6 

2.7 
43.1 
52.4 

8.6 

3.9 

0.4 

1.9 

1.5 

1.5 

122 

100 

91 

60 

86 

76 

54 

1 

65 

77 

37 

4 

"2 

93.0  per  cent 
76.0        " 

Pleura 

Bronchial  lymph  nodes 

Brain 

Liver  

Spleen 

Kidneys 

70.0 
46.0 
65.0 
58.0 
41.0 

Stomach 

Intestines 

Mesenteric  lymph  nodes 

Peritonaeum 

Pericardium 

0.8 
50.0 
59.0 
28.0 

3.0 

Endocardium 

Thymus ...        ... 

Suprarenal  capsules 

Pancreas 

1.6  per  cent 

The  Varieties  of  Tuberculosis  seen  at  Different  Ages. — During  the 
first  two  years  of  life,  tuberculosis  most  frequently  involves  the  lungs 
and  bronchial  lymph  nodes.  It  is  the  meningeal  or  pulmonary  process 
which  most  often  is  the  cause  of  death.  Death  from  other  forms  of 
tuberculosis  is  rare  at  this  time  of  life.  Of  232  deaths  from  tuberculosis 
in  the  first  three  years  of  life,  meningitis  was  the  cause  in  93,  tuberculous 
peritonitis  in  only  one,  and  haemorrhage  from  a  tuberculous  ulcer  of  the 
intestine  in  one. 

After  the  second  year,  tuberculosis  of  the  bones,  cervical  and  mesen- 
teric lymph  nodes,  peritonaeum,  and  intestines  becomes  more  frequent, 
and  may  occur  as  the  principal  lesion,  although  at  autopsy  the  lungs 
are  usually  involved  to  some  degree. 

Pulmonary  Lesions. — As  compared  with  that  of  adults,  the  pulmo- 
nary tuberculosis  of  young  children  is  more  widely  diffused,  and  the  pre- 
dominance of  cases  in  which  the  lesion  is  in  the  upper  lobes  is  less 
marked,  though  it  still  exists.  In  those  who  have  passed  the  sixth  or 
seventh  year,  the  pathological  processes  resemble  those  of  adult  life.  Al- 
though localised  tuberculous  processes  are  frequently  met  with  in  pa- 
tients dying  from  other  diseases,  those  who  die  from  tuberculosis  usually 
show  wide-spread  lesions  of  the  lungs. 

1.  Miliary  Tuberculosis  of  the  Lungs. — In  nearly  every  case  of  pulmo- 
nary tuberculosis,  miliary  tubercles  are  found  in  some  part  of  the  lung, 
usually  upon  the  surface  and  in  the  vicinity  of  some  older  process.    Occa- 


1024  THE  SPECIFIC  INFECTIOUS  DISEASES. 

sionally,  they  are  distributed  throughout  nearly  tlie  whole  of  both  lungs. 
In  some  places  the  lung,  with  the  exception  of  these  numerous  gray 
granulations,  appears  quite  normal ;  in  others  it  is  congested,  and  shows 
between  the  tubercles  the  lesions  of  simple  broncho-pneumonia  in  its 
various  stages.  There  is  also  an  acute  bronchitis  of  the  middle-sized 
and  smaller  bronchi.  The  microscope  shows  that  tlie  tubercles  usually 
develop  in  the  walls  of  the  small  bronchi  or  the  blood-vessels.  In  their 
gross  appearance,  the  lungs  in  these  cases  resemble  those  in  ordinary 
acute  broncho-pneumonia,  with  the  exception  that  everywhere  upon  tlie 
surface  and  throughout  the  substance  of  the  lung  are  seen  the  small 
gray  granulations,  and  in  most  cases  some  small  yellow  tuberculous 
nodules.  The  pleura  is  usually  normal  except  for  the  presence  of  the 
tubercles.  This  form  of  the  disease  represents  the  rapid  dissemination 
of  tubercle  bacilli  throughout  the  lungs,  the  miliary  tubercles  being  the 
result  of  the  inflammation  excited  by  their  presence. 

2.  Tuberculous  Broncho-pneumonia. — This  is  the  most  frequent  and 
the  most  characteristic  form  of  tuberculosis  in  infants  and  young  chil- 
dren, and  it  is  the  one  which  at  this  age  usually  causes  death.  In  this 
form  of  the  disease  there  are  produced  in  the  lung  caseous  nodules,  or 
larger  caseous  areas,  some  of  which  have  usually  undergone  softening  by 
the  time  the  case  comes  to  autopsy.  The  process  generally  runs  a  some- 
what subacute  course.  With  the  lesions  mentioned  there  are  always 
associated  those  of  simple  broncho-pneumonia. 

The  pleura  is  involved  in  almost  every  case.  There  may  be  simply 
dense  connective-tissue  adhesions  which  bind  the  lung  firmly  to  the  chest 
wall,  the  diaphragm,  and  the  pericardium,  or  the  pleura  may  be  greatly 
thickened  and  contain  caseous  deposits.  Occasionally  empyema  is  seen, 
but  it  is  almost  always  sacculated  and  small. 

Both  lungs  are  usually  involved,  but  one  to  a  much  greater  degree 
than  the  other.  There  are  found  large  areas  of  consolidation  which  some- 
times involve  an  entire  lobe,  but  more  often  smaller  areas  are  seen  in  sev- 
eral lobes.  These  portions  of  the  lung  appear  much  firmer  and  harder  than 
in  ordinary  pneumonia.  The  upper  lobes  are  more  often  affected  than 
the  lower,  and  especially  that  part  of  the  lobe  which  is  near  the  root 
of  the  lung,  on  account  of  its  frequent  association  with  tuberculosis  of 
the  bronchial  glands;  the  disease  very  often  extends  forward  from  this 
point  to  the  middle  lobe  of  the  right,  or  the  corresponding  part  of  the 
left  lung.  On  section  the  affected  part  of  the  lung  usually  shows  many 
caseous  nodules  varying  in  size  from  a  pin's  head  to  a  walnut,  which 
are  of  a  pale  yellow  colour,  and  resemble  caseous  lymph  nodes.  They 
contain  giant  cells  and  are  usually  filled  with  bacilli,  those  which  have 
softened  containing  yellow  pus.  There  is  nearly  always  seen  in  some 
part  of  the  lung  a  large  caseous  area;  and  not  infrequently  there  may 
be  diffuse  caseation  of  almost  an  entire  lobe  (Figs.  202,  204).     Some- 


TUBERCULOSI.S. 


1025 


times  no  spot  of  softening  is  seen  even  in  these  large  areas,  but  in  many 
cavities  are  present. 

Softening  and  excavation  represent  tlie  final  stages  of  tlie  process 
in  tuberculous  pneumonia.  Softening  usually  begins  in  the  centre  of  a 
caseous  part,  often  at  several  points  at  the  same  time.  Areas  of  excava- 
tion large  enough  to  deserve  tlie  name  of  cavities  were  present  in  about 


Fig.  202. — Tuberculous  Pneumonia.  A 
vertical  section  through  the  middle  of  the 
right  lung  of  a  child  thirteen  months  old. 
The  greater  part  of  the  upper  lobe  is  uni- 
formly caseous  —  a  diffuse  tuberculous 
pneumonia;  near  the  centre  the  com- 
mencement of  a  cavity  is  seen;  below  it 
has  the  appearance  of  a  consolidation  from 
simple  pneumonia.  The  part  of  the  lower 
lobe  shown  is  normal. 


Fig.  203. — Cavity  from  Breaking  Down 
OF  Tuberculous  Pneumonia.  Another 
view  of  the  same  lung,  the  section  being 
made  very  near  the  posterior  border  of  the 
lung.  The  cavity  occupies  at  this  point 
nearly  the  whole  of  the  upper  lobe.  At 
autopsy  this  cavity  contained  numerous 
loose  caseous  masses,  the  largest  being  the 
size  of  a  marble.  The  lower  lobe  is  nor- 
mal.    (For  history,  see  Fig.  208.) 


half  of  my  autopsies  upon  tuberculous  patients,  two  years  old  and  under. 
They  vary  in  size  from  a  cherry  to  a  hen's  egg,  and  sometimes  a  much 
larger  one  is  seen  (Fig.  203).  They  are  usually  rather  deeply  seated, 
and  are  partially  or  entirely  filled  with  caseous  masses  or  pus,  but  very 
seldom  perforate  the  pleura,  causing  pneumothorax  or  pyopneumothorax. 
66 


1026  THE  SPECIFIC   INFECTIOUS  DISEASES. 

It  is  rare  in  a  young  child  to  find  cavities  surrounded  by  dense  fibrous 
walls  such  as  are  seen  in  older  children  or  in  adults ;  for  in  infancy  the 
process  of  softening  once  begun  usually  advances  steadily  until  the  death 
of  the  patient. 

The  bronchial  lymph  nodes  are  in  these  cases  invariably  found  to  be 
tuberculous,  and  not  only  those  at  the  root  of  the  lung,  but  if  a  dissection 


Fig.  204. — Pulmonary  Tuberculosis,  Extensive  Caseation  of  Left  Lung  and 
Bronchial  Glands.  History. — Coloured  child,  £i^  years  old;  signs  over  left  lung 
were  feeble  breathing  and  flatness,  suggesting  empyema;  twenty-three  examinations 
of  the  sputum  made  for  bacilli,  all  negative.  For  the  last  three  and  a  half  weeks, 
temperature  showed  a  regular  daily  range  from  100°  to  104°  F. 

Autopsy. — Almost  complete  caseation  of  left  lung;  no  spots  of  softening;  through- 
out right  lung  were  small  tuberculous  nodules  and  miliary  tubercles.  Bronchial  glands 
very. large  and  caserms,  but  none  broken  down;  those  affected  were  not  only  the  group 
at  the  root  of  the  lung  but  the  chain  following  the  main  bronchus  some  distance  into  the 
lung  itself. 

is  made,  a  chain  of  these  tuberculous  glands  will  be  found  to  follow  the 
larger  bronchi  for  some  distance  into  the  lung  (Fig.  204).  Sometimes 
one  may  be  discovered  which  has  softened  and  ulcerated  through  into  a 
small  bronchus. 

Microscopical  examination  of  these  cheesy  nodules  shows  that  they 
most  frequently  begin  as  tuberculous  deposits  in  the  walls  of  the  small 
bronchi,  either  in  the  mucous  membrane,  the  fibrous  coat,  or  the  lymphat- 
ics ;  sometimes,  however,  they  begin  in  the  walls  of  a  small  vein  or  artery. 
Cell  proliferation  takes  place,  separating  the  coats  of  the  bronchus  or 


TUBERCULOSIS.  1027 

blood-vessel,  and  partly  or  entirely  obstructing  its  lumen.  Softening 
may  take  place  and  the  contents  be  discharged  into  tlie  bronchus  or'ljlood- 
vessel.  About  this  focus  other  changes  of  an  intlammatory  character 
occur,  as  a  result  of  which  each  cheesy  nodule  is  surrounded  by  a  zone 
of  simple  broncho-pneumonia  which  tends,  in  a  measure  at  least,  to  limit 
the  tuberculous  process.  The  larger  caseous  areas  are  formed  by  an 
extension  of  this  process  to  the  zone  of  ])neumonia  which  surrounds  it; 
but  in  its  further  growth  it  is  still  preceded  by  a  simple  pneumonia. 
The  rapidity  with  which  the  lesions  advance  differs  much  in  the  different 
cases;  in  infants  the  progress  is  apt  to  be  continuous  until  the  death  of 
the  patient;  in  older  children  it  is  usually  slower,  and  interrupted  by 
intervals  of  arrest  and  even  of  partial  retrogression. 

Not  infrequently  one  sees  in  the  post-mortem  room  one  or  two  caseous, 
or  less  frequently  calcareous,  nodules  encapsulated  by  firm,  organised  con- 
nective tissue  when  a  most  careful  search  fails  to  sliow  any  other  tuber- 
culous lesion  in  the  lung.  If,  however,  the  nodules  are  widely  scattered 
through  the  lung,  such  an  arrest  of  the  process  is  not  to  be  expected. 

3.  Chronic  Pulmonary  Tuberculosis,  Chronic  Phthisis. — In  children 
who  have  passed  the  seventh  or  eighth  year  the  pathological  process  re- 
sembles that  seen  in  adults;  but  in  younger  children,  and  especially  in 
infants,  nothing  corresponding  to  it  is  met  with. 

At  this  period  the  nearest  approach  to  this  condition  is  seen  in  the 
cases  of  tuberculous  broncho-pneumonia,  which  run  a  slow,  irregular, 
and  somewhat  chronic  course.  The  essential  features  of  the  process  in 
these  patients  is  a  chronic  interstitial  broncho-pneumonia  with  tuber- 
culous nodules  which  rarely  undergo  softening,  but  usually  become  en- 
capsulated. 

The  gross  lesions  closely  resemble  those  of  simple  chronic  broncho- 
pneumonia. There  are  the  same  generalised  pleuritic  adhesions  and  the 
shrunken  cicatricial  condition  of  the  part  of  the  lung  most  affected,  with 
bronchiectasis,  compensatory  emphysema,  etc.  The  tuberculous  nodules 
are  old  and  for  the  most  part  converted  into  dense  fibrous  tissue,  in  the 
centre  of  which,  however,  some  softened,  caseous  areas  are  often  seen. 

Bronchial  Lymph  Nodes  {bronchial  glands). — The  prominence  of  the 
lesions  of  the  lymph  nodes  is  one  of  the  most  striking  features  of  tuber- 
culosis in  infancy  and  early  childhood.  Those  which  are  most  frequently 
affected  are  connected  with  the  bronchi.  The  lymph  nodes,  to  which  the 
term  "  bronchial  glands  "  is  generally  applied,  consist  of  three  groups : 
the  first  of  which  surrounds  the  trachea;  the  second  is  situated  at  the 
bifurcation  of  the  trachea  and  surrounds  the  primary  bronchi ;  while  the 
third  follows  the  course  of  the  bronchi  into  the  lung,  being  found,  ac- 
cording to  anatomists,  as  far  as  the  fourth  division.  The  anatomical 
relation  of  the  different  groups  should  be  borne  in  mind,  since  upon  them 
the  symptoms  principally  depend.     The  first  group,  or  the  peri-tracheal 


1028  THE  SPECIFIC   INFECTIOUS  DISEASES. 

lymph  nodes,  are  in  relation  with  the  superior  vena  cava,  the  pulmonary 
artery;  the  pneumogastric  and  recurrent  laryngeal  nerves;  the  second 
group,  at  the  bifurcation  of  the  trachea,  with  the  oesophagus,  pneumo- 
gastric nerve,  and  aorta ;  the  third  group,  with  the  bronchi  and  the 
branches  of  the  bronchial  and  pulmonary  arteries  and  veins. 

All  the  groups  are  usually  involved  at  the  same  time,  but  in  varying 
degrees,  and  in  most  cases  those  belonging  to  one  lung  to  a  greater  ex- 
tent than  the  other;  in  my  own  cases  those  of  the  right  side  have  much 
more  often  been  involved  than  those  of  the  left.  There  may  be  simply 
two  or  three  tumours  as  large  as  a  hazelnut,  or  there  may  be  a  mass  two 
or  three  inches  in  diameter,  which  is  made  up  of  ten  to  twenty  of  these 
nodes  fused  together  by  inflammatory  products,  completely  surrounding 
the  trachea  and  both  the  large  bronchi.  It  is  rare  that  the  individual 
glands  are  more  than  an  inch  in  diameter,  and  most  of  them  are  smaller 
than  this.  A  well-marked  but  not  unusual  example  of  this  condition  is 
shown  in  Plate  XIX.  There  is  usually  found  a  chain  of  these  tuber- 
culous glands  following  the  course  of  the  large  bronchi  for  some  distance 
into  the  lung;  sometimes  these  are  almost  as  large  as  the  external  group 
(Fig.  204)  ;  at  other  times  they  are  not  noticed  unless  a  somewhat  care- 
ful dissection  is  made.  The  process  is  not  infrequently  more  advanced 
in  these  deeply  seated  glands  than  in  those  situated  at  the  root  of  the 
lung;  and  lesions  here  are  also  more  important,  as  it  is  very  frequently 
through  them  that  the  lung  becomes  involved. 

The  pathological  changes  through  which  these  glands  pass  as  a  re- 
sult of  tuberculous  infection  are  very  similar  to  those  already  described 
with  reference  to  the  cervical  glands.  Suppuration  is  less  frequent  than 
in  the  region  of  the  neck,  while  calcific  degeneration  is  much  more  so. 
This  applies  especially  to  children  over  three  years  old.  In  infancy 
suppuration  is  not  infrequent  in  the  bronchial  glands,  while  at  this  age 
calcification  is  extremely  rare.  Although  the  process  has  gone  on  to 
caseation,  these  inflammatory  products  with  bacilli  may  become  encapsu- 
lated, and  may  remain  innocuous  for  an  indefinite  period.  The  bacilli 
may  die  or  may  exist  here,  living,  for  years.  At  any  time  the  old  process' 
may  be  lighted  up,  and  a  more  or  less  rapid  dissemination  of  tubercle 
bacilli  take  place  through  the  lungs  or  through  the  whole  body.  Latent 
tuberculosis  more  frequently  exists  in  the  bronchial  lymph  nodes  than 
in  any  other  structure  in  the  body. 

Secondary  lesions  may  be  produced  by  these  lymph  nodes.  The  pneu- 
mogastric and  recurrent  laryngeal  nerves  may  be  surrounded  by  one  of 
these  cheesy  masses  which  causes  pressure  and  irritation.  The  a'sophagus, 
the  trachea,  or  the  l)ronchi  may  be  compressed  or  opened  by  ulceration. 
The  superior  vena  cava  usually  suffers  only  compression,  but  this  or  any 
of  the  other  large  vessels  may  be  opened.  Ulceration  may  also  take  place 
into  one  of  the  large  or  small  bronchi  or  the  trachea.    If  the  gland  has 


PLATE    XIX. 


Tuberculosis  of  the  Tracheo-Bronchial  Lymph  Nodes. 

From  a  fairly  nourished  child,  four  months  old,  who  was  under  observation  for 
three  weeks,  with  slight  fever  and  a  most  severe,  teasing,  dry  cough,  which  was  almost 
constant,  and  upon  which  no  treatment  seemed  to  have  the  slightest  effect.  At  first 
there  were  no  signs  of  disease  in  the  lungs ;  later  there  were  a  few  coai-se  scattered 
rales. 

There  were  small  tuberculous  deposits  throughout  both  lungs,  with  quite  a  large 
area  of  cheesy  pneumonia  in  the  right  middle  lobe,  and  scattered  miliary  tubercles  in 
other  organs. 


TUBERCULOSIS.  1029 

softened  and  broken  down,  and  if  the  bronchus  is  a  small  one,  the  only 
result  of  this  may  be  a  rapid  spreading  of  tuberculous  infection  througli- 
out  the  lung.  If  sudden  rupture  occurs,  a  large  caseous  mass  may  escape 
into  the  trachea,  or  a  large  bronchus,  with  a  result  similar  to  that  pro- 
duced by  any  other  foreign  body.  If  suppuration  occurs,  the  abscess 
may  rupture  into  the  surrounding  cellular  tissue,  causing  mediastinal  or 
retro-oesophageal  abscess.  This  may  open  externally  at  the  suprasternal 
notch,  or  in  the  first  or  second  intercostal  space,  or  may  ulcerate  into  any 
of  the  large  vessels,  the  oesophagus,  or  the  pericardium. 

Pleura. — This  is  rarely  normal  in  any  case  of  tuberculosis.  In  acute 
general  tuberculosis  the  only  lesion  may -be  a  deposit  of  miliary  tubercles 
upon  the  visceral  pleura.  In  most  of  the  other  cases  there  are  found 
fibrous  adhesions  over  the  part  of  the  lung  involved,  binding  it  to  the 
pericardium,  the  diaphragm,  or  the  chest  wall.  The  amount  of  thicken- 
ing of  the  pleura  varies  a  good  deal,  but  is  rarely  great.  Pleurisy  with 
a  serous  effusion  is  not  common  in  infants  or  young  children;  when  it 
occurs  it  is  apt  to  be  sacculated.  Hsemorrhagic  exudation  is  very  rare 
at  this  age.  Empyema  is  also  rare,  being  seen  in  but  five  per  cent  of 
my  cases,  and  then  it  was  small  and  sacculated.  Pneumothorax  and 
pyopneumothorax  are  very  rare  in  children  under  three  years  of  age. 

Heart. — It  is  exceptional  for  the  pericardium  to  be  affected  even  in 
the  most  generalised  forms  of  acute  miliary  tuberculosis.  In  such  cases 
the  usual  lesion  is  a  deposit  of  a  few  gray  tubercles  upon  the  visceral 
surface.  In  chronic  cases  other  lesions  analogous  to  those  of  the  pleura 
may  be  seen,  but  all  are  rare  in  childhood.  In  rare  instances  miliary 
tubercles  are  seen  upon  the  endocardium. 

Brain. — Tuberculosis  of  the  brain  is  very  common  during  infancy, 
being  then  associated  in  nearly  all  cases  with  general  tuberculosis.  Mili- 
ary tubercles  are  occasionally  found  in  small  numbers  in  cases  which  have 
presented  no  symptoms.  The  lesions  of  tuberculous  meningitis  have  al- 
ready been  described.  Cheesy  nodules  are  rare  in  infancy,  being  noted 
in  but  2.5  per  cent  of  my  own  autopsies,  which  were  mainly  on  children 
under  three  years  old ;  while  in  the  Pendlebury  Hospital  cases,  including 
those  between  four  and  twelve  years  old,  they  were  noted  in  24.4  per  cent. 
These  nodules  vary  in  size  from  a  pea  to  a  hen's  egg;  they  are  usually 
associated  with  tuberculous  meningitis,  but  they  may  exist  alone.  Wlien 
they  are  large  they  rank  as  cerebral  tumours,  being  most  frequently  seen 
in  the  cerebellum. 

Liver. — This  is  frequently  involved  in  general  tuberculosis,  although 
it  is  doubtful  if  it  is  ever  the  seat  of  primary  infection  except  in  the  con- 
genital cases.  Usually  the  only  lesion  is  the  presence  of  miliary  tubercles 
on  its  surface  and  in  its  substance,  and  in  most  cases  these  are  not  nu- 
merous. They  are  found  in  about  two-thirds  of  the  cases.  In  a  smaller 
number  there  are  tuberculous  nodules  of  various  sizes,  especially  about 


1030  THE  SPECIFIC  INFECTIOUS  DISEASES. 

the  biliary  ducts.  In  nearly  every  protracted  case  the  liver  is  markedly 
fatty.  In  very  late  cases  of  tuberculosis  of  the  bones,  it  is  frequently  the 
seat  of  amyloid  degeneration. 

Spleen. — This  is  more  frequently  affected  than  the  liver,  but  the 
lesions  are  similar.  Tlie  size  of  the  spleen  is  not  much  increased  if  only 
miliary  tubercles  are  present;  but  with  tuberculous  nodules  it  may  be 
greatly  enlarged.  Amyloid  degeneration  is  found  under  the  same  condi- 
tions as  in  the  liver. 

Stomach. — Tuberculosis  of  the  stomach  is  one  of  the  rare  lesions; 
both  its  contents  and  its  acid  reaction  seem  to  protect  it  against  direct 
infection  from  the  mouth.  Tuberculous  ulcers  were  seen  in  five  of  my 
autopsies,  which  is  a  larger  proportion  than  is  usually  noted. 

Intestines. — That  these  are  less  seriously  affected  in  infancy  than  in 
older  children  is  rather  surprising  when  we  consider  how  susceptible  are 
the  intestines  of  infants  to  other  forms  of  infection.  The  explanation 
of  this  difference  seems  to  be  that  intestinal  infection  is  usually  sec- 
ondary to  disease  of  the  lungs,  primary  lesions  being  relatively  rare.  In- 
fants die  from  the  more  rapid  tuberculous  processes  in  the  lungs  or  brain 
before  there  has  been  time  or  opportunity  for  secondary  intestinal  lesions 
of  importance  to  occur.  The  intestinal  lesions  and  those  of  the  mesen- 
teric lymph  nodes  with  which  they  are  almost  invariably  associated,  are 
described  elsewhere. 

PentoncBum. — In  early  infancy  the  peritonaeum  is  not  often  involved 
even  in  general  tuberculosis,  and  at  this  age  it  is  very  rare  for  it  to  be  the 
seat  of  the  principal  tuberculous  process.  In  older  children  it  is  more 
frequent.  In  most  cases  of  general  tuberculosis  there  are  only  deposits 
of  miliary  tubercles;  less  frequently  there  are  tuberculous  nodules  with 
other  inflammatory  products.  The  lesions  in  these  cases  are  described 
with  Diseases  of  the  Peritonaeum. 

Thymus  Gland. — In  five  of  my  cases  tuberculous  nodules  were  found 
in  the  thymus  gland,  the  size  varying  from  a  small  pea  to  a  hazelnut.  All 
these  were  cases  showing  widely  disseminated  tuberculous  lesions. 

Pancreas. — In  four  of  ray  cases  this  organ  also  was  the  seat  of  small 
tuberculous  nodules,  all  of  them  being  cases  of  general  tuberculosis. 

Uro-genital  Organs. — Serious  tuberculosis  of  any  part  of  the  urinary 
tract  is  very  rare  in  children.  Miliary  tubercles  were  found  in  the  kid- 
neys in  about  one-third  of  my  autopsies  on  tuberculous  patients.  They 
are  generally  few  in  number.  Large  tuberculous  nodules  of  the  kidney 
I  have  seen  but  once  in  a  young  child.  They  are  very  rare  before  the 
fourteenth  year.  In  four  of  my  autopsies  tuberculous  nodules  were 
found  in  the  suprarenal  capsules.  Tuberculosis  of  the  testicle  has  been 
observed  in  rare  instances  among  children. 

Tuberculosis  of  the  bones  and  of  the  external  lymph  nodes  has  al- 
ready b^n  described. 


TUBERCULOSIS.  1031 

THE   CLINICAL  FORMS  OF  TUBERCULOSIS. 

I.  General  Tuberculosis. — Cases  of  tuberculosis  present  a  wide  variety 
in  their  symptomatology,  depending  upon  the  seat  of  infection,  the 
rapidity  with  which  the  bacilli  are  disseminated  through  the  body,  or 
the  numbers  in  which  they  enter.  The  general  symptoms  often  precede 
the  local  ones,  but  are  not  recognised  as  those  of  tuberculosis.  Often  it 
is  not  suspected  until  the  process  is  quite  well  advanced  in  some  one 
organ. 

In  Infants. — The  early  symptoms  in  infancy  are  often  only  those  of 
failing  nutrition.  The  patients  are  pale,  thin,  do  not  gain  in  weight 
no  matter  how  fed,  and  finally  lose  steadily  without  sufficient  reason. 
There  may  be  no  cough  or  fever  sufficient  to  attract  attention,  and  the 
case  may  even  go  on  to  a  fatal  termination  without  anything  else  than 
simple  marasmus  having  been  suspected,  tuberculosis  being  first  recog- 
nised at  the  autopsy. 

More  frequently,  however,  there  are  developed  toward  the  end  of  the 
illness  both  the  symptoms  and  signs  of  pulmonary  disease  and  fever. 
These  are  generally  found  together,  as  the  process  in  the  lungs  is  usually 
the  cause  of  the  rise  of  temperature.  The  feljrile  symptoms  are  often 
not  seen  until  the  last  two  or  three  weeks  of  life.  The  course  of  the 
temperature  is  irregular.  It  is  never  of  the  hectic  type  and  rarely  high. 
The  usual  range  is  between  100°  and  102°  F.  The  pulmonary  symp- 
toms are  generally  few  and  not  very  well  marked.  There  is  some  cough, 
but  it  is  rarely  severe.  The  breathing  is  more  rapid  than  would  be  ex- 
plained by  the  temperature  alone.  Severe  dyspnoea  and  cyanosis  are 
rare,  and  are  seen  only  at  the  close  of  the  disease.  The  physical  signs 
are  those  of  either  localised  or  general  bronchitis.  Digestive  symptoms 
are  usually  present  late  in  the  disease,  but  they  are  rarely  due  to  a 
tuberculous  lesion  of  the  stomach  or  intestines. 

The  progress  of  the  case  after  constitutional  symptoms  develop  is 
usually  steadily  downward,  and  the  child  lives  but  a  few  weeks  at  most. 
Death  generally  occurs  from  progressive  asthenia  without  the  develop- 
ment of  any  new  symptoms,  or  cerebral  symptoms  rapidly  develop,  and 
the  child  is  carried  off  in  a  few  days  by  tuberculous  meningitis.  Some- 
times there  is  a  rapid  spreading  of  the  disease  in  the  lungs,  and  death 
occurs  with  symptoms  of  acute  pneumonia. 

General  tuberculosis  in  infants  is  to  be  differentiated  principally 
from  marasmus  with  bronchitis;  less  frequently  it  may  be  confounded 
with  hereditary  syphilis. 

In  Older  Children. — The  development  of  active  general  tubercu- 
losis in  older  children  is  usually  preceded  by  a  protracted  period  of 
indefinite  symptoms.  They  are  persistently  anajmic  without  evident 
reason;  they  lose  weight;  digestion  is  disturbed;  the  appetite  is  capri- 


1032  THE  SPECIFIC  INFECTIOUS   DISEASES. 

cious;  they  sleep  badly;  they  are  irritable,  fretful,  and  easily  fatigued. 
These  symptoms  indicate  only  a  gradual  decline  in  general  health,  and 
may  readily  be  explained  by  many  other  causes  than  tuberculosis.  They 
should,  however,  excite  a  suspicion  of  tuberculosis  in  a  child  who  by 
surroundings  or  inheritance  is  predisposed  to  that  disease. 

After  these  indefinite  symptoms  have  lasted  for  a  few  weeks  fever  is 
added.  Sometimes  the  prodromal  symptoms  are  absent  or  unnoticed, 
and  fever  is  the  first  evident  symptom.  From  the  beginning  of  fever 
some  cases  progress  rapidly  to  a  fatal  termination  in  two  or  three  weeks. 
In  the  majority,  however,  the  disease  runs  a  slower  course.  The  fever 
often  exists  without  evident  cause  and  witiiout  any  local  manifestations 
of  disease.  The  temperature  is  not  often  high,  but  it  is  continuous.  The 
tympanites  and  the  rose-coloured  spots  are  not  present,  but  the  general 
aspect  of  the  patient  is  strikingly  suggestive  of  typhoid  fever.  But  the 
course  of  the  temperature  and  the  duration  of  the  illness  show  that  we 
have  to  deal  with  some  other  condition. 

After  the  fever  has  lasted  from  one  to  three  weeks  there  develop  some 
signs  of  localised  tuberculosis,  generally  in  the  lungs,  or  the  fever  may 
decline  gradually,  and  although  the  patient  improves  he  does  not  get 
well.  He  is  still  weak  and  does  not  gain  in  weight,  and  the  thermometer 
shows  the  existence  of  a  very  slight  amount  of  fever.  Before  long  he 
may  grow  rapidly  worse  and  the  course  of  the  temperature  becomes  ir- 
regular, with  alternate  exacerbations  and  remissions.  Such  an  irregular 
and  inexplicable  fever  sometimes  puzzles  the  physician  for  three  or  four 
weeks  before  the  characteristic  features  which  stamp  the  process  as  tuber- 
culous are  present.  Before  very  long  wasting  is  added  to  the  fever.  This 
may  not  be  rapid,  but  is  progressive.  The  tuberculous  cachexia  is  fre- 
quently unmistakable ;  but  in  most  of  the  cases  one  must  wait  for  the 
process  to  advance  far  enough  in  some  one  of  the  organs  to  give  local 
signs  or  symptoms  before  he  can  be  sure  of  tuberculosis.  In  four 
cases  out  of  five  this  is  in  the  lungs,  and  frequently  repeated  examinations 
of  the  sputum  may  reveal  the  bacilli.  Less  often  it  is  in  the  peri- 
tonaeum, the  brain,  or  a  general  infection  of  the  lymph  glands  throughout 
the  body.  If  in  the  lungs,  the  process  manifests  itself  as  a  broncho-pneu- 
monia whose  tuberculous  character  may  sometimes  be  suspected  from 
its  location — the  apex  or  the  middle  of  the  lung  in  front — but  chiefly 
from  the  fact  that  the  general  symptoms,  fever  and  wasting,  have  so  long 
preceded  the  local  signs.  From  this  time,  the  course  may  be  that  of  a 
typical  tuberculous  broncho-pneumonia. 

If  the  tuberculous  process  is  localised  in  the  brain,  there  may  be  vom- 
iting, headache,  drowsiness,  irregular  pulse,  irregular  respiration,  and 
finally  convulsions  and  coma — in  short,  the  symptoms  of  tuberculous 
meningitis;  if  in  the  peritonaeum,  there  are  abdominal  distention  from 
gas  or  fluid,  tenderness,  pain,  diarrhoea,  or  constipation ;  if  in  the  lymph 


TUBERCULOSIS. 


1033 


glands,  there  is  a  general  enlargement  of  those  situated  externally,  some- 
times with  symptoms  indicating  similar  changes  in  those  at  the  root  of 
the  lung. 

II.  Pulmonary  Tuberculosis. — Tuberculosis  of  the  lungs  in  children 
may  be  seen  in  a  variety  of  clinical  forms  which  correspond  with  the 
different  pathological  conditions.  The  pathological  conditions  are  often 
associated,  yet  the  main  clinical  types  are  sufficiently  distinct  to  give 
quite  a  definite  picture.  These  types  are:  (1)  miliary  tuberculosis  of 
the  lungs;  (2)  bronchitis  with  small,  scattered,  tuberculous  nodules;  (3) 
tuberculous  broncho-pneumonia  with  areas  of  consolidation,  often  ex- 
tensive, which  may  be  followed  by  caseation  and  excavation,  or  by  chronic 
fibrous  induration. 

Miliary  Tuberculosis  of  the  Lungs. — This  is  not  a  common  form 
of  pulmonary  tuberculosis,  but  may  be  met  with  even  in  young  infants. 


Fig.  2U5. — Miliary  Tuberculosis  of  the  Lungs.  Infant  fourteen  months  old;  symp- 
toms of  marasmus;  no  elevation  of  temperature;  tuberculides  of  the  skin;  positive 
von  Pirquet  reaction;  no  pulmonary  signs  or  symptoms.  The  radiograph  shows 
great  numbers  of  small  tuberculous  deposits  scattered  through  both  lungs. 


Both  the  general  and  pulmonary  symptoms  and  the  physical  signs  are 
rather  obscure  and  indefinite,  and  often  the  diagnosis  is  not  made.  Oc- 
casionally the  only  symptoms  are  those  of  marasnms,  neither  fever  nor 
physical  signs  in  the  chest  being  present  (Fig.  205).  As  I  have  seen 
it  in  young  children,  it  has  seldom  been  attended  by  high  teinperature. 


1034  THE  SPECIFIC   INFECTIOUS  DISEASES. 

101°  to  103°  F.  being  the  usual  range.  Throughout  the  greater  part  of 
the  disease  it  is  often  lower  than  this,  and  toward  tlie  close  perhaps  rather 
higher.  It  is  not  a  hectic  type  of  fever,  and  it  seldom  touches  the  normal 
line. 

The  duration  of  the  disease  in  these  cases,  after  fairly  definite  symp- 
toms begin,  varies  from  ten  days  to  a  month.  At  first,  and  often  for 
two  or  three  weeks,  the  temperature  is  almost  the  only  symptom.  Cough 
is  slight,  inconstant,  and  seldom  loose.  There  is  no  sputum.  The  respi- 
rations are  only  moderately  accelerated,  in  many  cases  not  enough  to 
draw  attention  to  the  lungs  as  the  seat  of  disease.  There  is  no  rapid 
wasting,  the  loss  in  weight  being  usually  not  more  than  would  be  ex- 
pected with  any  other  febrile  disease.  None  of  the  other  symptoms  sug- 
gest tuberculosis.  The  usual  problem  in  diagnosis  is  to  discover  the 
cause  of  the  fever.  Often  the  most  careful  examinations  of  the  chest 
made  daily  reveal  nothing  more  than  a  few  scattered  rales.  These  change 
in  position  from  time  to  time,  and  it  frequently  happens  tliat  for  days 
none  are  heard.  After  the  disease  has  progressed  somewhat  further,  the 
liver  and  spleen  are  generally  enlarged.  Cerebral  symptoms  may  de- 
velop, and  the  case  terminate  as  tuberculous  meningitis,  but  more  often 
it  is  the  pulmonary  symptoms  which  are  dominant.  The  respirations 
become  more  rapid;  the  cough  is  frequent,  but  rarely  loose;  there  may 
be  attacks  of  cyanosis.  Still  the  only  definite  signs  are  the  rales,  now 
fine  and  moist,  and  diffused  generally  over  the  chest.  The  case  usually 
ends  in  death  by  exhaustion,  but  without  rapid  or  marked  wasting.  One 
of  the  most  striking  things  in  the  clinical  picture  is  the  disproportion 
between  the  severity  of  tlie  general  and  pulmonary  symptoms  and  the 
few  physical  signs  in  the  chest. 

Tuberculous  Bkonchitis. — This  is  not  an  infrequent  condition 
even  in  infancy.  In  many,  perhaps  in  most,  cases  it  marks  the  earliest 
clinical  stage  of  a  tuberculous  broncho-pneumonia,  but  this  is  not  always 
true.  The  condition  seems,  therefore,  of  sufficient  importance  to  require, 
separate  consideration.  Besides  bronchitis,  there  are  found  at  autopsy  a 
few  small  tuberculous  nodules,  and  tuberculosis  of  the  bronchial  glands, 
although  these  may  give  neither  signs  nor  symptoms  during  life.  The 
symptoms  of  this  condition  are  few  and  not  distinctive,  and  may  differ 
in  no  respect  from  bronchitis  due  to  other  causes.  Tuberculosis  may  not 
even  be  suspected  until  the  lesion  has  so  far  developed  as  to  be  classed 
as  tuberculous  broncho-pneumonia.  Cough  is  present,  but  has  nothing 
characteristic  about  it  except  its  persistence.  Fever  may  be  absent  for 
a  long  time,  but  comes  as  the  disease  advances.  Then  it  is  low  and 
very  irregular,  the  temperature  generally  varying  from  99°  to  101.5°  F. 
There  may  be  slow  but  progressive  loss  in  weight,  or  the  infant  may 
gain  regularly  for  a  number  of  weeks  in  spite  of  the  cough.  This  fact 
often  leads  to  a  mistake  in  diagnosis.    The  nutrition  is  influenced  much 


TUBERCULOSIS.  1035 

more  by  the  condition  of  the  digestive  organs  than  })y  the  tuberculous 
process.  Other  symptoms  generally  regarded  as  l)elonging  to  early  tu- 
berculosis, such  as  pallor,  anaemia,  perspiration,  etc.,  are  usually  absent. 
The  physical  signs  are  few  and  not  cliaracteristic.  Scattered  rales,  some- 
times coarse  and  sometimes  finer,  but  inconstant,  are  all  the  signs  that 
are  present  for  a  long  time,  often  several  weeks. 

Cases  like  these  are  recognised  as  tuberculous  only  by  finding 
bacilli  in  the  sputum  or  by  one  of  the  tuberculin  testa.  It  has  been  my 
custom  to  consider  as  probably  tuberculous  every  infant  wlio  h^s  been 
for  any  length  of  time  in  contact  with  a  tuberculous  parent  or  other 
member  of  a  household.  Regarding  all  sucli  infants  as  suspicious  has 
led  me  in  hospital  practice  to  search  the  sputum  carefully  for  bacilli, 
with  the  result  of  finding  them,  sometimes  in  great  numbers,  in  infants 
whose  only  outward  symptom  was  a  moderate  cough,  and  who  were 
admitted  to  the  hospital  for  some  other  reason.  At  other  times  the  condi- 
tion has  been  unexpectedly  discovered  by  making  routine  eye  or  skin  tests 
in  hospital  inmates  with  tuberculin.  A  typical  reaction  having  been  ob- 
tained in  a  child  not  hitherto  suspected,  the  diagnosis  of  tuberculosis 
has  been  subsequently  confirmed  by  finding  bacilli  in  the  sputum, 
although  the  only  signs  in  the  chest  were  a  few  indefinite  rales  and  the 
only  outward  symptom  a  moderate  cough.  How  many  infants  there  are 
with  such  a  form  of  tuberculosis  and  how  long  such  a  condition  may  con- 
tinue without  more  definite  signs  developing,  one  can  only  conjecture; 
but  the  number  of  such  cases  is,  I  am  convinced,  not  small.  They  form  a 
very  distinct  but  important  group  of  tuberculous  cases.  The  regularity 
with  which  bacilli  are  present  in  the  sputum,  indicates  what  a  factor 
they  may  be  in  spreading  the  disease.  How  many  recover  and  in  how 
many  the  disease  goes  on  to  the  development  of  more  serious  lesions  it  is 
impossible  to  say. 

Tuberculous  Broncho-pneumonia. — This  is  altogether  the  most 
frequent  form  of  tuberculosis  seen  in  young  children.  It  may  be  primary 
in  the  lungs  or  it  may  be  secondary  to  tuberculosis  elsewhere,  most  fre- 
quently in  the  bronchial  glands.  It  may  be  preceded  by  constitutional 
symptoms  such  as  those  described  under  the  head  of  general  tuberculosis. 
It  may  follow  single  or  repeated  attacks  of  what  was  apparently  a  simple 
acute  bronchitis  or  broncho-pneumonia,  whether  it  occurred  as  a  primary 
disease  or  was  in  turn  a  sequel  to  one  of  the  infectious  diseases,  especially 
measles,  whooping-cough,  or  influenza. 

Tuberculous  broncho-pneumonia,  as  a  rule,  begins  more  gradually, 
and  its  course  is  less  rapid  than  simple  broncho-pneumonia,  its  progress 
being  generally  marked  by  weeks.  When  primary  it  is  often  preceded 
by  symptoms  described  as  tuberculous  bronchitis.  When  it  follows  one 
of  the  infectious  diseases  it  is  usually  engrafted  upon  the  original  dis- 
ease without  any  intervening  symptoms.    The  early  symptoms  are  cough. 


1036  THE  SPECIFIC   INFECTIOUS   DISEASES. 

rapid  respiration,  fever,  progressive  weakness,  and  anaemia.  The  weight 
may  be  at  first  stationary,  but  soon  there  is  steady  loss,  wliich  may  con- 
tinue until  there  is  marked  emaciation.  At  first  the  usual  range  of  tem- 
perature is  from  100°  to  102°  F. ;  later  it  is  rather  higher  than  this. 
In  many  of  the  cases  it  differs  little  from  the  temperature  of  simple 
broncho-pneumonia.  Sometimes  the  general  symptoms  are  severe  and 
the  physical  signs  wide-spread,  and  yet  the  range  of  temperature  is  not 
high.  To  be  sure,  this  is  occasionally  seen  in  simple  broncho-pneumonia, 
but  it  is  more  frequent  in  tuberculosis.  The  cough  early  in  the  disease 
is  slight,  but  later  becomes  severe  and  often  distressing.  In  infants  and 
young  children  it  may  be  of  a  paroxysmal  character,  resembling  pertussis. 
Expectoration  is  not  often  seen  in  those  under  five  years  old.  Bloody 
expectoration  is  very  rare  in  children. 

The  conditions  in  the  lungs  which  give  physical  signs  are  bronchitis 
of  the  smaller  tubes  with  areas  of  complete  or  partial  consolidation.  In 
character,  these  signs  are  identical  with  those  of  simple  broncho-pneu- 
monia. They  may  be  scattered  throughout  the  whole  of  both  lungs; 
but  when  localised  they  are  more  frequently  in  the  upper  than  in  the 
lower  lobes,  and  more  frequently  in  front  tlian  behind.  Although  both 
lungs  are  involved,  they  are  usually  not  affected  to  the  same  degree.  The 
patient  may  die  before  signs  of  complete  consolidation  are  present ;  more 
often  there  are  during  the  last  few  days  areas  of  consolidation,  as  shown 
by  bronchial  breathing  and  voice  and  dulness.  In  some  cases  although 
wide-spread  lesions  are  found  at  autopsy  the  physical  signs  during  life 
are  few  and  indefinite;  sometimes  there  may  be  almost  none.  (See  Fig. 
205.) 

From  the  beginning  of  acute  symptoms  the  progress  of  the  disease  is 
steadily  downward,  death  occurring  as  in  simple  broncho-pneumonia. 
The  end  is  marked  by  cyanosis,  great  dyspnoea,  weak  pulse,  and  extreme 
prostration.  In  a  few  cases  there  develop  shortly  before  death  cerebral 
symptoms,  indicating  tuberculous  disease  of  the  brain.  Such  symptoms 
may  be  the  first  to  lead  the  physician  to  suspect  the  process  to  be  a 
tuberculous  one.  But  even  this  is  not  conclusive,  for  one  may  be  deal- 
ing with  an  acute  meningitis  due  to  the  pneumocoecus.  Lumbar  punc- 
ture will  decide. 

In  the  more  protracted  eases  there  are  foiind  in  the  lungs  caseous 
nodules,  with  larger  areas  of  caseous  pneumonia,  and  usually  some  areas 
of  softening.  The  process  is  not  usually  so  generalised  ■  as  in  the  cases 
just  described,  but  as  in  them  there  is  always  associated  a  certain  amount 
of  simple  pneumonia.  The  pathological  process  may  terminate  (1)  in 
diffuse  caseation,  or  (2)  in  localised  caseation  and  excavation,  or  (3) 
in  partial  resolution  and  the  development  of  a  chronic  fibroid  pneu- 
monia. In  the  first  two  varieties  the  progress  is  as  a  rule  steadily  down- 
ward to  a  fatal  termination,  wliich  takes  place  in  from  one  to  three 


TUBERCULOSIS. 


1037 


months.     In  the  third  form^  wJiich  is  described  later,  there  is  partial 
recovery. 

The  mode  of  onset  will  depend  upon  the  conditions  under  which  the 
disease  develops.  When  the  general  symptoms  of  tuberculosis  have  pre- 
ceded those  in  the  lungs,  the  evolution  of  the  latter  is  gradual,  with 
cough,  rapid  breathing,  dyspnrea,  increased  prostration,  etc.  When  the 
pulmonary  symptoms  are  present  from  the  beginning,  they  are  the  same 
as  in  simple  broncho-pneumonia,  with  the  exception  that  they  usually 
come  on  less  acutely.  The  latter  is  true  of  cases  which  are  secondary  to 
some  other  form  of  tuberculosis  in  the  bones,  peritonaeum,  etc. 


CAY 

1 

2 

3 

4 

5 

0 

7 

8 

9 

10 

11 

12 

13 

14     15 

10  [17 

18 

19    20 

21    22 

23 

24 

25 

26 

27 

28 

20 

30 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 

M  E 

M  E 

M  E 

M  E 

ME 

ME 

ME 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  e 

M  E   M  E 

M  E 

HEME 

ME 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

A 

A 

" 

vl 

1 

1 

L 

K 

t 

\ 

A 

A 

N 

I 

/ 

y' 

/ 

hJ 

\/\/\-r 

Al 

IT 

A 

1 

V. 

V 

A 

^ 

n 

y 

1     / 

V 

/^ 

\    1 

/ 

1 

\ 

V 

\ 

A 

'y 

^ 

/ 

vW  j 

1 

\    V- 

w 

i/ 

\ 

\/ 

\ 

/ 

\ 

/ 

1    1 

yj  wi 

/ 

V 

\ 

V 

/ 

v| 

\ 

1 

1 

1    ! 

V 

/ 

DAY 

31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 

43 

44 

* 

70 

71 

72 

73 

74 

75 

7C 

77 

78 

79 

80 

81 

82 

83 

84 

100° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 

M  E 

ME 

ME 

ME 

M  E 

ME 

M  E 

ME 

ME 

ME 

ME 

M  E 

ME 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  L 

M  E 

M  E 

M  E 

M  E 

M  E 

* 

* 

A, 

/ 

^ 

A.n 

1       t 

* 

/ 

/\ 

f 

r 

1 

t 

\ 

/ 

A/ 

rJ 

V 

\j 

•^ 

r 

/) 

\/ 

v 

A 

« 

1 

/ 

\ 

/ 

V 

1 

V 

\ 

I 

1 

* 

V 

V 

V 

V 

A 

r^ 

y 

\l\ 

\/^ 

J 

V 

/ 

\ 

V. 

J 

T 

'  n 

♦ 

V 

^ 

Fig.  206. — TuBERCtrLOSis  Following  Measles.  Child  sixteen  months  old,  inmate  of 
an  institution.  Chart  begins  on  fifth  day  of  a  severe,  but  uncomplicated  attack 
of  measles,  and  shows  a  natural  decline  to  normal.  Fever  then  returned  and  con- 
tinued till  death,  twelve  weeks  later.  Record  for  the  period  which  is  omitted  was 
much  like  that  which  immediately  precedes  and  follows.  Early  symptoms  not  acute, 
only  slow  wasting,  slight  cough  and  fever,  with  scattered  rales  throughout  chest. 
Signs  of  consolidation  not  distinct  till  eighth  week,  then  present  in  right  upper  lobe. 
Toward  the  end,  rapid  emaciation,  marked  pulmonary  symptoms,  and  signs  of  cavity 
at  right  apex.  ■  Autopsy  showed  a  large  cavity,  extensive  tuberculous  deposits 
throughout  both  lungs  and  in  nearly  all  abdominal  organs. 


When  pulmonary  tuberculosis  follows  measles  (Fig.  206)  or  whoop- 
ing-cough which  has  been  complicated  by  simple  pneumonia,  the  early 
symptoms  may  present  no  unusual  features.  After  two  or  three  weeks 
the  temperature  gradually  falls,  and  the  physical  signs  improve,  but 
neither  quite  disappears.  The  cough  continues,  though  its  severity  some- 
what abates.    In  the  course  of  a  few  weeks  the  child,  who  has  meanwhile 


1038 


THE  SPECIFIC   INFECTIOUS   DISEASES. 


improved  somewhat  in  his  general  condition,  becomes  distinctly  worse, 
often  without  any  assignable  cause.  The  temperature  rises  to  102°  or 
103°  F. ;  the  cough  increases,  and  an  extension  of  the  disease  in  the 
lungs  is  evident  by  the  physical  signs.  In  other  cases  the  progress  of 
the  disease,  after  a  pneumonia  which  complicates  measles,  is  with- 
out an  intervening  period  of  apparent  improvement.  It  sometimes  hap- 
pens that  the  attack  of  measles  or  whooping-cough  is  not  accompanied 
by  any  serious  pulmonary  symptoms,  and  the  case  goes  on  to  apparent 
recovery,  except  that  there  remain  anaemia,  a  slight  cough,  and  fever. 
The  temperature,  although  not  high,  persists ;  but  it  may  be  two  or  three 
weeks  before  there  are  present  definite  symptoms  and  signs  of  disease  in 
the  lungs. 

Fever  is  a  constant  accompaniment  of  all  active  tuberculous  processes 
in  the  lungs  in  the  child  as  in  the  adult,  it  being  absent  only  during  the 
periods  of  remission  which  occur  in  the  cases  of  slow  and  irregular  prog- 
ress. It  is  a  very  important  guide  to  the  progress  of  the  disease.  The 
early  fever  may  depend  in  part  upon  coexisting  broncho-pneumonia, 
and  its  course  may  resemble  that  of  simple  pneumonia  of  the  protracted 
variety.  There  is  no  typical  curve.  The  fever  is  not  often  steadily  high, 
and  in  many  cases  it  is  never  high  (Fig.  207).     It  frequently  runs  for 


DAY 

1 

2 

3 

4 

s 

G    7 

8 

9 

10 

11 

12 

13 

14 

z 

16 

IjjlS 

19 

20 

21 

22 

23 

24  25 

2fl'27|28j2ll'»i  :;,   .-   >;  ->a  x,  ",.  :j:  :l-   Jv  :      ^'    ;;  ;  '   t4  vJ.Vi 

il 

1(10° 
!(» 
104° 

"• 

"' 

" 

•• 

•■ 

•■ 

"• 

"• 

•• 

•« 

" 

•  I 

•• 

•« 

'• 

•' 

•••• 

r« 

•• 

•• 

•• 

•• 

•■ 

•■ 

" 

" 

•' 

" ........-..•.■>■-.-.■-->■' 

"' 

•' 

. 

|\ 

102° 
101° 
100° 
99 
98 

1 

, 

J 

/ 

V 

V 

\ 

1 

^l 

^ 

A 

A 

/\ 

/ 

V. 

. 

f 

\ 

/ 

kA 

J 

S. 

\ 

'V 

/ 

\ 

1 

\ 

. 

' 

v\ 

/ 

'\ 

/ 

(\ 

N« 

>^ 

f 

(/ 

u 

V 

/ 

i 

J 

V 

V 

/■ 

\ 

V 

/ 

J 

\ 

\ 

V 

'\ 

u 

I 

1 

—1 

Fia.  207. — Tuberculous  Pneumonia;  General  Tuberculosis.  Patient  eleven  months 
old,  and  under  observation  at  the  time  he  was  taken  sick.  Chart  of  entire  illness 
is  given.  Disease  began  as  an  acute  pneumonia  in  lower  part  of  left  axilla  and  spread 
to  entire  lower  lobe.  Early  signs  of  consolidation;  at  end  of  two  weeks,  flatness  so 
marked  that  a  needle  was  inserted,  fluid  being  suspected.  Vomited  frequently,  and 
had  loose  discharges  from  bowels  throughout  the  illness;  abdomen  much  swollen  for 
last  two  weeks.  Autopsy  showed  cheesy  pneumonia  of  part  of  the  upper  and  the  entire 
left  lower  lobe,  where  there  were  two  small  cavities.  Recent  tubercles  found  through- 
out right  lung,  and  extensive  deposits  in  abdominal  organs  with  peritonitis,  and  intes- 
tinal ulcers. 


several  days  between  99°  and  102°  F.,  and  then,  without  evident  cause, 
rises  to  104°  F.  or  over.  In  infants  the  morning  temperature  is  fre- 
quently subnormal,  although  the  evening  temperature  may  be  102°  or 
103°  F.  Even  toward  the  close  of  the  disease,  when  softening  and  break- 
ing down  are  actively  going  on,  the  regular  hectic  temperature  of  adults 
is  rarely  seen  in  a  young  ciiikl  (Fig.  208).  While  the  presence  of  fever 
is  of  great  significance,  its  course  has  almost  no  diagnostic  importance 
in  early  life.     Especially  should  one  beware  of  drawing  the  conclusion 


TUBERCULOSIS. 


1039 


that,  because  the  fever  is  not  hectic,  there  is  no  breaking  down  of  tlie 
lung. 

Sweating  belongs  only  to  the  late  stage  of  tlie  disease,  and  is  usually 
associated  with  the  hectic  type  of  fever ;  both  those  are  regular  symptoms 
in  children  over  seven  years  old,  but  not  in  ver}'  young  children. 


"' 

1 

2 

nr 

rr' 

5 

u 

7 

8 

rr 

- 

11 

12 

in 

H 

- 

- 

i; 

IS 

- 

i'll 

21 

22 

2:i 

24 

25 

20 

27 

28 

29 

I 
z 

I 

u. 

106 
100 
104 
103 
102 
101 
100 
99 
98 
97° 

M  E 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

f 

U'  1 

11 

1^ 

I 

v/.  A 

\A 

1 

yy 

A 

/ 

^ 

^ 

\ 

\ 

1 

V 

V 

\ 

/ 

f 

/ 

/ 

/ 

^ 

/ 

y 

\l- 

I] 

/ 

i    / 

^ 

i 

1/ 

\^ 

/ 

I 

K 

y 

V 

If 

Fig.  208. — Tuberculous  Pneumonia  with  Extensive  Softening  and  Excavation. 
A  delicate  child,  thirteen  months  old;  weight,  10  pounds;  came  under  observation 
four  weeks  before  death,  with  consolidation  at  apex  of  right  lung.  Signs  increased 
in  intensity,  and  extended  in  area  until  there  were  heard,  from  clavicle  to  below  the 
nipple,  exaggerated  bronchial  voice  and  breathing  and  many  moist  rales;  percussion 
note  was  flat;  behind,  the  same  signs  at  extreme  apex.  No  distinct  signs  of  a  cavity; 
no  hectic  fever;  no  sweating.  Autopsy  showed  large  cavity  (Fig.  202)  at  right  apex 
partly  filled  with  caseous  masses;  diffuse  caseous  pneumonia  (Fig.  203)  of  the  rest 
of  right  upper  lobe,  with  scattered  deposits  in  the  other  lobes,  the  opposite  lung,  and 
a  few  in  the  abdominal  organs. 


Wasting,  like  fever,  is  characteristic  of  active  tuberculous  processes. 
Whenever  they  are  associated,  tuberculosis  should  always  be  suspected, 
no  matter  how  obscure  the  other  symptom.s  may  be.  The  wasting  is 
not  always  rapid,  but  it  is  usually  continuous  while  fever  lasts.  Dur- 
ing the  periods  of  temporary  improvement,  children  may  not  only  cease 
to  lose,  but  may  actually  gain  in  weight.  In  the  early  stage  of  the  dis- 
ease, wasting  is  especially  suggestive  when  it  continues  without  apparent 
cause  after  measles  or  pertussis,  or  when  it  persists  under  other  circum- 
stances in  spite  of  a  good  appetite  and  apparently  good  digestion.  It  may 
at  first  be  so  slight  as  not  to  be  noticed  unless  the  scales  are  employed. 
In  obscure  cases  this  steady  loss  of  weight  is  a  point  of  much  diagnostic 
value,  and  is  frequently  overlooked.  Toward  the  close  of  the  disease 
there  is  rapid  and  frequently  extreme  emaciation. 

Cough,  although  almost  invariably  present,  shows  no  peculiarities. 
It  may  be  hard,  dry,  or  suppressed;  it  sometimes  occurs  in  paroxysms 
resembling  pertussis,  which  may  or  may  not  depend  upon  the  presence 
of  enlarged  bronchial  glands. 

Expectoration  is  absent  in  infants,  the  material  coughed  up  being 
swallowed.  In  children  over  seven  years  old,  we  often  get  a  profuse 
muco-purulent  expectoration,  but  it  is  very  exceptional  below  this  age. 

Haemoptysis  is  a  rare  symptom,  but  not  unknown  even  in  young 
children.    Henoch  has  reported  a  case  of  fatal  haemoptysis  in  a  child  ten 


1040  THE   SPECIFIC  INFECTIOUS   DISEASES. 

months  old,  where  the  lifemorrhage  was  due  to  tlie  rapture  of  an  aneu- 
rism in  the  wall  of  a  cavity.  Herz,  in  247  clinical  cases  of  tuherculosis 
in  children,  records  8  of  iiaemoptysis — 4  of  them  under  five  years,  and  the 
youngest  only  eighteen  months  old.  The  records  of  131  autopsies  on 
tuberculous  children  in  the  Pendlehury  Hospital  show  that  haemoptysis 
was  four  times  a  cause  of  death;  two  of  these  patients  were  under  five 
years,  and  one  was  only  twelve  months  old.  I  have  never  met  with  a 
case  of  haemoptysis  under  five  years  old. 

The  respiration  is  accelerated,  and  usually  out  of  proportion  to  the 
rise  in  temperature.  As  the  lung  becomes  more  and  more  extensively 
invaded  there  is  constant  dyspnoea.  The  pulse  is  rapid  in  the  early  stage, 
and  continues  so  throughout  the  disease ;  toward  the  end  it  becomes  weak 
and  irregular.  Irregular  respiration  and  a  slow,  irregular  pulse  may 
occur  at  any  time  from  the  development  of  cerebral  complications. 

Pleuritic  pains  in  the  chest  are  not  frequent  in  children.  Gastro- 
intestinal symptoms,  such  as  indigestion,  vomiting,  diarrhoea,  etc.,  are 
generally  present,  but  are  not  peculiar  to  this  disease.  They  usually 
depend  upon  the  patient's  general  condition,  only  exceptionally  upon 
tuberculous  disease  of  the  stomach  or  intestines.  The  characteristic 
symptoms  of  intestinal  tuberculosis — abdominal  pain,  tenderness,  uncon- 
trollable diarrhcea,  and  intestinal  haemorrhage — are  seldom  met  with 
in  children  under  five  years.  I  have  seen  but  two  cases.  With  such 
symptoms,  and  sometimes  when  they  are  doubtful  or  absent,  careful 
palpation  of  the  abdomen  may  disclose  the  presence  of  enlarged  mesen- 
teric glands.  When  these  are  not  readily  felt  through  the  abdominal 
walls,  they  may  sometimes  be  discovered  by  a  rectal  examination. 

The  spleen  is  often  enlarged,  sometimes  very  much  so,  but  tliis  does 
not  occur  with  sufficient  frequency  to  be  of  much  diagnostic  value.  It 
may  be  due  to  tuberculous  deposits,  to  causes  connected  with  the  lungs 
or  heart,  or  to  fever.  The  liver  is  not  enlarged  from  tuberculous  deposits, 
but  may  be  so  from  amyloid  or  fatty  degeneration,  or  from  obstructed 
circulation,  as  in  the  case  of  the  spleen. 

Dropsy  is  rare.  It  may  depend  upon  anaemia,  upon  complicating 
nephritis,  especially  amyloid  degeneration,  upon  cardiac  or  pulmonary 
conditions  leading  to  interference  with  the  return  circulation,  or  upon 
pressure  of  tuberculous  retro-peritoneal  or  mesenteric  glands  upon  the 
inferior  vena  cava.  Clubbing  of  the  fingers  is  occasionally  seen  in 
cases  running  a  very  protracted  course,  and  is  due  to  obstructed  cir- 
culation. 

Anaemia  is  commonly  associated  with  wasting,  and  it  is  of  special 
importance  when  the  latter  is  slight  or  absent.  It  is  a  frequent  sequel 
of  acute  disease  in  infancy  when  not  dependent  on  tuberculosis;  when, 
however,  it  is  associated  with  low  fever,  cough,  and  persistence  of  rales 
in  the  chest,  it  should  excite  apprehension. 


TUBERCULOSIS.  1041 

Chronic  Tuberculous  Pneumonia. — In  young  children  this  is  a 
chronic  interstitial  pneumonia  associated  with  tuberculous  deposits. 
These  cases  have  usually  had  their  beginning  in  one  of  the  acute  forms. 
There  is  a  slow  convalescence  and  apparent  recovery,  although  this  is  not 
complete.  Often  a  slight  cough  remains,  or  returns  from  the  slightest 
exposure  or  other  exciting  cause.  The  child  does  not  regain  his  former 
weight  or  vigour,  and  careful  examination  of  the  lungs  shows  that  some 
abnormal  signs  remain. 

After  a  few  months,  possibly,  the  child  has  another  attack  resembling 
the  first.  It  is  accompanied  by  fever,  cough,  and  perhaps  there  is  a 
fresh  consolidation  of  some  part  of  the  lung,  generally  in  the  neighbour- 
hood of  the  old  disease.  All  active  symptoms  finally  subside,  and  most 
of  the  signs  of  recent  disease  disappear ;  but  it  is  tlien  usually  found  that 
the  condition  of  the  lung  is  not  quite  so  good  as  before  this  second 
illness.  The  acute  attacks  may  be  repeated  several  times  and  pass 
under  the  name  of  bronchitis,  broncho-pneumonia,  or  pleurisy.  They 
may  extend  over  a  period  of  years.  The  general  health  in  the  interval 
is  not  good,  there  being  present  in  most  cases  anjemia,  with  the  usual 
symptoms  of  malnutrition;  the  children  are  regarded  as  very  delicate. 

The  course  of  this  disease  thus  differs  in  no  essential  particulars  from 
that  of  simple  chronic  broncho-pneumonia;  the  pliysical  signs  likewise 
are  identical  in  character,  although  they  may  differ  in  their  location. 
They  are  generally  found  in  the  same  conditions  as  are  the  signs  in  the 
more  rapid  forms  of  pulmonary  tuberculosis  in  early  childhood.  A  fatal 
result  in  these  cases  is  usually  brought  about  by  the  development  of 
acute  tuberculous  pneumonia  or  miliary  tuberculosis  of  the  lungs,  by 
tuberculous  meningitis,  or  by  a  simple  broncho-pneumonia. 

Ppiysical  Signs  of  Pulmonary  Tuberculosis. — Speaking  gener- 
ally, except  in  situation  there  is  little  difference  in  a  young  child  between 
the  signs  of  a  bronchitis  or  broncho-pneumonia  due  to  the  tubercle  ba- 
cillus, and  those  of  the  same  lesions  when  due  to  other  causes.  Cavities, 
although  present  at  autopsy  in  most  of  the  advanced  cases,  are  seldom 
of  such  size  or  so  situated  as  to  be  recognised  during  life.  In  children 
over  six  or  seven  years  old,  the  signs  are  essentially  like  those  in  adults. 

The  upper  lobes  are  the  seat  of  the  most  advanced  disease  twice  as 
frequently  as  the  lower  lobes,  and  the  right  lung  rather  more  frequently 
than  the  left.  The  region  most  often  involved  is  the  middle  zone  of  the 
lung.  If  the  signs  appear  first  behind  they  are  usually  in  the  inter- 
scapular space ;  if  in  the  lateral  part  of  the  chest,  they  are  in  the  middle 
or  upper  part  of  the  axilla ;  if  in  front,  they  are  in  the  mammary  region. 
The  explanation  is  found  in  the  fact  that  the  disease  in  infants  and 
young  children  so  often  extends  from  the  lymph  nodes  at  the  root  of  the 
lung  to  the  lung  itself.  The  physical  signs  themselves  may  be  grouped 
under  four  heads,  corresponding  to  the  pathological  conditions  existing 
67 


1042  THE  SPECIFIC   INFECTIOUS   DISEASES. 

in  the  disease,  viz.,  (1)  broncliitis;  (2)  partial  consolidation ;  (3)  com- 
plete consolidation;  (4)  excavation.  The  early  signs  are  almost  identi- 
cal with  those  described  in  broncho-pneumonia.  As  a  mle,  however,  tiie 
transition  of  the  signs  from  one  stage  to  another  is  much  slower  in  tuber- 
culous than  in  simple  broncho-pneumonia. 

Tuberculous  bronchitis  gives  rales  which  may  be  of  all  sizes  and 
varieties,  localised  or  general.  If  the  process  goes  on  to  a  partial  con- 
solidation there  are  gradually  developed  in  addition  slightly  impaired 
resonance  or  even  dulness,  broncho-vesicular  respiration,  and  increased 
voice.  These  signs  are  usually  over  a  localised  area.  Later  tiie  signs  of 
complete  consolidation  are  present — marked  dulness,  increased  fremitus, 
bronchial  respiration,  and  voice,  but  still  rales  and  friction  sounds  are 
generally  heard. 

The  later  signs  depend  upon  what  course  the  pathological  process 
follows.  If  it  terminates  in  a  diffuse  or  localised  caseation,  the  signs 
differ  little  from  those  of  a  lobar  pneumonia  with  extensive  and  complete 
consolidation  except  that  the  dulness  on  percussion  is  usually  greater. 
There  may  be  even  flatness,  so  marked  as  to  suggest  the  presence  of  a 
pleural  effusion.  Empyema  is  often  the  diagnosis  made.  These  signs 
may  persist  until  the  death  of  the  patient  from  exhaustion. 

If  the  caseation  is  localised  and  followed  by  excavation,  the  signs 
of  a  cavity  may  be  present.  Cavities,  however,  are  often  so  small  and 
deeply  seated  as  not  to  give  definite  physical  signs.  Furthermore,  they 
are  frequently  filled  with  thick  pus  or  cheesy  matter,  and  rarely  com- 
municate freely  with  the  bronchi.  If  large  and  superficial  they  give  the 
same  signs  as  in  adults.  Like  the  areas  of  tuberculous  pneumonia,  they 
are  most  frequent  in  the  middle  zone  of  the  lung  in  front.  In  the  young 
child  similar  signs  are  often  present  where  there  are  only  dilated  bron- 
chi associated  with  a  fibroid  condition,  or  when  a  superficial  bronchus  is 
surrounded  by  an  area  of  diffuse  caseation.  Cavities  are  very  often  diag- 
nosticated when  they  do  not  exist,  and  quite  as  often  overlooked  when 
present. 

If  the  acute  process  terminates  in  a  chronic  tuberculous  pneumonia 
the  signs  are  those  of  an  unresolved  or  slowh'  resolving  pneumonia,  in 
which  the  area  of  consolidation  gradually  diminishes,  but  the  signs  do 
not  altogether  disappear.  When  recovery  goes  further  there  may  remain 
only  some  dulness  on  percussion,  broncho-vesicular  respiration,  rales, 
and  friction  sounds.  Such  signs  may  last  indefinitely,  exacerbations  and 
remissions  occurring  from  time  to  time.  These  signs  can  not  be  dis- 
tinguished from  those  of  simple  chronic  broncho-pneumonia. 

Diagnosis  of  Pulmonary  Tuberculosis. — In  arriving  at  a  diag- 
nosis one  should  investigate  the  family  history,  surroundings,  and  pre- 
vious condition  of  the  patient;  also  consider  the  mode  of  onset,  the  course 
of  the  disease,  and  the  evidence  afforded  by  the  examination. 


TUBERCULOSIS.  1043 

A  careful  examination  of  the  family  history  and  surroundings  should 
be  made  to  determine  the  existence  of  pulmonary  tuberculosis  in  the 
parents  or  in  other  members  of  the  household.  Inquiry  should  also  be 
made  regarding  meningitis,  disease  of  the  cervical  glands,  spine,  hip, 
knee,  or  ankle,  especially  in  other  children  of  the  family.  Other  condi- 
tions favourable  for  acquiring  the  disease  should  be  considered,  as  in 
cases  where  a  child  has  been  reared  in  a  tenement  house,  or  has  been  long 
an  inmate  of  a  hospital  or  other  institution.  In  the  child's  previous  his- 
tory, it  is  important  to  know  if  he  has  had  measles  or  pertussis,  and 
whether  they  were  severe,  accompanied  by  puhnonary  complications,  or 
followed  by  a  protracted  cough  or  obscure  fever.  The  child's  general 
constitution  should  be  considered,  whether  he  is  delicate,  narrow-chested, 
poorly  nourished,  or  habitually  anaemic. 

In  its  symptoms  and  course  it  is  with  simple  broncho-pneumonia  that 
tuberculous  disease  is  likely  to  be  confounded.  The  onset  of  simple 
pneumonia  is  usually  rapid  and  often  abrupt ;  tuberculous  pneumonia 
usually  develops  gradually  with  constitutional  symptoms  preceding  the 
local  ones  by  several  days  or  even  weeks.  In  acute  tuberculosis  one  is 
often  struck  by  the  disproportion  between  the  general  symptoms — loss 
of  flesh,  prostration,  and  temperature — and  the  local  evidences  of  pul- 
monary disease.  When  the  pulmonary  disease  lasts  longer  than  usual 
the  question  arises  whether  we  have  to  deal  with  a  case  of  persistent 
broncho-pneumonia  or  with  tuberculosis.  In  children  whose  general 
condition  is  poor  it  is  not  infrequent  for  simple  broncho-pneumonia  to 
resolve  slowly  or  to  go  on  to  the  development  of  chronic  interstitial  pneu- 
monia, so  that  other  means  of  diagnosis  are  needed. 

The  course  of  the  temperature  can  not  be  depended  upon  to  differ- 
entiate any  form  of  pulmonary  tuberculosis  from  simple  broncho-pneu- 
monia. Anaemia  and  wasting  are  usually  more  marked  in  tuberculosis, 
and  in  most  cases  they  are  progressive.  A  higli  leucocyte  count,  e.  g., 
above  20,000 — especially  when  accompanied  by  a  high  polymorphonu- 
clear percentage,  strongl}'^  favours  pneumonia.  Meningitis  developing 
during  a  pulmonary  disease  of  doubtful  character  is  generally  tubercu- 
lous, and  its  occurrence  is  usually  to  be  interpreted  as  establishing  the 
tuberculous  nature  of  the  process  in  the  lungs.  But  acute  pneumococcus 
meningitis  may  occur  under  very  similar  circumstances,  and  only  a 
lumbar  puncture  may  differentiate  between  them.  A  copious  muco- 
purulent expectoration  is  seen  quite  as  frequently  in  the  other  forms 
of  chronic  pneumonia  as  in  the  tuberculous  variety. 

Examination  for  Bacilli. — Discovery  of  the  bacilli  in  the  sputum  of 
even  young  infants  is  by  no  means  impossible,  nor  even  a  very  difficult 
matter.  Both  time  and  patience  are  required,  and  in  most  cases  repeated 
examinations  are  necessary.  Infants  do  not  expectorate,  but  cough  up 
the  bronchial  secretion  into  the  pharynx  and  swallow  it.     Sputum  must 


1044  THE  SPECIFIC   INFECTIOUS  DISEASES. 

therefore  be  obtained  from  the  pharynx  or  the  a'sophagus ;  to  seek  for  the 
bacilli  in  the  vomitus,  as  has  been  recommended,  is  almost  a  hopeless 
task.  The  method  which  has  given  me  the  most  satisfactory  results  is 
to  excite  a  cough  by  irritating  the  pharynx,  and  then  to  catch  the  sputum 
brought  up  into  view  upon  a  cotton  swab  or  a  bit  of  muslin  in  the  jaws 
of  an  artery  clamp.  Inversion  during  a  paro.xysm  of  coughing  some- 
times causes  the  infant  to  discharge  a  considerable  mass  of  iimco-pus- 
into  a  sputum  cup.  By  the  procedure  mentioned  it  has  not  been  found 
more  diflBcult  to  obtain  good  sputum  for  examination  in  very  young 
patients  than  in  adults.  Good  sputum  may  be  described  as  muco- 
purulent masses,  for  bacilli  are  very  seldom  to  be  found  in  clear,  glairy 
mucus.  Following  the  method  described,  bacilli  have  been  found  in  over 
eighty  per  cent  of  my  hospital  cases  of  pulmonary  tuberculosis  in  infants, 
although  in  over  half  of  them  the  disease  was  not  advanced,  judging 
by  symptoms  and  physical  signs. 

Bacilli  may  readily  be  found  in  the  stools  of  many  children  suffering 
from  tuberculosis.  Their  presence  does  not  necessarily  indicate  a  tuber- 
culous lesion  of  the  intestines,  for  their  source  is  more  frequently  a 
pulmonary  lesion,  the  bacilli  being  coughed  up  and  swallowed.  Hence, 
it  is  sometimes  easier  to  find  them  in  the  stools  than  in  the  sputum. 
They  must  be  carefully  differentiated  from  the  smegma  bacilli. 

in.  Chronic  Phthisis. — This  form  of  tuberculosis,  with  its  chronic 
hectic  fever,  slow  cavity  formation,  progressive  emaciation,  night  sweats, 
etc.,  is  very  rarely  seen  before  the  fifth  year,  and  it  is  not  at  all  frequent 
until  the  tenth  or  twelfth  year.  In  its  symptoms,  course,  termination, 
and  physical  signs,  it  resembles  the  same  disease  in  adults,  and  need  not 
be  described  at  length  here. 

IV.  Tuberculosis  of  the  Bronchial  Lymph  Nodes  (Bronchial  Glands). 
— This  condition  is  usually  associated  with  some  form  of  j)ulinonary 
tuberculosis,  but  it  may  exist  as  the  most  important  and  sometimes  as 
the  only  tuberculous  lesion. 

Its  symptoms  are  usually  associated  with  those  of  pulmonary  or  gen- 
eral tuberculosis;  but  they  may  occur  when  the  pulmonary  changes  are 
too  few  to  be  recognised  either  by  symptoms  or  physical  signs.  From  the 
great  frequency  with  which  this  lesion  is  found  in  infants  and  young 
children,  it  might  be  expected  that  local  symptoms  would  be  common 
in  such  patients.  They  are,  however,  in  my  experience,  quite  exceptional. 
Most  of  the  cases  in  which  well-marked  symptoms  occur  are  in  children 
over  two  years  old,  and  it  is  between  the  third  and  tenth  years  that  they 
are  usually  seen.  In  infancy,  although  these  glands  are  almost  inva- 
riably affected,  death  in  the  great  majority  of  eases  occurs  from  the 
pulmonary  disease,  before  the  later  changes  in  the  glands  have  had  time 
to  develop. 

General  symptoms  may  or  may  not  precede  the  local  ones.     The 


TUBERCULOSIS.  1045 

latter  are  chiefly  mechanical,  and  depend  upon  the  size  of  the  glands  and 
upon  their  anatomical  relations,  and  very  little  or  not  at  all  upon  the 
nature  of  the  changes  in  them.  The  most  important  relations,  so  far  as 
the  production  of  symptoms  is  concerned,  are  those  which  they  hear  to 
the  pneumogastric  and  recurrent  laryngeal  nerves,  the  superior  vena 
cava,  the  trachea,  and  bronchi ;  those  less  important  are  to  the  aorta, 
pulmonary  artery,  and  oesophagus. 

Pressure  upon  or  irritation  of  the  pneumogastric  or  recurrent  nerves 
produces  cough,  dyspnoea,  and  sometimes  a  change  in  the  voice.  The 
cough  is  hoarse,  persistent,  and  teasing,  and  frecjuently  occurs  in  parox- 
ysms which  in  many  respects  resemble  those  of  pertussis,  but  it  lacks 
the  characteristic  whoop,  and  is  not  accompanied  by  the  expectoration  of 
a  mass  of  tenacious  mucus.  These  paroxysms  are  severe  and  often  pro- 
longed, but  careful  observation  shows  distinct  differences  from  those  of 
pertussis,  though  by  an  unfamiliar  ear  the  two  are  easily  confounded. 
The  dyspnoea,  like  the  cough,  is  paroxysmal,  and  sometimes  strongly 
resembles  ordinary  spasmodic  croup;  at  other  times  it  is  like  a  severe 
attack  of  asthma.  Such  symptoms  may  come  and  go,  but  they  are  fre- 
quently prolonged,  and  usually  in  the  interval  l)etween  the  severe  seizures 
the  patient  is  not  wholly  free  from  dyspncea.  Although  the  chief  cause 
of  dyspnoea  is  no  doubt  nerve  irritation,  it  may  be  due  in  part  to  pressure 
upon  the  trachea  or  one  of  the  large  bronclii.  Tn  dyspnoea  from  pressure 
on  the  trachea  the  head  is  usually  thrown  back,  and  the  obstruction  is 
more  frequently  on  expiration  than  on  inspiration. 

After  such  symptoms  as  those  mentioned  have  existed  for  a  few  days 
or  weeks,  and  in  some  cases  without  any  warning,  there  may  occur  a  sud- 
den attack  of  asphyxia  which  may  prove  fatal.  This  is  generally  due  to 
ulceration  of  a  caseous  gland  into  the  trachea  or  a  large  bronchus  and 
the  escape  of  a  large  mass  into  the  air  passages,  where  it  produces  the 
same  effects  as  does  any  other  foreign  body. 

Of  fifteen  cases  of  this  kind  collected  by  Loeb,  death  by  suffocation 
occurred  in  most  in  from  five  to  ten  minutes  after  the  first  definite  symp- 
toms; in  some  the  fatal  attack  was  preceded  for  some  time  by  milder 
attacks  or  by  a  cough;  in  others  no  previous  symptoms  were  present, 
the  child  being  apparently  in  perfect  health.  Rarely  after  ulceration  into 
the  trachea  the  patient  has  recovered  after  coughing  up  a  large  amount 
of  foul  pus. 

Pressure  upon  the  superior  vena  cava  is  usually  associated  with  spas- 
modic dyspnoea  and  cough,  and  causes  cyanosis  of  the  face  and  blueness 
of  the  lips.  There  is  frequently  a  puffiness  of  the  face,  and  there  may 
be  marked  oedema.  The  coexistence  of  cyanosis  with  such  oedema,  when 
the  urine  is  free  from  signs  of  renal  disease,  should  always  lead  one  to 
suspect  pressure  at  the  root  of  the  lung.  In  some  rare  cases  the  interfer- 
ence with  the  return  circulation  has  been  so  marked  that  meningeal 


1046  THE  SPECIFIC  INFECTIOUS  DISEASES. 

haemorrhage  has  resulted.  By  a  process  of  ulceration  set  up  by  these 
glands  they  may  open,  not  only  into  the  air  passages,  but  into  the  peri- 
cardium, tiie  oesophagus,  or  any  of  the  large  vessels.  The  last  mentioned 
is  usually  followed  by  instant  death.  Aldibert  reports  two  cases  in  which 
the  pulmonary  artery  was  opened,  death  occurring  from  haemoptysis,  as 
there  was  also  a  communication  with  one  of  the  large  bronchi.  In 
Vogel's  case  the  subclavian  vein  was  perforated,  and  death  resulted  from 
the  entrance  of  air.  If  ulceration  takes  place  into  the  surrounding  con- 
nective tissue,  a  mediastinal  abscess  may  residt,  producing  any  of  the 
pressure  symptoms  noted  above,  and,  in  addition,  dysphagia  from  pres- 
sure on  the  oesophagus.  Such  an  abscess  may  point  in  the  suprasternal 
notch ;  it  may  open  through  the  chest  anteriorly  between  the  ribs  or  at 
the  xiphoid  cartilage;  or  it  may  burrow  along  the  oesopliagus  to  the 
peritoneal  cavity.  As  a  rule,  however,  patients  die  of  general  tubercu- 
losis before  the  local  conditions  have  advanced  so  far. 

Physical  Signs. — In  order  to  produce  pliysical  signs,  the  mass  of 
tuberculous  lymph  nodes  must  be  large  enough  to  form  a  mediastinal 
tumour,  or  so  situated  as  to  produce  pressure  on  the  trachea  or  bronchi. 
As  a  rule,  the  signs  are  more  characteristic  behind  than  in  front.  Per- 
cussion may  give  dulness  anteriorly  over  the  first  piece  of  the  sternum 
but  very  rarely  posteriorly  ;  when  present  it  is  found  along  one  or  both 
sides  of  the  spine  from  the  third  to  the  seventh  dorsal  vertebra.  Auscul- 
tation posteriorly  gives  in  the  most  marked  cases  a  voice  and  respiration 
of  a  peculiar  character,  somewhat  amphoric,  but  with  a  distinctly  nasal 
quality.  The  auscultatory  signs  may  so  resemble  those  of  a  cavity  tliat  it 
is  often  difficult  to  believe  that  a  cavity  does  not  exist.  If  one  of  the  pri- 
mary bronchi  or  one  of  its  lobar  divisions  is  compressed,  there  may  be 
very  feeble  respiration  over  one  lung  or  one  lol)e ;  if  the  pressure  is  suffi- 
cient to  prevent  the  entrance  of  air,  or  if  one  of  these  large  tubes  has 
been  plugged  by  a  caseous  mass,  there  is  an  absence  of  respiratory  mur- 
mur over  a  single  lobe  or  an  entire  lung.  This  sign  is  of  great  diagnos- 
tic value,  but  it  is  not  often  present. 

Diagnosis. — Enlargement  of  the  bronchial  glands  to  a  suflEicient 
degree  to  produce  symptoms,  may  occur  in  syphilis,  in  Hodgkin's  dis- 
ease, and  in  various  forms  of  malignant  disease  of  the  mediastinum.  A 
certain  amount  of  swelling  is  seen  in  nearly  all  cases  of  simple  bronchitis 
or  pneumonia,  especially  in  those  running  a  subacute  or  chronic  course. 
Whether  this  simple  hyperplasia  is  ever  sufficient  to  cause  such  symptoms 
as  those  mentioned  is  exceedingly  doubtful.  I  have  myself  never  known 
it  to  produce  anything  more  marked  than  a  spasmodic  cough.  Tiie  great 
infrequency  of  other  forms  of  enlargement  sufficient  to  be  of  any  clin- 
ical importance,  usually  warrants  us,  from  the  symptoms  mentioned, 
in  making  the  diagnosis  of  tuberculosis.  The  development  in  a  child  of 
a  chronic  abscess  in  the  anterior  mediastinum,  is  almost  always  due  to 


TUBERCULOSIS. 


1047 


tuberculous  glands ;  and  so  is  one  in  tlie  posterior  mediastinum,  provided 
Pott's  disease  can  be  excluded. 

The  most  important  points  for  diagnosis  arc  the  a.ssociation  of  a  spas- 
modic cough  witli  paroxysms  of  dyspnoea  resond)ling  asthma  or  croup, 
and  oedema  or  congestion  of  the  face.  More  stress  is  to  be  laid  upon 
the  symptoms  than  upon  the  physical  signs;  the  latter  are  at  most  only 
confirmatory.  The  chief  difficulty  in  diagnosis  is  found  in  those  cases 
which  present  few  or  no  other  signs  of  tuberculosis,  and  which  come  first 
under  observation  with  attacks  of  dyspna^a  or  asphyxia  resembling  those 
seen  in  laryngeal  stenosis.  In  many  such  cases  tracheotomy  lias  been 
done  without  finding  any  cause  for  the  dyspnoea,  ilie  autopsy  showing  it 
to  be  due  to  the  ulceration  and  impaction  of  a  caseous  g]an<l. 


Fig.  209. — Tuberculous  Bronchial  Glands. 
A  very  large  mass  upon  the  right  side,  A,  A;  a  smaller  one  upon  the  left  side,  B,  B. 


In  many  cases  very  positive  information  is  given  by  the  X-ray,  the 
radiographic  shadows  usually  showing  better  on  the  right  side  than  on 
the  left  on  account  of  the  heart  (see  Fig.  209).  This  means  of  diagnosis 
is,  however,  of  no  value  in  distinguishing  tuberculous  glands  from  en- 
larged glands  due  to  otlicr  causes ;  the  latter,  however,  are  very  rare. 

The  Tuberculin  Tests. — The  Fever  Reaction  Folloiuing  Tuberculin 
Injections. — This  is  quite  as  reliable  in  children  as  in  older  patients.  It 
is  limited  in  its  application,  since  most  cases  of  active  tuberculosis  at 
this  period  of  life  are  accompanied  by  fever.     Since  the  other  tests  are 


1048  THE  SPECIFIC   INFECTIOUS  DISEASES. 

easier  to  employ  and  not  open  to  the  same  objections,  there  is  now  very 
seldom  a  need  for  the  use  of  this  test. 

The  Ophthalmic  Test  {Calmette  or  Woljf -Eisner  Test). — This  gen- 
erally gives  reliable  results,  but  its  use  is  attended  by  some  risk  and  it 
has  no  advantages  over  the  von  Pirquet  test. 

The  Cutaneous  Test  {von  Pirquet's  Test). — Usually  the  forearm  is 
the  part  chosen  for  inoculation.  The  skin  is  carefully  washed  with 
alcohol  or  ether.  A  small  drop  of  pure  tuberculin  is  placed  upon  the  skin. 
With  a  small  instrument  resembling  a  tiny  chisel  a  simple  scarification 
for  control  is  made  at  a  distance  of  two  or  three  inches  from  this  drop. 
A  similar  scarification  is  then  made  through  the  drop.  Linear  scratches 
one-quarter  inch  in  length  with  a  sterile  needle  serve  equally  well  as  a 
means  of  inoculation  and  control.  The  child  should  be  watched,  and  if 
very  young  the  arm  should  be  held  until  the  skin  is  quite  dry  to  prevent 
infection  by  rubbing.  As  an  added  precaution  it  may  be  covered  with 
a  piece  of  sterile  gauze.  The  reaction  consists  in  a  red  areola  about  the 
point  or  along  the  line  of  inoculation.  This  generally  begins  in  from 
twelve  to  eighteen  hours,  rarely  as  late  as  twenty-four  hours,  and  reaches 
its  height  during  the  next  twenty-four  hours.  The  diameter  of  the 
areola  indicates  the  degree  of  reaction.  It  continues  in  most  cases  for 
from  one  to  three  days  and  slowly  fades,  often  being  followed  by  a  slight 
local  desquamation.  Rarely  there  may  be  vesiculation.  There  is  in  most 
of  the  cases  slight  infiltration  of  the  skin  readily  appreciable  to  the  touch ; 
and  there  may  be  a  distinct  induration.  The  more  marked  reactions  con- 
tinue for  from  four  to  ten  days.  Any  definite  inflammatory  reaction 
which  follows  this  course  may  be  regarded  as  positive.  The  arm  should 
be  observed  daily  to  note  the  results.  There  seems  to  be  no  relation 
between  the  intensity  of  the  reaction  and  the  extent  or  the  activity  of 
the  tuberculous  disease. 

The  Puncture  Test  {Stich-reaction  of  Hamburger). — Tliere  is  in- 
jected just  beneath  the  skin  of  the  forearm  a  measured  dose,  from  ystt 
to  TT^ir  rngr.  of  tuberculin.  The  reaction  is  seen  at  two  points;  the 
greater,  corresponding  to  the  place  where  the  fluid  is  deposited,  the  less, 
where  the  needle  perforates  the  skin.  Swelling,  redness,  induration  and 
local  rise  of  temperature  are  present.  The  reaction  begins  within  the 
first  twenty-four  hours ;  the  induration  and  discolouration  of  the  skin  last 
five  to  six  days  and  slight  desquamation  follows.  A  reaction  beginning 
later  than  twenty-four  hours  is  not  diagnostic.  Hamburger's  statement 
that  in  older  children  this  is  the  most  sensitive  of  all  tests  seems  probable. 

Inunction  Test  of  Moro. — There  is  used  for  this  test  tuberculin  made 
up  with  anhydrous  lanolin,  fifty  per  cent  strength.  A  mass  of  this,  the 
size  of  a  pea,  is  rubbed  for  half  a  minute  into  the  skin  of  the  abdomen 
or  chest  over  an  area  two  inches  in  diameter.  The  reaction  consists  in 
the  formation  of  a  papular,  sometimes  a  vesicular,  eruption  which  ap- 


TUBERCULOSIS.  1049 

pears,  according  to  the  severity  of  the  reaction,  in  from  twelve  to  forty- 
eight  hours.  It  remains  for  several  days  and  slowly  disappears,  being 
followed  by  pigmentation  in  the  severer  cases. 

A  Comparison  of  the  Different  Tests. — No  one  of  the  tests  is  so  ab- 
solutely conclusive  as  is  the  demonstration  of  the  tubercle  bacillus  in  the 
sputum,  the  cerebro-spinal  fluid,  or  elsewhere.  One  sliould  not  therefore 
depend  upon  local  tests  and  omit  the  search  for  bacilli,  even  though  it 
involves  greater  labour.  While  these  tests  when  followed  by  a  positive  re- 
action furnish  evidence  of  the  existence  of  a  tuberculous  lesion,  they  do 
not  enable  us  to  distinguish  between  latent  and  active  conditions.  Thus, 
a  child  may  give  a  positive  skin  reaction  when  suffering  from  acute 
pulmonary  disease,  which  by  its  covirse  is  shown  to  be  non-tuberculous; 
although  grave  suspicion  of  an  acute  pulmonary  tuberculosis  may  have 
existed  and  apparently  be  confirmed  by  the  tuberculin  test.  Much  need- 
less alarm  may  therefore  be  produced  by  a  positive  reaction,  which  really 
demonstrates  only  that  somewhere  the  child  has  a  tuberculous  focus, 
but  it  does  not  prove  that  his  present  disease  is  of  a  tuberculous  nature. 

Shortly  before  death,  whether  from  general  or  any  form  of  localised 
tuberculosis,  as  a  rule  there  is  no  reaction  to  any  of  the  local  tests. 
Likewise,  a  child  in  an  extremely  astlienic  condition  from  any  cause 
whatever  may  give  no  reaction  altliough  he  has  a  latent  tuberculosis. 
During  active  measles  also  the  test  is  of  little  value.  No  conclusions 
therefore  can  be  drawn  from  tests  made  under  tbese  conditions.  On  the 
whole  von  Pirquet's  cutaneous  test  is  to  be  preferred  for  general  use. 

Tuberculides  of  the  Skin. — These  are  at  times  of  considerable  value 
in  the  diagnosis  of  tuberculosis  in  general.^  Although  seldom  seen  in 
the  acute  varieties,  they  are  not  uncommon  in  the  more  slowly  progress- 
ing forms.  The  distribution  of  the  lesions  is  fairly  constant.  They  are 
found  chiefly  on  the  buttocks,  lower  abdomen,  genitalia  and  thighs.  The 
number  present  is  generally  small,  half  a  dozen  to  a  dozen ;  but  they  are 
sometimes  numerous  and  may  be  widely  distributed.  The  lesion  begins 
as  a  minute  red  pa])ide,  which  is  soon  surmounted  by  a  small  vesicle. 
This  dries  to  form  a  crust.  If  the  crust  is  removed  a  small  pit-like 
depression  remains,  which  heals  quickly,  leaving  a  white,  glistening 
scar  surrounded  by  a  pigmented  border.  Tbe  lesion  runs  its  entire  course 
in  two  or  three  weeks.  Tubercle  bacilli  are  often  present  but  difficult 
to  demonstrate.  Tuberculides  of  the  skin  in  young  children  are  evidence 
of  a  widely  disseminated  process  and  are  a  very  bad  prognostic  sign. 
Such  patients  rarely  survive  more  than  a  few  weeks. 

General  Prognosis  of  Tuberculosis. — The  outlook  for  a  young  child 
with  general  or  pulmonary  tuberculosis  is  always  bad.  So  long  as  the 
disease  remains  confined  to  the  lymph  nodes,  the  child  is  not  usually  in 


*  Tileston,  Archives  of  Internal  Medicine,  July,  1909. 


1050  THE   SPECIFIC   INFECTIOUS   DISEASES. 

danger,  except  from  accidents  connected  with  their  softening  and  ulcer- 
ation, which  after  all  are  rare.  Spontaneous  cure  may  occur  in  these 
glands  in  the  same  way  as  in  others  in  the  body,  vi/..,  by  encapsulation, 
calcification,  etc.  Such  a  result  is  no  doubt  a  very  frequent  one ;  exactly 
how  often  it  occurs  it  is  impossible  to  say.  But  when  once  the  disease 
has  gained  any  headway  in  the  lung  itself,  its  steady  advance  is  almost 
certain  in  a  young  child.  In  those  who  are  older  and  have  more  resist- 
ance the  chances  of  an  arrest  of  the  process  are  much  greater. 

If  the  bacilli  have  gained  entrance  into  the  body  in  any  considerable 
numbers,  even  though  they  are  shut  up  in  an  encapsulated,  caseous, 
bronchial  gland,  the  patient  is  never  free  from  the  danger  of  general 
infection. 

Prophylaxis. — The  prevention  of  tuberculosis  nmst  have  constant  ref- 
erence to  its  cause.  The  first  essential  is  the  destruction  of  the  tubercle 
bacilli  wherever  they  exist.  Since  most  of  those  existing  in  the  air 
are  derived  from  the  sputum  of  patients  affected  with  pulmonary  tuber- 
culosis, it  should  be  insisted  upon,  everywhere  and  at  all  times,  that  the 
sputum  from  such  cases  should  be  collected  in  special  cups  or  cloths  and 
destroyed  either  by  germicides  or  by  fire.  The  next  point  is  to  avoid 
needless  exposure.  A  tuberculous  mother  should  on  no  account  nurse 
her  child  nor  kiss  it  upon  the  mouth.  A  wet-nurse  likewise  should  be 
free  from  any  tuberculous  taint.  No  nurse  or  other  care-taker  should 
ever  be  employed  about  children  who  has,  or  ever  has  had,  pulmonary 
tuberculosis.  It  is  wise  to  exclude  also  those  who  suffered  when  chil- 
dren from  tuberculosis  of  the  bones  or  the  cervical  glands,  although  the 
danger  from  such  persons  is  extremely  slight.  If  active  tuberculosis 
exists  in  any  member  of  the  family,  a  young  child  should  be  kept  away 
from  the  room,  and  if  possible  should  not  reside  in  the  house.  On  no 
account  should  infected  persons  be  allowed  to  kiss  cliildren  or  sleep  in 
the  same  bed  with  them.  The  danger  from  drinking-cups  and  other 
dishes  should  not  be  forgotten.  A  tuberculous  person  should  either  have 
his  special  dishes,  or  the  utmost  care  should  be  taken  to  boil  all  those 
which  he  has  used.  Cows  whose  milk  is  used  for  children  should  be 
under  regular  veterinary  inspection  and  should  have  passed  the  tuber- 
culin test.  In  any  case  when  the  slightest  doubt  regarding  the  health  of 
the  cows  exists,  or  when  the  source  of  the  milk  is  unknown,  the  milk 
should  be  heated  to  a  temperature  of  140°  F.  for  forty  minutes.  The 
danger  of  infection  through  the  alimentary  canal  is  very  much  less  than 
through  the  respiratory  tract,  and  consequently  the  precautions  first 
mentioned  are  much  more  important  than  those  relating  to  the  food, 
although  the  latter  should  on  no  account  be  neglected. 

In  the  case  of  delicate  children  and  those  with  tuberculous  parents  or 
with  other  tuberculous  near  relatives,  everything  possible  should  be  done 
to  fortify  them  against  the  disease.    They  should  be  kept  under  more  or 


TUBERCULOSIS.  1051 

less  constant  medical  supervision.  Attacks  of  iironcliitis  or  broncho- 
pneumonia should  be  watclied  witli  the  greatest  solicitude.  Exposure  to 
influenza,  measles  or  pertussis  should  especially  l)e  avoided.  The  coun- 
try rather  than  the  city  should  be  chosen  for  residence,  and  the  child 
should  spend  the  winter  and  spring  in  some  warm,  dry  climate.  Parents 
should  be  distinctly  taught  that  watchfulness  and  care  do  not  mean  cod- 
dling or  the  keeping  of  children  in  the  house  the  greater  part  of  the 
time.  Such  children  should  live  as  mucli  as  possible  in  the  open  air, 
and  every  form  of  sport  encouraged  wliich  tends  to  keep  them  there. 
Overheated  houses  are  one  of  the  most  prolific  agencies  in  perpetuating 
a  delicate  condition  of  health.  Plenty  of  fresh  air  in  sleeping  apart- 
ments should  always  be  insisted  upon.  All  catarrhal  troubles  of  the  nose 
and  pharynx  should  receive  early  and  prompt  attention,  especially  should 
hypertrophied  tonsils  and  adenoid  growths  of  the  pharynx  l)e  removed, 
since  these  are  conditions  which  form  a  most  favourable  nidus  for  the 
growth  of  tubercle  bacilli. 

Treatment  of  General  and  Pulmonary  Tuberculosis. — If  fresh  air  and 
a  proper  climate  are  necessary  for  the  cure  of  this  disease  in  adults,  they 
are  tenfold  more  necessary  in  the  case  of  children.  Without  them  there 
is  little  hope  for  a  child  with  active  pulmonary  tuberculosis.  Nowhere 
do  these  cases  do  so  badly  as  in  a  hospital  located  in  a  city,  and  no  class 
of  hospital  cases  do  worse  than  these.  The  same  regions  that  are  bene- 
ficial for  adult  cases  usually  agree  with  children,  with  the  exception  that 
the  latter,  as  a  rule,  do  better  in  a  warm  than  in  a  cold  climate.  Plenty 
of  fresh  air  and  sunshine  are  essential.  A  child  must  be  where  he  can 
be  kept  in  the  open  air  for  the  greater  part  of  each  day,  in  spite  of 
fever,  cough,  or  other  acute  symptoms. 

For  the  most  acute  eases  when  the  cliildren  are  confined  to  the  bed, 
the  largest,  best-ventilated,  and  sunniest  room  available  shoiild  be  secured, 
and  the  windows  should  be  constantly  open.  The  general  management 
of  such  cases  is  the  same  as  for  those  with  acute  pneumonia. 

No  specific  remedy  for  tuberculosis  has  as  yet  stood  the  test  of  ex- 
perience. The  diet  is  a  matter  of  the  utmost  importance.  Tuberculous 
patients  must  be  fed  like  most  other  sick  children,  care  being  taken  not 
to  disturb  the  digestion  by  the  unnecessary  use  of  drugs.  For  a  staple 
article  of  diet,  milk  is  the  best,  and  when  this  is  not  well  borne  some  of 
its  substitutes — buttermilk,  kumyss,  matzoon,  etc. — may  be  tried.  Cream 
is  almost  as  useful  as  cod-liver  oil,  and  should  be  given  in  one  form  or 
another  whenever  the  child's  digestion  can  tolerate  it. 

Tuberculin  in  the  treatment  of  this  disease  in  young  children  has  as 
yet  been  too  little  employed  to  enable  one  to  form  any  definite  conclu- 
sions as  to  its  value.  Its  application  should  be  directed  by  the  same 
rules  as  those  employed  in  adults.  It  is  a  therapeutic  procedure  which 
deserves  more  attention  than  it  has  hitherto  received. 


1052  THE  SPECIFIC  INFECTIOUS   DISEASES. 

The  two  drugs  which  are  most  useful  are  creosote  and  cod-liver  oil. 
Creosote  may  be  given  both  by  the  stomach  and  by  inhalation,  as  in  cases 
of  pneumonia.  By  the  stomach  there  may  be  used  for  older  children,  the 
shellac-coated  pills  or  capsules  containing  one  or  two  drops  of  creosote; 
it  may  be  given  in  conjunction  with  cod-liver  oil.  Cod-liver  oil  is  usually 
best  given  in  a  fresh  emulsion,  although  some  children  bear  the  pure  oil 
better  than  its  preparations.  Inunctions  of  tliis  or  other  oils  are  of  some 
value  wlien  not  well  tolerated  by  the  stomach.  Arsenic,  iron,  and  the 
compound  syrup  of  the  hypophospliites  are  all  useful  as  general  tonics, 
but  as  specifics  tiieir  action  is  very  questionable. 


CHAPTER    XI. 
SYPHILIS. 

Syphilis  is  a  communicable  disease  due  to  a  specific  organism,  the 
spirochceta  pallida  of  Schaudinn.  In  acquired  syphilis  this  is  found  in 
the  primary  lesion,  in  the  mucous  patches  and  in  the  lymph  nodes.  In 
hereditary  syphilis  it  is  found  in  the  cutaneous  lesions,  in  the  fissures 
at  the  angle  of  the  mouth  and  in  the  mucous  patches  of  the  buccal 
cavity,  with  less  regularity,  in  the  internal  organs,  especially  the  liver 
and  spleen.  While  in  the  still-born  child  and  in  early  cases,  the  num- 
ber of  organisms  found  is  very  great,  tliey  are  not  so  numerous  at 
a  later  period,  and  they  diminish  rapidly  after  treatment  is  begun. 
In  the  late  lesions  the  spirochsetae  are  not  numerous,  and  are  difficult 
to  demonstrate. 

In  infancy  and  childhood  both  the  acquired  and  the  hereditary  forms 
of  syphilis  are  seen. 

ACQUIRED   SYPHILIS. 

While  acquired  syphilis  is  very  much  less  frequent  than  the  hered- 
itary variety,  it  is  by  no  means  a  rare  disease  in  early  life.  It  is  not  im- 
probable that  some  of  the  manifestations  of  syphilis  in  later  childhood 
which  are  usually  denominated  "  late  hereditary  syphilis,"  are  really 
due  to  the  acquired  form. 

Etiology. — An  infant  may  be  infected  by  its  mother  during  parturi- 
tion; but  this  is  extremely  rare  and  can  take  place  only  when  there  are 
lesions  upon  the  mother's  genitals.  Infection  is  more  likely  to  be  from 
a  mother  who  contracts  syphilis  subsequent  to  the  birth  of  the  child, 
and  may  occur  through  nursing  or  accidental  contact  by  kissing,  etc. 
In  either  of  these  ways  children  may  be  infected  by  wet-nurses,  or  from 
a  venereal  sore  upon  the  nipple.    AVhether  syphilis  can  be  communicated 


HEREDITARY  SYPHILIS.  1053 

through  the  milk  when  the  nipple  is  perfectly  healtliy  and  free  from 
fissures,  is  somewhat  doubtful. 

Syphilis  may  be  communicated  directly  from  a  syphilitic  child  to  one 
who  is  healthy  by  kissing,  by  sexual  contact,  or  indirectly  by  means  of 
bottles,  spoons,  cups,  clothing,  etc.  The  latter  mode  of  infection  is  most 
likely  to  occur  in  institutions.  Vaccination  was  formerly  a  not  infre- 
quent mode  of  communicating  syphilis,  but  since  tlie  general  introduc- 
tion of  bovine  virus  this  is  very  rarely  seen.  Cases  have  been  recorded 
where  the  disease  has  been  conveyed  by  the  rite  of  circumcision,  either 
from  the  mouth  or  the  instruments  of  the  operator. 

The  relative  frequency  of  the  different  sources  of  infection  is  shown 
by  Fournier's  statistics  of  40  cases :  The  source  of  infection  was  the 
parents  in  19;  nurses,  in  8;  servants,  in  4;  sexual  contact,  in  4;  vaccina- 
tion, in  2;  other  children,  in  2;  a  physician,  in  1.  The  ages  at  which 
the  disease  was  acquired  in  this  series  of  cases  were  as  follows :  During 
the  first  year,  19 ;  during  the  second  year,  10 ;  during  the  third  and 
fourth  years,  7 ;  from  the  fifth  to  the  fourteenth  year,  6. 

Symptoms. — The  symptoms  of  acquired  syphilis  in  children  are  in  all 
respects  similar  to  the  same  disease  in  the  adult.  A  primary  sore  is  pres- 
ent at  the  site  of  infection,  which  is  most  frequently  the  lips,  the  mouth, 
or  some  part  of  the  face;  very  rarely  is  it  seen  on  the  genitals.  There 
are  very  few  individual  symptoms  belonging  to  hereditary  syphilis  which 
may  not  also  be  present  when  the  disease  is  acquired.  Its  course,  how- 
ever, is  very  much  milder  in  the  latter  and  a  fatal  termination  is  rare. 
Fournier  states  that  of  his  forty-two  cases  only  one  died  of  marasmus. 
This  marked  contrast  to  hereditary  syphilis  is  due  chiefly  to  the  fact  that 
in  the  acquired  variety  the  infant  is  rarely  affected  during  the  early 
months  of  life,  a  time  when  hereditary  syphilis  is  so  very  fatal. 

Tertiary  s}Tnptoms  may  appear  at  any  time  from  three  to  twenty 
years  after  the  original  infection. 

The  treatment  is  the  same  as  that  of  hereditary  syphilis. 

HEREDITARY  SYPHILIS. 

Etiology. — If  both  parents  are  syphilitic,  the  child  is  usually  but  not 
invariably  so.  The  s^-mptoms,  however,  are  not  more  severe  than  when 
the  inheritance  is  from  one  parent  only.  The  likelihood  of  transmission 
depends  upon  the  stage  of  the  disease  in  the  parents.  If  the  mother 
is  suffering  from  secondary  symptoms,  transmission  is  almost  certain. 
If  active  treatment  has  been  employed  for  several  months,  if  the  child  is 
born  at  a  period  when  no  active  symptoms  are  present,  or  if  the  symptoms 
are  of  a  tertiary  character,  the  offspring  will  probably  escape.  First-born 
children  are  more  likely  to  suffer  severely  from  syphilis  than  the  later 
ones,  provided  infection  of  the  parents  has  taken  place  prior  to  the  birth 
of  all  the  children. 


1054  THE   SPECIFIC   INFECTIOUS  DISEASES. 

The  transmission  of  syphilis  from  the  father  without  the  intermedi- 
ate infection  of  the  mother  was  once  held  to  be  possible.  At  the  present 
time,  however,  this  question  must  be  placed  among  those  not  yet  defi- 
nitely settled.  There  can  be  no  doubt  that  in  the  vast  majority  of  the 
cases  the  infection  of  the  child  is  from  the  mother. 

If  both  parents  are  healthy  at  the  time  of  conception  and  the  mother 
becomes  infected  during  her  pregnancy  the  child  may  or  may  not  be 
syphilitic.  Transmission  to  the  child  is  much  less  likely  to  occur  if  the 
mother  is  infected  during  the  last  two  months  of  her  pregnancy  than 
earlier,  although,  as  Hutchinson's  cases  conclusively  show,  there  is  no 
certainty  that  the  child  will  escape.  Diday.  states  that  if  the  mother  is 
infected  before  the  fourth  week  and  proper  treatment  is  instituted,  the 
child  will  usually  escape  on  account  of  the  relation  of  the  embryo  to  the 
maternal  circulation  during  this  early  period. 

In  1837  Colles  enunciated  the  following  proposition,  the  trutli  of 
which  has  been  abundantly  verified  since  his  time :  "  A  new-born  cliild 
affected  with  inherited  syphilis,  even  although  it  may  have  symptoms  in 
the  mouth,  never  causes  ulceration  of  the  breasts  which  it  sucks  if  it  be 
the  mother  who  suckles  it,  although  continuing  capable  of  infecting  a 
strange  nurse." 

Caspary  inoculated  with  sjrphilis  a  woman,  apparently  healthy,  who 
had  aborted  with  a  syphilitic  child ;  the  result  was  negative.  A  similar 
experiment  was  made  by  Xeumann,  with  a  like  result.  Widal  reports  a 
case  of  an  apparently  healthy  woman  who  had  a  syphilitic  child  by  an 
infected  husband ;  later,  by  a  second  husband  who  was  free  from  syphilis, 
she  had  a  syphilitic  child.  The  conclusion  seems  irresistible  that  the 
carrying  of  a  syphilitic  child  gives  immunity  to  the  mother  against  the 
disease,  and  that  this  immunity  is  due  to  the  fact  that  she  herself  suffers 
from  syphilis,  or  a  modification  of  that  disease.  The  mother  under 
these  circumstances  can  not  be  inoculated,  either  by  her  syphilitic  nurs- 
ing infant  or  artificially. 

That  hereditary  syphilis  is  contagious  is  conclusively  shown  by  a 
number  of  recorded  instances  in  which  a  healthy  wet-nurse  has  been 
infected  by  a  syphilitic  infant.  However,  such  examples  of  contagion 
are  very  rare,  and  many  writers  of  large  experience  state  that  they  have 
never  seen  it.  It  is  certainly  true  that  the  danger  of  spreading  infection 
from  a  case  of  hereditary  syphilis  has  been  exaggerated. 

Lesions. — Death  may  be  due  to  syphilis,  and  yet  the  autopsy  may  re- 
veal no  characteristic  anatomical  changes,  and  in  fact  there  may  be  no 
demonstrable  changes  in  any  of  the  organs  except  the  presence  of  the 
spirochaeta. 

Bones. — In  the  case  of  a  syphilitic  foetus,  a  still-born  child,  or  one 
dying  soon  after  birth,  the  changes  in  the  bones  are  more  uniformly 
present  than  are  any  other  lesions.     They  are,  in  fact,  rarely  wanting, 


HEREDITARY   SYPHILIS.  1055 

and  it  is  by  them  usually  that  syphilis  is  recognised  post  mortem.  The 
long  bones  are  principally  affected,  the  most  important  changes  being 
found  at  the  junction  of  the  shaft  with  the  epiphyseal  cartilage.  The 
lesion  is  termed  an  epiphyseal  osteo-chondritis  or  acute  epiphysitis. 
There  is  in  the  early  stage  congestion,  swelling,  and  cell  proliferation, 
which  may  be  followed  by  separation  of  the  epiphysis,  suppuration  in  the 
neighbouring  joint,  osteomyelitis,  and  necrosis.  These  changes  are  more 
fully  considered  under  Diseases  of  the  Bones. 

Liver. — This  is  probably  more  frequently  involved  in  the  foetus  and 
newly-bom  infant  than  any  other  organ.  The  syphilitic  lesions  of  the 
liver  consist  in  an  interstitial  hepatitis,  a  gummatous  hepatitis,  or  a 
combination  of  the  two  varieties. 

In  the  interstitial  form,  which  is  most  frequent  in  infancy,  there  is 
first  a  congestion  and  swelling  of  the  organ,  with  the  exudation  of  leuco- 
cytes in  groups.  The  liver  is  enlarged,  frequently  very  much  so,  but 
presents  few  other  gross  changes.  Later,  new  connective  tissue  forms, 
and  atrophy  of  the  liver  cells  takes  place,  with  obliteration  of  some  of 
the  portal  and  hepatic  vessels.  This  process  may  be  diffuse,  but  it  is. 
usually  in  patches.  Groups  of  miliary  syphilomata  may  also  be  found. 
If  the  process  is  diffuse,  the  liver  is  large,  firm,  and  of  a  grayish-yellow 
colour.  If  it  is  localised,  the  affected  areas  are  yellow  or  gray  and  the 
other  parts  are  normal. 

Tlie  gummatous  form  is  not  frequent  in  early  infancy,  but  belongs  to 
a  little  later  period.  In  this  there  may  be  miliary  syphilomata  with 
interstitial  changes,  and  in  addition  the  formation  of  small  or  large 
gummatous  tumours,  which  may  be  softened  at  the  centre.  They  are 
surrounded  by  zones  of  new  connective  tissue  and  the  liver  cells  are 
atrophied.     Amyloid  changes  may  be  present. 

In  the  late  form  of  hereditary  syphilis,  usually  seen  in  children  over 
four  or  five  years  old,  the  liver  is  occasionally  affected.  The  lesions 
resemble  those  of  the  congenital  variety.  There  are  found  cirrhotic 
changes,  which  may  be  diffuse  or  circumscribed,  and  gummatous  deposits, 
which  vary  from  a  minute  size  to  that  of  a  cherry ;  there  may  be  amyloid 
degeneration. 

Spleen. — This  is  almost  invariably  enlarged  in  newly-born  children 
with  syphilis  and  in  syphilitic  foetuses,  but  nothing  characteristic  is 
found  under  the  microscope.  In  older  children  the  enlargement  of  the 
spleen  is  apt  to  be  greater;  the  organ  may  be  the  seat  of  interstitial 
changes,  and  sometimes  there  may  be  gummatous  deposits.  These 
changes  are  rare  in  children  under  two  years  of  age. 

Respiratory  System. — In  syphilitic  infants  who  are  still-born  and 
in  those  who  die  soon  after  birth,  there  is  frequently  found  in  the  lungs 
what  is  known  as  "  white  pneumonia."  This  process  consists  in  fatty 
changes  in  the  epithelium  of  the  air  vesicles;  with  this  there  is  associated 


1056  THE  SPECIFIC  INFECTIOUS  DISEASES. 

a  certain  amount  of  interstitial  pneumonia,  wliich  is  cliiefly  peribron- 
chial. In  older  cases  the  interstitial  pneumonia  is  extensive,  and  the 
lungs  ma_y  be  the  seat  of  gummatous  deposits,  which  soften  and  form 
small  cavities.  Accompanying  these  changes  there  may  be  bronchiec- 
tasis, emphysema,  and  the  usual  secondary  lesions  which  follow  chronic 
interstitial  pneumonia.  In  syphilitic  infants  there  is  a  strong  tendency 
for  all  inflammations  of  the  lungs  to  become  chronic. 

The  trachea  and  bronchi  are  in  rare  cases  the  seat  of  stenosis,  which 
results  from  cicatrisation  following  the  softening  of  gummatous  de- 
posits in  their  walls.  Lesions  of  the  larynx  are  also  infrequent.  There 
is  usually  perichondritis,  which  more  often  involves  the  epiglottis  than 
any  other  part,  and  sometimes  there  is  the  formation  of  papillomatous 
masses;  but  ulceration  and  stenosis  are  both  rare. 

The  nasal  mucous  membrane  in  the  early  stage  of  the  disease  is  very 
constantly  the  seat  of  a  chronic  catarrhal  inflammation,  which  may  be 
accompanied  by  superficial  ulceration.  In  the  late  cases  there  is  deeper 
ulceration,  from  the  breaking  down  of  gummata,  with  extension  to  the 
.periosteum,  cartilages,  and  bones,  causing  perforation  of  the  septum, 
necrosis  of  the  bones,  etc. 

Nervous  System. — Syphilitic  lesions  of  the  brain  and  cord  are  rare  in 
children  as  compared  with  adults,  and  they  are  especially  so  in  infancy. 
The  most  characteristic  cerebral  lesion  of  the  newly-born  child  is  hydro- 
cephalus, which  may  depend  upon  ependymitis,  as  in  two  cases  reported 
by  D' Astros,  the  disease  proving  fatal  in  the  second  month.  Syphilitic 
meningitis  is  exceedingly  rare  under  two  years.  There  is  occasionally 
seen*  in  young  infants  a  chronic  basilar  meningitis  of  syphilitic  origin. 
Chronic  pachymeningitis  associated  with  gummata  has  been  observed  as 
early  as  the  fourth  year.  There  have  been  reported  in  infants  a  few 
cases  of  chronic  meningitis  with  great  thickening  of  the  dura  mater  and 
cerebral  sclerosis. 

Nearly  all  the  syphilitic  lesions  of  the  nervous  system  which  are  seen 
in  adult  life  have  been  observed  in  childhood,  but  infrequently,  and  in 
young  children  they  are  extremely  rare. 

Heart  and  Arteries. — These  may  be  affected  even  in  young  infants. 
Adler,  of  four  cases  examined,  found  two  in  which  well-marked  lesions 
were  present  in  infants  under  four  months.  There  was  endarteritis  of 
the  coronary  arteries  accompanied  by  the  early  changes  belonging  to 
interstitial  myocarditis.  Chiari  has  reported  syphilitic  endarteritis  of  the 
brain  at  fifteen  months,  followed  by  thrombosis  and  softening. 

Digestive  System. — Chronic  catarrhal  pharyngitis  is  almost  a  con- 
stant symptom  of  the  early  cases.  Later  there  is  seen  superficial  or  deep 
ulceration  of  the  pharynx,  tonsils,  or  fauces,  whicii  may  lead  to  perfora- 
tion of  the  soft  palate  or  to  the  formation  of  condylomata. 

There  are  no  important  lesions  of  the  stomach  or  intestines  either 


HEREDITARY  SYPHILIS.  1057 

with  early  or' late  syphilis.  The  rectum  is  occasionally  the  seat  of  ulcera- 
tion, and  condylomata  may  form  even  in  young  children. 

Organs  of  Special  Sense. — Otitis  is  a  frecjuent  accompaniment  of  the 
early  syphilitic  pharyngitis.  It  is  very  likely  to  become  chronic,  and  in 
many  cases  results  in  a  permanent  impairment  of  hearing.  Iritis  is  rela- 
tively rare  in  children,  but  it  may  occur  even  in  intra-uterine  life,  as 
shown  by  the  presence  of  adhesions  in  newly-born  children.  It  is  usually 
seen  in  infants  four  or  five  months  old,  and  is  always  serious.  Interstitial 
keratitis  occurs  frequently  as  a  late  manifestation  of  syphilis.  Choroiditis 
and  optic  neuritis  are  both  occasionally  seen,  ])ut  they  are  rare. 

Genito-urinary  Organs. — Nearly  all  these  may  be  afFe(;ted,  but  gener- 
ally in  the  late  period  of  the  disease.  There  may  be  chronic  interstitial 
nephritis  and  more  rarely  gummatous  deposits  in  tlie  kidney,  interstitial 
changes  in  the  suprarenal  bodies,  and  orchitis,  wliicli  iisually  affects  the 
body  of  the  organ,  rarely  the  epididymis;  it  is  generally  an  interstitial 
inflammation,  with  or  without  gummatous  deposits. 

Among  the  less  frequent  visceral  lesions  may  be  mentioned  abscesses 
of  the  thymus,  whicli  are  usually  small  and  multiple ;  enlargement  of  the 
pancreas,  with  an  increase  of  connective  tissue  and  glandular  atrophy; 
and  chronic  peritonitis.  The  lesions  of  the  mucous  membranes  will  be 
considered  under  Symptoms. 

Symptoms. — As  the  result  of  syphilis,  abortion  may  take  place  at  any 
period  of  pregnancy,  with  the  discharge  of  a  dead  or  macerated  foetus,  or 
the  child  may  be  still-born  at  term,  or  it  may  be  born  alive  prematurely, 
but  with  so  feeble  a  vitality  that  it  survives  but  a  few  hours.  Under 
these  circumstances  it  is  often  difficult  and  sometimes  impossible  to  de- 
cide positively  with  reference  to  the  existence  of  syphilis.  Maceration  of 
the  foetus  or  peeling  of  the  skin  is  no  proof,  and  even  the  examination 
of  the  internal  organs  may  not  be  conclusive,  except  for  the  presence  of 
spirochffitse.  Lomer  examined  43  foetuses,  all  dying  before  the  thirtieth 
week  of  pregnancy;  he  found  the  spleen  and  liver  enlarged  in  all,  and 
marked  bone  changes  in  31.  Birch-Hirschfeld  examined  108  newly-born 
syphilitic  infants;  he  found  the  spleen  invariably  enlarged;  typical  bone 
changes  were  present  in  35,  but  in  many  cases  the  bones  were  normal. 
Mervis,  from  an  examination  of  93  syphilitic  foetuses,  states  that  no 
eruption  upon  the  skin  was  found  earlier  than  the  eighth  month. 

Symptoms  are  present  at  birth  in  only  a  small  number  of  cases.  In 
such  there  is  usually  a  very  severe  degree  of  infection,  and  the  infants 
do  not  often  live  more  than  a  few  days.  Upon  the  skin  there  may  be 
seen  an  eruption  of  pustules,  papules,  or  bullae.  The  bullae  are  usually 
upon  the  soles  and  palms,  but  may  be  found  upon  other  parts  of  the  body. 
The  name  "  syphilitic  pemphigus  "  is  often  given  to  this  condition.  The 
bullae  are  at  first  small,  and  then  coalesce  and  form  larger  ones  two  inches 
or  more  in  diameter.  They  contain  a  turbid  serum  which  is  sometimes 
68 


1058  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tinged  with  blood,  and  sometimes  yellow  from  pus.  Pustules,  when  pres- 
ent, are  usually  seen  upon  the  face  or  scalp.  The  general  appearance  of 
these  infants  is  wretched  in  the  cxtren\e.  The  body  is  wasted,  tlie  skin 
wrinkled,  and  temperature  subnormal.  The  spleen  is  usually  enlarged 
and  often  the  liver  also.  Death  usually  occurs  from  inanition  within 
two  weeks. 

In  the  great  majority  of  cases  the  infant  appears  healthy  at  birth, 
and  continues  so  for  a  variable  time  before  the  manifestation  of  the  char- 
acteristic symptoms  of  syphilis.  As  a  rule,  the  more  intense  the  infec- 
tion, the  earlier  the  symptoms  make  their  appearance.  The  earliest 
symptoms  are  generally  seen  between  the  second  and  the  sixth  weeks. 
If  three  months  pass  without  evidence  of  syphilis,  the  probabilities  are 
that  the  child  will  escape.  Miller  (Moscow)  gives  the  following  statistics 
of  the  time  of  beginning  of  symptoms  in  1,000  cases : 

Syroptoms  appeared  during  the  first  week 85  cases. 

"              "         "    second  week 138  " 

"             "         "    third  week 240  " 

"                 "              "         "    fourth  week 177  " 

"    fifth  week 86  " 

"                 "              "         "    sixth  week 54  " 

"                 "              "         "    seventh  week 50  " 

"                "             "         "    eighth  week 30     " 

After  the  eighth  week 140  " 

Sometimes  the  constitutional  symptoms — wasting,  cachexia,  etc. — 
are  noticed  before  the  local  ones,  but  usually  this  is  not  the  case.  Gener- 
ally the  first  symptom  is  the  coryza  or  "  snuffles,"  which  resembles  an 
ordinary  cold  in  the  head,  except  that  it  persists.  It  is  accompanied  by 
a  hoarse  cry,  indicating  that  the  larynx  participates  in  the  catarrhal  in- 
flammation. Soon  the  eruption  makes  its  appearance,  being  generally 
first  seen  upon  the  hands,  feet,  and  face.  Fissures  and  mucous  patches 
may  be  seen  upon  the  lips,  about  the  anus,  and  elsewhere.  There  is  often 
slight  fever,  from  99°  to  101°  F.  There  may  also  be  observed  excessive 
tenderness  and  swelling  about  the  shoulders,  elbows,  wrists,  or  ankles, 
due  to  acute  epipliysitis,  which  may  cause  the  child  to  cry  from  the 
slightest  amount  of  handling,  and  the  limbs  may  be  moved  so  little  that 
paralysis  is  suspected. 

In  a  severe  case,  as  these  local  symptoms  develop,  the  infant's  gen- 
eral nutrition  suffers.  He  loses  steadily  in  weight,  he  becomes  extremely 
anaemic,  and  whines  and  frets  almost  continually,  but  especially  at  night. 
The  features  have  a  pitiful,  dra'wn  expression ;  and  the  face  is  wrinkled, 
giving  the  infant  a  very  old  appearance.  The  skin  has  a  peculiar  sal- 
low colour,  which  has  been  well  described  as  cafe  au  lait.  The  symp- 
toms may  continue  until  a  condition  of  extreme  marasmus  is  reached, 
or  death  occurs  from  some  intercurrent  affection  of  the  lungs  or  diges- 
tive organs. 


HEREDITARY    SYPHILIS. 


1059 


In  the  milder  forms  of  infection  tlie  severe  constitutional  symptoms 
described  are  not  seen,  although  the  local  evidences  of  disease  are  well 
marked.  The  severity  of  the  symptoms  is  also  nmch  modified  by  treat- 
ment, especially  when  this  is  begun  early. 

The  most  important  local  symptoms  are  tlie  coryza,  eruption,  fissures 
about  the  mouth  and  anus,  mucous  patches,  painful  swellings  at  the  ex- 
tremities of  the  long  bones,  pseudo-paralysis,  and  onychia. 

Coryza. — In  most  of  the  cases  this  is  the  first  symptom.  J^cginning 
like  an  ordinary  catarrh,  it  is  distinguished  by  its  severity  and  its  per- 
sistence. There  is  a  copious  discharge  of  nmcus  and  serum,  often  tinged 
with  blood.  Thick  crusts  form,  which  produce  the  iisual  symptoms  of 
nasal  obstruction;  there  is  great  difficulty  in  nursing;  the  infant  breathes 
through  the  mouth,  and  the  mucous  membrane  of  the  mouth  is  dry,  caus- 
ing great  discomfort.  If  untreated,  the  process,  which  at  first  involves 
the  mucous  membrane  only,  may  extend  to  the  submucous  tissue,  causing 
ulceration;  but  the  cartilages  and  the  bones  of  the  nasal  fossje  are  not 
involved  till  a  later  period  in  the  disease. 

The  nasal  catarrh  is  associated  with  more  or  less  laryngitis,  causing 
hoarseness  or  aphonia,  and  rarely  there  may  be  laryngeal  stenosis.  Dil- 
lon Brown  has  reported  one  case  in  an  infant  six  weeks  old,  which  recov- 
ered after  intubation. 

Eruption.— The  early  eruption  usually  appears  after  the  coryza  has 
lasted  about  a  week ;  but  the  two  may  come  at  tiie  same  time ;  or  the 
coryza  may  be  absent,  or  so 
slight  that  the  rash  seems 
to  be  the  first  symptom. 

Occasionally  there  is 
seen  a  diffuse  blush  or  ro- 
seola, but  more  frequently 
the  eruption  is  macular, 
occuring  in  small,  dark- 
red  spots  about  the  size  of 
the  infant's  finger  nails, 
usually  circular  and  often 
slightly  elevated ;  there  is 
no  surrounding  inflamma- 
tion, and  rarely  any  itch- 
ing. It  is  usually  most 
abundant  upon  the  face, 
the  neck,  and  the  extensor 
surface  of  the  upper  and 
lower  extremities,  espe- 
cially the  hands  and  feet,  sometimes  extending  over  the  entire  body, 
although  it  is  generally  scanty  over  the  chest  and  abdomen.    At  first  the 


Fig.  210. — Early  Eruption  of  Hereditary 
Syphilis.     Infant  two  months  old. 


1060 


THE  SPECIFIC   INFECTIOUS   DISEASES. 


colour  is  bright,  but  gradually  becomes  of  a  dusky-red  or  coppery  hue. 
After  a  little  time  very  fine  scales  may  be  seen  upon  the  surface  of  the 
red  macules.  The  rash  comes  out  slowly,  usually  requiring  from  one  to 
three  weeks  for  its  full  development.  It  fades  gradually,  leaving  a 
coppery  discolouration  of  the  skin,  which  continues  for  a  long  time.  Tiie 
duration  of  the  eruption  is  from  three  to  eight  weeks;  less  if  active 
treatment  is  employed. 

A  papular  eruption  is  rarely  seen  alone,  but  is  usually  associated 
with  the  macular  variety.  The  papules  are  of  a  brownish  colour  and 
are  hard.    They  are  seen  most  frequently  upon  the  palms  and  soles. 


Fio.  211. — Early  Eruption  of  Hereditary 
Syphilis.  Infant  two  and  one-half  months 
old. 


Fig.  212. — Syphilitic  Scaling  of  the 
Foot.  From  an  infant  eight  weeks 
old. 


A  squamous  eruption  is  frequently  seen  upon  the  palms  and  soles,  but 
very  rarely  elsewhere.  In  a  few  cases  this  scaliness  forms  the  most  dis- 
tinctive feature  of  the  cutaneous  lesion  (see  Fig.  212). 

Fissures  and  Mucous  Patches. — These  are  among  the  most  diagnostic 
features  of  early  hereditary  syphilis.  Fissures  are  most  frequently  seen 
on  the  lips  and  about  the  anus,  but  they  may  occur  about  the  nostrils  and 
occasionally  elsewhere.  The  fissures  of  the  lips  are  really  linear  ulcers, 
and  are  distinguished  by  their  persistence  in  spite  of  local  treatment. 
They  are  nmltiple,  deep,  painful,  and  bleed  easily.  After  healing, 
these  fissures  may  leave  many  cicatrices  radiating  from  the  mouth, 
the  contraction  of  which  produces  the  so-called  "  purse-string  de- 
formity." 

Mucous  patches  may  develop  from  fissures,  but  more  frequently  from 
papules  which  are  situated  in  regions  where  they  are  exposed  to  constant 


HEREDITARY  SYPHILIS. 


1061 


moisture  and  friction.  Tliey  are  very  common  upon  the  mnco-cutaneous 
surfaces  and  wherever  the  skin  is  especdally  thin.  They  are  most  apt 
to  be  seen  about  the  lips,  anus,  s{;rotum,  and  vulva,  but  they  may  also  be 
found  behind  the  ears,  between  the  toes,  in  the  folds  of  the  groin,  axillae, 
or  buttocks.  They  vary  from  an  eighth  to  half  an  inch  in  diameter,  are 
whitish  in  colour,  and  are  raised  rather  than  excavated. 


Fig.  213. — A  Later  Form  of  Eruption  in  Hereditary  Syphilis. 
Infant  eight  months  old. 


Ulcers  may  be  present  upon  any  of  the  mucous  membranes,  fre- 
quently in  the  mouth  or  on  the  genitals;  they  are  seldom  symmetrical, 
and  while  they  may  be  broad  they  are  never  deep. 

Ilcemorrhagcs. — They  are  generally  associated  with  the  lesions  of  the 
mucous  membranes,  especially  of  the  nose.  In  young  infants  with  severe 
infection,  bleeding  may  occur  from  the  bullous  eruption  upon  the  skin, 
or  from  the  fissures  at  any  of  the  orifices,  particularly  the  mouth  and 
anus.  Fischl  has  reported  seven  cases  of  multiple  haemorrhages  in  the 
newly  born,  associated  with  other  symptoms  of  congenital  syphilis. 
Mracek  noted  haemorrhages  in  thirty-three  per  cent  of  160  autopsies  on 
syphilitic  still-born  infants  or  those  dying  soon  after  birth.  Examination 
of  the  blood-vessels  in  some  of  these  cases  showed  infiltration  of  their 
walls  and  narrowing  of  their  lumen.  The  vascular  changes  were  thought 
to  be  the  cause  of  the  bleeding. 

Nails. — The  nails  present  several  peculiarities  in  syphilitic  infants. 
There  may  be  a  disease  of  the  matrix  resulting  in  suppuration  and  ex- 
foliation of  the  nail ;  frequently  the  dorsum  is  much  arched,  and  the  nail 
appears  as  if  it  had  been  pinched  by  a  pair  of  forceps — i.  e.,  claw-shaped ; 
this  is  an  early  symptom  of  some  diagnostic  importance.  The  hair  and 
eyebrows  frequently  fall  out  completely.  This  symptom  is  not  usually 
present  in  very  early  infancy. 

Pseudo-paralysis. — Tliis  is  due  to  acute  epiphysitis,  and  it  may  be 
the  first  symptom  of  hereditary  syphilis  to  attract  attention.     It  is  usu- 


1062  THE  SPECIFIC   INFECTIOUS  DISEASES. 

ally  noticed  when  the  infant  is  a  few  weeks  old  that  one  or  sometimes 
both  arms  are  not  moved,  and  that  the  parts  are  tender  when  handled. 
The  arm  is  very  frequently  held  in  marked  inward  rotation  with  the  palm 
looking  outward,  resembling  the  position  in  Erb's  palsy ;  but  careful  ex- 
amination makes  it  evident  that  the  loss  of  power  is  only  apparent,  and 
that  it  is  due  either  to  the  pain  which  motion  produces  or  to  epiphyseal 
separation.  A  history  will  usually  be  obtained  that  loss  of  power  did 
not  exist  at  birth,  but  developed  subsequently.  The  electrical  reactions 
in  these  cases  are  normal,  and  the  rapid  improvement  under  mercurial 
treatment  is  diagnostic. 

The  only  visceral  symptoms  of  importance  are,  enlargement  of 
the  spleen,  which  is  almost  invariably  present  in  the  active  stage  of 
hereditary  syphilis,  and  jaundice  with  or  without  enlargement  of  the 
liver. 

Late  Hereditary  Syphilis. — The  symptoms  may  come  on  at  any 
period  during  childhood  or  about  the  time  of  puberty,  but  very  rarely 
at  a  later  time  than  this.  They  are  seen  both  in  those  who  have  had 
the  usual  symptoms  of  hereditary  syphilis  in  early  infancy,  and  in  others 
where  the  most  careful  examination  into  the  history  fails  to  disclose  any 
symptoms  whatever  of  early  syphilis.  It  is  fair  to  assume  in  such  cases 
either  that  early  symptoms  were  absent  or  that  they  were  of  trivial  im- 
portance. 

Late  hereditary  syphilis  shows  itself  by  symptoms  which  in  acquired 
disease  would  be  classed  as  tertiary.  The  most  characteristic  are  the 
affections  of  the  teeth,  the  bones,  gummatous  deposits  in  the  solid  vis- 
cera, the  skin,  or  mucous  membranes,  the  breaking  down  of  which  may 
lead  to  ulceration. 

Teeth. — There  are  no  peculiarities  in  the  first  teeth  of  syphilitic  chil- 
dren except  their  proneness  to  early  decay.  They  are  rather  more  likely 
to  appear  early  than  late. 

The  characteristic  teeth  of  syphilis  are  those  of  the  second  set.  In 
estimating  the  diagnostic  value  of  these  changes,  only  the  upper  central 
incisors  are  to  be  relied  upon ;  these  are  the  test  teeth.  Although  changes 
are  frequently  seen  in  other  teeth,  they  are  not  always  diagnostic.  Typi- 
cal syphilitic  teeth,  according  to  Hutchinson, 

|HpHHIH|H|  have  each  a  single  notch  in  the  centre  of  the 

r^^^W  edge  (Fig.  ^14).     The  notch  is  usually  shal- 

Tkf^^fg-'tm^  lf>w  and  more  or  less  crescentic  in  shape.    The 

^  enamel  is  general Iv  deficient  in  the  centre  of 

Fig.  214.— Typical  "HoTCH-     ,,  +  u  i  x,    "  .      - 1    ,  .    ,      ,       v 

inson's  Teeth."     (After    ^"^  notch,  and  the  tooth  here  is  apt  to  be  dis- 

Fournier.)  coloured.     The  teeth  in  other  cases  are  vari- 

ously dwarfed  and  deformed.  (See  Fig. 
215.)  They  often  taper  regularly  from  the  base  to  the  edge,  giving  rise 
to  the  term  "  screw-driver  teeth."    The  teeth  are  not  so  flat  as  the  normal 


HEREDITARY  SYPHILIS. 


1063 


Thcv  arc  not  properly  placed, 
each  other.     They  are  seldom 


Fig.  215. — Syphilitic  Teeth.  Boy 
eight  years  old;  under  observation 
several  years  with  various  syphi- 
litic manifestations. 


It  has  already  heen  de- 


incisors,  but  often  rounded  and  peg-like, 
but  incline  either  toward  or  away  from 
large    enough    to    touch    the    adjacent 
teeth  on  both  sides. 

Although  Hutchinson's  teeth  may 
generally  be  taken  as  conclusive  evi- 
dence of  syphilis,  they  are  not  invari- 
ably so,  as  Keyes  and  others  have 
shown.  It  is  to  be  remembered  in  this 
connection  that  the  absence  of  changes 
in  the  teeth  is  of  no  importance  what- 
ever as  evidence  that  syphilis  is  not 
present.  Hutchinson  states  that  they 
are  wanting  in  more  than  half  the 
cases. 

Bones. — The  form  of  disease  which 
is   usually   seen   at   this   period    is    an 
osteo-periositis,     affecting     principally 
the  shaft  of  the  long  bones  and  the  cranium 
scribed  elsewhere. 

Lymph  Nodes. — They  are  less  frequently  affected  than  in  adults,  and 
in  early  infancy  they  are  seldom  much  involved.  In  most  cases  after  the 
first  year  there  may  be  found  a  moderate  degree  of  enlargement  of  the 
post-cervical  and  epitrochlear  glands,  swelling  of  the  latter  having  con- 
siderable diagnostic  value.  Under  normal  conditions  the  latter  can 
scarcely  be  felt;  but  in  syphilitic  children  they  may  be  as  large  as  a  pea 
or  a  small  bean;  sometimes  two  or  three  of  them  can  be  distinguished. 
They  are  so  rarely  enlarged  from  other  constitutional  conditions  that, 
provided  no  local  cause  for  the  swelling  exists,  they  should  always  create 
a  suspicion  of  syphilis.  The  post-cervical  glands  are  frequently  affected, 
but  are  not  so  diagnostic.  The  degree  of  enlargement  is  rarely  great. 
Occasionally  there  are  seen  in  the  neck  large  masses  of  swollen  lymph 
glands  which  resemble  tuberculous  swellings.  They  are,  however,  very 
rare. 

Special  Senses. — The  most  frequent  affection  of  the  eye  in  late  syph- 
ilis is  interstitial  keratitis,  the  close  connection  of  which  with  hereditary 
syphilis  was  first  pointed  out  by  Hutchinson.  It  is  usually  found  asso- 
ciated with  the  typical  notched  teeth.  The  diagnostic  value  of  keratitis 
in  syphilis  is  denied  by  Fournier,  who  states  that,  w^hile  often  syphilitic, 
it  is  not  infrequently  due  simply  to  malnutrition.  Both  eyes  are  usually 
affected,  and  in  all  degrees  of  severity,  from  a  slight  haziness  of  the 
cornea  to  complete  opacity.  However,  with  an  early  diagnosis  and 
prompt  treatment,  a  marked  degree  of  improvement  may  be  expected  in 
most  cases. 


1064  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Chronic  otitis  may  be  a  result  of  tlie  acute  process  seen  in  early 
infancy.  There  is  nothing  peculiar  about  the  inflammation  in  these 
cases.  A  form  of  deafness  occurs  in  older  children,  which  Hutchinson 
states  is  almost  invariably  due  to  syphilis.  Its  onset  is  quite  sudden, 
without  pain.  Tiie  loss  of  hearing  is  apt  to  be  permanent,  and  if  it 
occurs  early  in  childhood  it  is  a  cause  of  deaf-nmtism. 

Skin. — The  most  important  of  the  later  manifestations  of  syphilis 
consists  in  the  formation  of  subcutaneous  gummata.  In  the  early  stage 
they  are  indurated,  elastic,  of  a  grayish  colour,  with  red  borders.  Under 
treatment  they  disappear  quite  rapidly  by  absorption ;  but  when  neglected 
they  break  down,  leaving  large  deep  ulcers.  These  ulcers  are  quite  char- 
acteristic in  appearance,  but  may  be  confounded  with  those  due  to  tuber- 
culosis. The  syphilitic  ulcer  has  rounded,  thickened,  indurated  borders, 
and  a  base  which  is  depressed  and  has  the  appearance  of  being  scooped 
out.  It  is  sometimes  covered  by  hard  crusts  and  is  surrounded  by  a  red 
areola.  It  leaves  a  smooth  white  scar.  The  most  frequent  situation 
is  upon  the  face  and  upper  part  of  the  legs  or  thighs.  Tuberculous 
ulcers  have  usually  soft,  flat  edges,  and  do  not  extend  so  deeply; 
they  are  more  irregular  in  outline;  the  cicatrix  left  is  of  a  purplish 
colour,  which  becomes  red  and  slowly  fades.  Tubercle  bacilli  may  be 
found. 

Nose  and  Palate. — Disease  of  these  parts  generally  begins  as  the 
breaking  down  of  gummatous  deposits  in  the  mucous  membrane.  The 
nose  may  in  consequence  be  the  seat  of  a  protracted  foetid  discharge 
(ozaena).  The  disease  may  take  on  a  destructive  form  of  ulceration  which 
is  at  times  phagedenic,  and  may  cause  rapid  destruction  of  the  nasal  car- 
tilages and  bones,  perforation  of  the  septum,  and  occasionally  of  the  floor 
of  the  nasal  fossae.  There  may  be  necrosis  of  the  turbinated  bones,  the 
vomer,  or  the  ethmoid.  In  the  most  severe  forms  the  nose  may  be  almost 
destroyed  in  the  course  of  a  few  weeks.  There  may  be  at  the  same  time 
deep  ulceration  of  the  soft  palate,  leading  to  perforation.  In  a  young 
person  this  is  almost  invariably  due  to  syphilis.  In  many  particulars 
these  ulcerations  of  the  nose  and  palate  resemble  lupus;  tliey  are  dis- 
tinguished by  the  rapidity  of  their  progress,  syphilis  often  doing  as 
much  damage  in  weeks  as  is  done  by  lupus  in  years. 

Other  Symptoms: — Syphilitic  disease  of  the  larynx  and  bronchi  is 
rare  in  childhood.  The  former  may  give  rise  to  hoarseness  or  aphonia 
and  occasionally  to  stenosis ;  the  latter  to  a  chronic  cough  and  asthmatic 
attacks.  There  are  no  characteristic  symptoms  belonging  to  syphilis 
of  the  lungs.  The  different  lesions  of  the  central  nervous  S3^stem  which 
may  be  due  to  syphilis  are  all  quite  rare.  The  forms  have  already  been 
mentioned,  and  their  symptomatology  is  discussed  in  Diseases  of  the 
Nervous  System. 

The  only  visceral  changes  which  aid  much  in  diagnosis  are  those  of 


HEREDITARY  SYPHILIS.  1065 

the  liver  and  spleen.  The  liver  is  often  enlarged,  sometimes  to  a  marked 
degree,  and  occasionally  there  is  ascites,  but  very  seldom  jaundice. 

Enlargement  of  the  spleen  is  a  very  frequent  symptom — in  fact,  it  is 
almost  constant  during  active  syphilitic  disease.  I  have  several  times 
seen  it  so  swollen  as  to  form  an  abdominal  tumour  of  considerable  size. 
In  one  case,  in  a  boy  three  years  old,  the  spleen  extended  five  inches  be- 
low the  free  border  of  the  ribs,  quite  to  the  crest  of  the  ileum.  It  was 
associated  with  moderate  enlargement  of  the  liver,  as  is  usually  the 
case. 

In  addition  to  the  local  symptoms  of  late  liereditary  syphilis  enu- 
merated, there  are  others  of  a  general  character  which  are  quite  as  im- 
portant. The  body  is  usually  undersized ;  the  constitution  is  delicate, 
and  shows  but  little  resistance  to  all  forms  of  disease;  puberty  is  fre- 
quently delayed,  and  the  development  of  the  breasts  and  the  genital 
organs  often  imjjerfect;  anaemia  is  usually  present,  and  the  skin  has  a 
sallow  appearance.  Mentally,  many  of  these  children  are  somewhat  de- 
ficient, and  in  a  few  instances  they  become  idiotic,  epileptic,  or  the  sub- 
jects of  dementia. 

Diagnosis. — The  diagnosis  of  early  syphilis  in  most  cases  is  not  diffi- 
cult. The  coryza,  eruption,  labial  fissures,  mucous  patches  about  the 
anus  and  genitals,  enlarged  spleen,  and  later  the  general  cachexia — all 
unite  to  form  a  picture  which  it  is  difficult  to  mistake.  In  irregular 
cases  the  diagnosis  is  easy  just  in  proportion  to  the  number  of  the  fore- 
going symptoms  which  are  present.  Special  care  should  be  taken  not  to 
confound  the  moist  papules  of  simple  intertrigo  upon  the  buttocks  or 
thighs  with  those  of  syphilis.  In  doubtful  cases  much  assistance  may 
be  obtained  from  the  discovery  of  the  spirochsetae  in  the  external  lesions 
and  from  the  Wassermann  reaction. 

In  late  syphilis  the  following  symptoms  are  the  most  reliable  for 
diagnosis :  notching  of  the  teeth,  falling  in  of  the  bridge  of  the  nose, 
interstitial  keratitis,  deafness  not  traceable  to  ordinary  otitis,  enlarge- 
ment of  the  spleen  and  epitrochlear  glands,  ulceration  of  the  palate  or 
nose,  the  sabre-like  deformity  of  the  tibia,  and  nodes  upon  the  tibia  or 
cranium.  There  are  often  found  in  older  children  indefinite  symptoms 
in  regard  to  which  a  suspicion  of  syphilis  exists.  For  such  cases  the 
Wassermann  test  is  of  very  great  value. 

It  becomes  at  times  important  to  distinguish  hereditary  from  ac- 
quired syphilis.  Visceral  lesions  in  acquired  syphilis  are  not  common 
and  belong  to  the  late  period  of  the  disease ;  in  the  hereditary  form  they 
are  well-nigh  constant  and  occur  early,  often  being  present  at  birth. 
The  acute  epiphysitis,  sometimes  accompanied  by  pseudo-paralysis,  sel- 
dom if  ever  occurs  in  acquired  syphilis,  though  frequent  in  the  hereditary 
form.  Symptoms  due  to  defects  in  development,  like  the  misshapen  fin- 
ger-nails, are  seen  only  in  hereditary  syphilis.     The  early  symptoms  re- 


1066  THE  SPECIFIC   INFECTIOUS   DISEASES. 

ferable  to  the  mucous  membranes  and  muco-cutaueous  surfaces — coryza, 
hoarseness,  haemorrhages,  labial  fissures,  etc. — so  characteristic  of  he- 
reditary syphilis,  have  no  place  in  the  acquired  form,  while  the  single 
primary  lesion  sometimes  found  in  the  acquired  form  does  not  exist  in 
the  hereditary  disease. 

Prognosis. — Generally  speaking,  the  prognosis  is  worse  in  infantile 
syphilis  than  in  that  of  adults.  In  infancy  it  is  much  worse  when  hered- 
itary than  when  acquired,  for  the  reason  that  often  the  child  who  is  the 
subject  of  hereditary  syphilis  has  been  affected  by  the  poison  from  the 
very  beginning  of  its  existence,  and  this  lias  modified  its  entire  de- 
velopment. 

The  results  of  206  syphilitic  pregnancies  observed  by  Jullien  (Paris) 
were  as  follows:  Abortion  occurred  in  36,  stillbirtlis  in  8,  and  69  chil- 
dren died  soon  after  birth,  making  a  total  mortality  of  55  per  cent; 
60  were  living  and  syphilitic;  only  43  living  and  in  good  health.  Still 
worse  were  tiie  results  in  cases  observed  by  Le  Pileur :  Of  154  pregnancies 
in  syphilitic  women,  there  were  120  abortions  or  stillbirths,  26  children 
died  soon  after  birth,  and  only  8  survived.  The  statistics  of  the  Found- 
ling Asylum  in  Moscow  for  ten  years  showed  that  of  2,038  syphilitic  in- 
fants the  mortality  was  over  70  per  cent. 

Such  a  mortality  as  that  indicated  in  the  above  statistics  is  seen  only 
in  institutions  where  little  or  no  previous  treatment  lias  been  employed. 
In  private  practice  certainly  nothing  approaching  it  occurs. 

In  addition  to  those  who  die  early  as  the  result  of  syphilitic  infection, 
there  must  be  added  many  whose  constitutions  are  so  impaired  by  syphilis 
that  they  fall  an  easy  prey  in  infancy  to  pneumonia,  diarrhoea,  or  other 
forms  of  acute  disease.  The  remote  effects  of  syphilis  in  infancy  it  is 
hard  to  estimate;  it  may  exert  an  injurious  influence  upon  the  constitu- 
tion in  childhood  and  even  throughout  the  life  of  the  individual. 

The  prognosis  in  an  individual  case  depends  upon  the  age  at  which 
the  symptoms  develop,  the  time  when  treatment  is  begun,  upon  its  thor- 
oughness, and  upon  the  surroundings  and  mode  of  nourishment  of  the 
child.  The  outlook  is  better  the  longer  after  birth  the  first  symptoms 
appear;  it  is  also  better  in  infants  who  are  nursed  than  in  those  who 
are  artificially  fed. 

As  compared  with  syphilis  of  the  adult,  relapses  are  rare,  and  when 
they  occur  early  they  are  nearly  always  the  result  of  insufficient  treat- 
ment. If  proper  early  treatment  is  carried  out,  the  severe  late  symptoms 
are  rare;  patients  are  usually  free  from  all  symptoms  until  six  or  seven 
years  old,  or  until  near  the  time  of  puberty — two  periods  when  they  are 
likely  to  develop. 

The  prognosis  is  better  in  the  later  children  of  syphilitic  parents  than 
in  the  earlier  ones,  provided  infection  has  preceded  the  birtli  of  all  the 
children.     This  fact  illustrates  the  general  tendency  of  the  syphilitic 


HEREDITARY   SYPHILIS.  1067 

poison  to  diminish  in  virulence  as  time  passes,  even  without  treatment. 
The  following  instance  cited  by  Bertin  well  illustrates  tliis  point: 

In  the  first  pregnancy,  tlic  mother  aborted  with  a  dead  child  at  the 
sixth  month;  in  the  second,  at  the  seventh  month;  in  tiie  third,  at  seven 
and  a  half  months;  in  the  fourth  tlie  chihl  was  l)orn  at  term,  and  lived 
eighteen  days ;  in  the  fifth  it  lived  six  weeks ;  in  the  sixth  the  child  lived 
four  months,  without  treatment. 

Prophylaxis. — ^No  infected  person  should  be  allowed  to  marry  until 
at  least  two  years  have  passed  after  the  initial  sore,  treatment  being  con- 
tinued meanwhile;  nor  if  there  are  any  active  symptoms,  no  matter  how 
long  a  time  has  elapsed  since  infection.  There  is  no  certainty  in  any 
ease  that  the  child  will  escape. 

The  mother  should  be  treated  during  her  pregnancy:  (1)  If  she  is 
syphilitic,  whether  the  disease  was  acquired  at  the  time  of  conception 
or  subsequently;  (8)  if  the  father  is  known  to  be  suffering  from  syphilis, 
whether  the  mother  has  symptoms  or  not;  (3)  if  the  mother  has  ever 
previously  shown  signs  of  syphilis,  even  if  she  has  had  no  active  symptoms 
for  a  considerable  period.  In  all  these  conditions  if  efficient  treatment  is 
carried  on  throughout  pregnancy  there  is  a  strong  probability,  but  in  no 
case  a  certainty,  that  the  child  will  escape.  The  third  condition  men- 
tioned is  the  one  in  which  treatment  is  most  likely  to  be  neglected, 
especially  if  the  mother  has  previously  borne  a  child  who  was  not 
syphilitic.  Syphilis,  however,  shows  a  strong  tendency  to  reappear  and 
become  active  during  pregnancy,  even  though  it  has  been  long  quiescent, 
as  the  following  case  cited  by  Diday  shows : 

A  woman  who  had  lost  seven  children  from  syphilis  was  put  under 
treatment  during  the  eighth  pregnancy;  result — child  born  healthy,  and 
continued  so.  In  the  ninth  pregnancy  treatment  was  continued  with  a 
like  result;  in  the  tenth  pregnancy,  no  treatment,  child  syphilitic,  dying 
when  six  months  old;  in  the  eleventh  pregnancy,  treatment  repeated, 
child  healthy. 

The  danger  of  infection  during  labour  is  slight.  As  the  greatest 
danger  of  infecting  a  child  after  birth  is  from  its  parents  or  a  wet-nurse, 
syphilitic  parents  should  be  duly  warned  of  the  danger  to  their  children, 
and  especially  should  be  cautioned  against  kissing  them  or  sleeping  in 
the  same  bed  with  them.  The  utmost  care  should  be  exercised  to  pre- 
vent a  healthy  child  from  being  infected  by  a  syphilitic  nurse.  A  nurse 
should  never  be  accepted  without  a  thorough  examination,  no  matter 
how  clear  a  history  may  be  given.  As  a  syphilitic  child  in  the  household 
may  be  the  means  of  infecting  other  children,  the  same  precautions 
should  be  taken  as  in  the  case  of  other  contagious  diseases.  The  chief 
danger  to  other  children  comes  from  kissing  or  from  using  bottles,  spoons, 
or  cups  which  have  been  infected ;  as  the  syphilitic  infant  is  chiefly  dan- 
gerous on  account  of  the  lesions  in  the  mouth.    Trouble  most  frequently 


1068  THE  SPECIFIC   INFECTIOUS   DISEASES. 

occurs  because  of  ignorance  regarding  the  nature  of  the  disease.  It  is 
possible  for  a  syphilitic  child  to  nurse  a  healthy  woman  without  com- 
municating syphilis,  if  the  child's  moutli  is  treated  and  the  nipjile  not 
allowed  to  become  fissured;  but  it  is  an  experiment  which  should  never 
be  tried. 

Treatment. — This  should  always  be  begun  as  soon  as  the  first  positive 
symptoms  of  syphilis  appear.  Under  certain  circumstances  it  may  be 
advisable  not  to  wait  for  symptoms;  as,  for  example,  when  both  parents 
have  recently  suffered  from  active  symptoms,  when  previous  children 
have  died  soon  after  birth,  or  when,  with  marked  symptoms  in  the  par- 
ents, the  child  exhibits  the  cachexia  of  syphilis,  but  no  definite  local 
symptoms.  Such  anticipatory  treatment  need  not  be  continued  longer 
than  six  weeks  unless  symptoms  appear. 

The  indirect  treatment,  designed  to  reach  the  child  through  the 
mother's  milk,  has  fallen  into  deserved  disuse,  as  it  is  very  uncertain 
and  altogether  unsatisfactory. 

Mercury  is  as  much  a  specific  for  hereditary  as  for  acquired  syphilis. 
There  are  many  ways  of  introducing  it  into  the  system :  it  may  be  given 
by  inunctions,  by  the  mouth,  by  fumigations,  by  baths,  or  hypodermic- 
ally.  In  most  cases  inunction  is  the  manner  to  be  preferred  in  young 
infants.  Gr.  x  of  mercurial  ointment,  diluted  with  the  same  amount  of 
vaseline,  may  be  rubbed  daily  into  the  palms,  soles,  axilla^,  or  the  inner 
surface  of  the  thighs.  It  is  advisable  to  change  the  place  of  inunction 
from  day  to  day ;  and  if  this  is  done,  it  is  extremely  rare  that  erythema 
is  produced.  If  for  any  reason  inunctions  are  ol)jectionable,  as  they 
may  be  when  the  family  are  to  be  kept  in  ignorance  of  the  treatment, 
either  the  gray  powder  or  the  bichloride  may  be  given  by  the  mouth. 
The  usual  dose  of  the  gray  powder  should  be  gr.  |  four  times  a  day ; 
that  of  the  bichloride  gr.  ^^  four  times  a  day,  always  well  diluted.  It 
is  rare  that  larger  doses  are  advisable.  When  the  symptoms  are  urgent, 
it  is  often  best  to  substitute  calomel  for  a  few  weeks,  as  the  system  can 
usually  be  brought  more  rapidly  under  the  influence  of  mercury  by 
this  than  by  the  other  preparations  mentioned;  gr. -j^  four  times  a  day 
is  the  usual  dose  required.  Other  methods  of  administration  and  other 
preparations  offer  no  advantages,  and  have  some  very  obvious  dis- 
advantages. 

The  iodide  of  potassium  is  to  be  used,  either  alone  or  in  combination 
with  mercury,  whenever  such  lesions  exist  as  are  classed  among  adults 
as  tertiary.  This  includes  all  the  late  manifestations,  and  the  earlier 
ones  whenever  the  bones  or  viscera  are  affected.  The  iodide  is  usually 
well  borne  by  children,  and  may  be  given  in  almost  any  desired  dosage. 
In  infancy  it  is  rare  that  more  than  twenty  grains  daily  are  required,  but 
in  older  children  the  necessary  amount  may  be  frojn  one  to  two  drachms 
daily.     It  should  always  be  given  largely  diluted. 


HEREDITARY  SYPHILIS.  1069 

The  duration  of  mercurial  treatment  should  be  at  least  one  year.  The 
doses  during  the  last  six  months  may  be  reduced  to  one-half  or  one-third 
those  employed  while  active  symptoms  are  present.  Treatment  should 
be  longer  than  a  year  if  symptoms  exist.  It  is  often  better  not  to  give 
the  mercury  continuously,  but  with  short  periods  of  intermission. 

Ehrlich's  salvarsan  is  quite  as  efficacious  in  infants  as  in  older  pa- 
tients. Experience  has  shown  that  a  single  dose  does  not  cure  syphilis. 
A  repetition  is  necessary;  two  or  more  injections  should  be  given,  and  the 
best  results  are  obtained  when  it  is  combined  with  the  mercurial  treat- 
ment. In  older  children  the  intravenous  method  of  administration  is 
to  be  preferred;  an  alkaline  solution  should  be  employed.  For  a  child 
of  five  years  the  dose  is  gramme  0. 1  or  gramme  0.2.  In  infancy  the  dif- 
ficulties in  the  way  of  intravenous  administration  are  so  great  that  the 
remedy  must  in  most  cases  be  injected  into  the  muscles.  For  this  pur- 
pose suspension  in  a  bland  oil,  such  as  benzoinol,  is  preferable  to  solu- 
tions, or  aqueous  suspensions.  The  best  site  for  injection  is  the  outer 
part  of  the  buttock  high  enough  to  avoid  the  sciatic  nerve.  Before  re- 
moving the  needle  from  the  tissues,  a  few  drops  of  saline  solution  should 
be  injected  through  it  so  as  to  leave  none  of  the  salvarsan  in  the  sub- 
cutaneous tissue  as  the  needle  is  withdrawn ;  otherwise  sloughing  may 
result.    The  dose  for  an  infant  is  gramme  0.03  to  gramme  0.05. 

The  tonic  treatment  of  syphilis  is  important  and  should  not  be  neg- 
lected. After  specific  treatment  has  been  carried  on  for  a  time,  particu- 
larly if  rapidly  pushed,  the  child  often  becomes  anaemic,  and  suffers 
greatly  from  general  malnutrition.  Under  such  circumstances  it  is 
often  wise  to  discontinue  mercury  altogether  for  a  time,  or  at  least  to 
reduce  the  dose  very  much,  and  administer  cod-liver  oil,  iron,  and  other 
tonics.  Such  a  change  is  frequently  found  to  act  most  beneficially,  even 
when  lesions  are  present,  which  perhaps  have  been  very  little  or  not  at 
all  affected  by  the  specific  remedies  employed.  A  judicious  combination 
of  specific  and  tonic  treatment  is  required  in  every  case,  whether  the 
remedies  are  given  simultaneously  or  alternately. 

Local  Treatment. — Ulcerative  lesions  of  the  skin  require  cleanliness, 
dusting  with  calomel  or  iodoform,  or  bathing  with  the  black  wash.  Mu- 
cous patches  should  be  dusted  with  equal  parts  of  calomel  and  bismuth. 
Fissures  and  ulcers  of  the  mucous  membranes  should  be  treated  by  nitrate 
of  silver.  Phagedenic  ulcers  of  the  palate  or  nose  should  be  cauterised 
with  nitric  acid  or  the  acid  nitrate  of  mercury.  The  late  syphilitic  ulcers 
of  the  skin,  due  to  the  breaking  down  of  gummata,  should  be  treated 
aseptically. 


1070  THE  SPECIFIC   INFECTIOUS   DISEASES. 


CHAPTER    XII. 

INFLUENZA. 

{La  grippe.) 

Influenza  is  an  infectious,  conmumieable  disease,  whicli  is  now 
generally  admitted  to  be  due  to  the  bacillus  described  by  Pi'eiffer  in  1892. 
It  is  serious  in  children  chiefly  from  its  tendency  to  complications  of 
the  respiratory  tract. 

Etiology. — The  influenza  bacillus  is  found  in  the  secretions  of  the 
lower  air-passages,  less  frequently  in  those  of  the  rhino-pharynx,  oc- 
casionally in  the  discharge  of  acute  otitis,  rarely  in  empyema  and  men- 
ingitis. In  meningitis  the  organism  is  generally  found  in  the  blood, 
i.  e.,  it  is  a  part  of  a  general  influenza  septicaemia.  In  the  sputum  its 
presence  can  be  demonstrated  with  certainty  only  by  cultures  upon  blood 
agar.  In  acute  cases  it  may  disappear  very  early;  in  protracted  cases 
its  presence  can  often  be  demonstrated  for  weeks  or  even  months.  Be- 
sides the  bacillus  of  Pfeiffer,  there  are  usually  found  in  patients  suffer- 
ing from  influenza,  the  pneumococcus,  the  staphylococcus  aureus,  and 
the  streptococcus,  either  separately  or  in  combination.  It  is  often  dif- 
ficult in  these  mixed  infections  to  tell  what  part  tlie  different  organisms 
play  in  the  pathological  process. 

Influenza  is  highly  contagious  and  is  almost  invariably  transmitted 
by  direct  contact.  In  Xew  York  the  disease  attracted  little  attention 
until  the  great  epidemic  of  1891,  since  which  time  it  has  regularly  been 
seen  every  winter  season  with  greater  or  less  severity.  It  disappears 
with  the  advent  of  warm  weather.  Epidemics  prevail  chiefly  in  winter 
and  spring.  All  ages  are  liable  to  the  disease,  infants  under  one  year 
especially  so. 

The  period  of  incubation  is  uncertain.  It  is  usually  short,  generally 
from  one  to  seven  days.  Little  if  any  imnmnity  seems  to  be  afforded 
by  one  attack;  recurrencco  and  second  attacks  are  not  uncommon  in  the 
same  epidemic. 

Lesions. — There  are  no  characteristic  lesions  of  influenza;  those 
which  are  most  frequently  found  are  due  to  inflammations  of  the  respir- 
atory tract  which  differ  little  from  the  same  inflammations  when  due 
to  other  organisms.  In  some  cases  the  upper  respiratory  tract  is  alone 
or  chiefly  involved.  These  cases  are  frequently  complicated  by  otitis, 
although  the  influenza  bacillus  is  not  often  found  in  the  aural  discharge. 
In  other  cases  only  the  lower  respiratory  tract  is  involved,  the  process 
usually  spreading  in  infancy  to  the  lungs,  resulting  in  broncho-pneu- 
monia. 

Symptoms. — The  symptoms  of  influenza  are  due  to  the  systemic 
effects  of  a  general  infection,  and  to  certain  local  inflammations  which 


INFLUENZA. 


1071 


may  be  regarded  as  complications.  The  two  classes  of  symptoms — the 
general  and  the  local  ones — are  found  in  all  possible  combinations. 

The  milder  attacks  last  from  two  to  five  days,  occasionally  a  week. 
The  onset  is  usually  abrupt,  with  chilliness,  muscular  pains,  and  some- 
times vomiting.  The  temperature  ranges  from  101°  to  103°  F.  Even 
though  the  fever  is  not  high,  the  prostration  is  considerable,  and  chil- 
dren are  often  ill  enough  to  remain  in  bed  for  several  days.  The  usual 
general  symptoms  which  accompan}^  fever  are  present.  Convalescence 
is  frequently  protracted,  and  it  may  be  three  or  four  weeks  before  the 
general  health  is  regained.  Often  tliere  is  in  addition  a  mild  coryza 
at  the  outset  and  a  slight  but  persistent  cough. 

More  severe  attacks  are  characterised  by  liigher  temperature,  but 
only  moderate  prostration.     They  often  resemble  cases  of  pneumonia. 


Fig.  216. — Temperature  Chart  of  Uncomplicated  Influenz.\.  Infant  fourteen, 
months  old.  No  local  signs  of  disease;  repeated  blood  examinations  for  malaria 
negative;  the  wide  fluctuations  of  the  temperature  independent  of  therapfeutic  meas- 
lu-es.     Prompt  cessation  of  fever  on  removal  from  the  city.        -    '  ' 


except  that  the  local  symptoms  and  physical  signs  in  the  chest  are  want- 
ing. The  onset  is  usually  abrupt  with  vomiting  and  headache,  rarely 
with  convulsions.  The  temperature  ranges  from  100°  to  106.5°  F.  It 
seldom  remains  steadily  high,  but  fluctuates  widely,  often  being  sub- 
normal. I  have  repeatedly  seen  a  temperature  of  over  106°  F.  in 
uncomplicated  influenza.  Marked  nervous  symptoms  are  sometimes 
present;  there  may  be   headache,   stupor,   and   convulsions — symptoms 


1072 


THE  SPECIFIC   INFECTIOUS  DISEASES. 


somewhat  suggesting  meningitis,  but  not  so  continuous  as  in  that  dis- 
ease. More  frequently,  however,  one  is  struck  by  the  disproportion 
existing  between  the  high  temperature  and  the  general  symptoms.  The 
course  of  the  temperature  is  unlike  that  seen  in  any  other  disease.  It 
is  high  and  fluctuates  widely  and  irregularly  without  apparent  reason. 
Variations  of  six  or  seven  degrees  in  the  course  of  a  few  hours  are  very 
often  seen.  Often,  although  the  temperature  rises  every  day  to  104°  or 
even  105°  F.,  the  patient  may  seem  to  be  scarcely  ill  at  all.  The  usual 
duration  of  these  severe  attacks  is  from  five  to  ten  days;  but  even  when 
no  complication  develops  symptoms  may  last  much  longer,  sometimes 
until  a  change  of  climate  is  made.  (See  Fig.  216.)  Although  tlie  symp- 
toms are  very  alarming,  except  in  young  infants,  the  attacks  are  seldom 
fatal  unless  pneumonia  develops. 

Besides  these  general  manifestations  the  symptoms  of  acute  rhino- 
pharyngitis may  be  present.  The  whole  pharynx  may  be  the  seat  of  an 
acute,  erythematous  blush,  or  the  mucous  membrane  may  present  a  gran- 
ular or  spongy  appearance.  Occasionally  there  is  follicular  tonsillitis. 
These  catarrhal  symptoms  may  last  for  several  days  and  gradually  subside. 
A  moderate  amount  of  inflammation  of  the  mucous  membrane  of  the 
larynx,  trachea,  and  large  bronchi  occurs  in  most  of  the  cases  of  influ- 
enza. In  the  more  severe  forms, 
broncho-pneumonia  often  develops. 
Sometimes  the  pulmonary  symp- 
toms do  not  appear  for  two  or  three 
days,  or  even  a  week ;  at  other  times 
they  are  coincident  with  tlie  devel- 
opment of  the  fever  and  other  con- 
stitutional symptoms,  and,  except 
for  the  prevalence  of  influenza,  this 
would  not  be  considered  a  factor  in 
these  cases. 

The  broncho-pneumonia  compli- 
cating influenza  may  not  differ  es- 
sentially from   the   ordinary  types, 
except  that  the  proportion  of  cases 
which  do  not  go  on  to  the  develop- 
ment  of   areas   of  consolidation   is 
larger  than  is  seen  under  most  other 
conditions.    If  lobar  pneumonia  de- 
velops, it  frequently  runs  its  regular 
course.     But  besides  these  two  vari- 
eties of  pneumonia,  quite  a  large  number  of  cases  of  an  irregular  type  are 
seen  with  influenza.    These  are  often  of  short  duration,  but  accompanied 
by  extremely  high  temperature  (Fig.  217). 


IHl' 


loe 


P 


^?e5 


2s: 


Fig.  217. — Acute   Broncho-pneumonia, 
Abortive   Type,   Complicating   In- 

FI>UENZA   IN  AN  InFANT    SiX   MoNTHS 

Old.    The  entire  left  lung  posteriorly 
was  involved. 


INFLUENZA.  1073 

Vomiting  and  diarrhoea  are  frequent  at  the  beginning  of  influenza, 
and  in  some  cases,  especially  in  infants,  they  may  continue  throughout 
the  attack. 

Protracted  and  recurring  attacks  of  influenza  are  exceedingly  com- 
mon and  the  influenza  bacillus  may  be  demonstrated  for  months  in  the 
secretions  of  such  patients.  Tlie  protracted  cases  in  my  experience  have 
almost  invariably  been  preceded  by  a  well-defined  acute  attack,  after 
which  there  is  improvement  but  not  recovery,  and  an  irregular  low  fever 
follows,  which  may  drag  on  indefinitely  or  there  may  recur,  at  intervals 
of  a  few  days  or  weeks,  periods  of  very  high  temperature  sometimes 
accompanied  by  pulmonary  symptoms  and  signs  and  sometimes  not. 
The  cases  are  often  called  malaria,  or  chronic  intestinal  poisoning,  and 
not  infrequently  tuberculosis  is  siispected;  but  the  special  features  of 
all  these  diseases  are  wanting.  In  the  cases  I  have  seen  the  symptoms 
have  been  controlled  by  change  of  climate,  but  without  this  they  have 
not  infrequently  continued  until  the  following  warm  season.  The  rare 
cases  of  influenza  in  which  the  organisms  are  found  in  the  blood  are 
characterised  by  severe  constitutional  symptoms.  They  usually  prove 
fatal  either  from  the  development  of  extensive  pneumonia  or  from  menin- 
gitis. The  physical  signs  in  influenza  pneumonia  and  the  nervous  symp- 
toms in  influenza  meningitis  are  not  characteristic.  Occasionally  with 
severe  infections  abscesses  may  develop  in  the  large  joints. 

Complications  and  Sequelae. — The  most  frequent  complications  are — 
pneumonia,  otitis,  and  adenitis.  Cutaneous  eruptions  are  not  infrequent, 
and  are  often  very  puzzling.  There  may  be  a  general  urticaria,  or  an 
erythema  which  sometimes  simulates  measles,  but  more  frequently 
scarlet  fever.  In  most  of  the  cases  with  high  temperature  the  urine  con- 
tains albumin,  and  acute  nephritis  is  not  infrequent.  I  have  seen  three  cases 
of  haemorrhagic  nephritis  in  a  single  season.  All  recovered  promptly. 
The  nervous  sequelae  of  adults — mental  disturbances,  multiple  neuritis, 
etc. — are  extremely  rare  in  childhood,  although  they  have  been  observed. 
One  of  the  most  frequent  sequelae  is  anaemia;  this  may  be  very  severe. 
Following  tlie  inflammation  of  the  mucous  membranes,  there  may  be 
chronic  enlargement  of  the  cervical  lymph  glands.  Attacks  of  influenza 
bear  the  same  relation  to  the  development  of  tuberculosis  as  do  those  of 
measles. 

Convalescence  after  influenza  is  usually  very  slow,  and  it  is  often 
many  months  before  the  full  effects  of  a  severe  attack  have  disappeared. 
For  a  long  time  the  mucous  membranes  are  in  an  extremely  sensitive  con- 
dition. Eelapses  are  often  brought  about  by  slight  exposure  before  the 
symptoms  have  quite  disappeared,  and  I  have  seen  them  occur  from  a 
single  outing. 

Diagnosis. — The  ordinary  head  colds  even  when  severe  and  epidemic 
are  very  rarely  due  to  influenza  infection.     There  are  certain  features 


1074 


THE  SPECIFIC   INFECTIOUS  DISEASES. 


which  distinguish  influenza  infections  of  tlie  lower  respiratory  tract  from 
those  due  to  other  causes :  these  are  a  tendency  to  chronicity,  to  relapses, 
and  to  recurrences.  In  the  febrile  cases  a  very  high  and  widely  fluctuat- 
ing temperature  accompanied  by  few  constitutional  symptoms  is  always 
suggestive  in  the  winter  season.  Kecurring  attacks  of  pneumonia  sep- 
arated by  an  interval  of  days  or  weeks  with  partial  or  apparently  complete 
recovery  are  very  often  due  to  influenza. 

Influenza  can  be  differentiated  from  the  catarrhal  inflammations  due 
to  other  causes  only  by  cultures  upon  blood  agar.  These  should  be  made 
from  the  bronchial  secretion  which  is  obtained  as  in  cases  of  tuberculosis 
(q.  v.).  A  culture  made  from  the  pharyngeal  secretion  is  not  conclusive. 
Influenza  may  be  confounded  with  malaria  or  cerebro-spinal  meningitis ; 
from  both  of  these  it  is  distinguished  by  the  methods  of  diagnosis  used 


IMY 

1 

2 

3   4 

5 

6 

7 

8 

9 

10 

771 

12 

laji 

4  15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28!29  30'3li32|33  34 

35 

IDS'' 
105° 
IM° 
103° 
102° 
101° 
100° 
89° 
98° 
87° 
96° 

K 

I    It 

I 

I 

f 

1 

1 

fl 

\  lul 

ft 

1 

t 

/ 

A 

\  III 

A 

A 

i 

k, 

I 

«J 

A 

Mi 

\l  I  1 

n 

\ 

A 

/ 

J 

\ 

J 

s 

J 

/ 

^ 

(V 

A 

A 

Tl 

"yrrn  v/^ 

r\ 

/ 

/ 

/ 

V 

V 

V 

/ 

\ 

\ 

/' 

ft 

I 

U4   1 

K 

/ 

■/ 

/\lA^^w^ 

L 

y 

ii 

r 

/ 

M 

1        f    1 

J 

i 

^ 

1 

__ 

1      t  1 

BBC 









^^ 

™ 

Fig.  218. — Influenza-bronchitis;  Double  Otitis;  Late  Broncho-pneumonia;  Au- 
topsy. Infant,  nine  months  old,  admitted  with  influenza-bronchitis;  double  para- 
centesis fourth  day,  repeated  on  tenth  day;  the  left  ear  opened  again  on  twelfth  and 
twenty-fourth  days.  The  only  signs  in  the  chest  were  those  of  bronchitis  until  the 
eighteenth  day,  then  broncho-pneumonia  which  persisted  until  death.  On  account 
of  the  wide  fluctuations  in  temperature  from  the  eighth  to  the  eighteenth  day,  mas- 
toiditis and  sinus  thrombosis  suspected.  Operation  not  permitted,  partly  because 
of  the  child's  poor  condition,  but  chiefly  because  the  bacillus  influenzae  was  con- 
stantly present  in  the  bronchial  secretion  and  this  was  regarded  as  a  sufficient  ex- 
planation of  the  temperature.  Autopsy. — Moderate  broncho-pneumonia;  cultures 
from  the  lungs  showed  the  influenza  bacillus  and  pneumococcus.  Careful  examina- 
tion of  the  mastoid  and  sinus  showed  no  trace  of  disease. 


to  identify  these  diseases.  Especial  difficulties  of  diagnosis  often  exist 
when  influenza  is  complicated  by  otitis.  Although  the  operation  of 
paracentesis  may  relieve  the  local  condition  it  does  not  arrest  the  general 
infection,  and  the  characteristic  fluctuations  of  the  temperature  belong- 
ing to  influenza  may  continue.  Under  such  circumstances  the  diagnosis 
of  mastoiditis  or  sinus  thrombosis  is  often  erroneously  made.  (See 
Fig.  218.) 

Prognosis. — Uncomplicated  cases  are  seldom  fatal,  except  in  infants 
under  six  months  old ;  and  even  though  the  temperature  is  very  high  and 
the  83rmptom8  severe,  recovery  may  be  predicted  as  long  as  there  is  no 
evidence  of  serious  complications.  The  prognosis  of  the  pneumonia  of 
influenza  is  rather  worse  than  that  of  simple  broncho-pneumonia.     In  a 


MALARIA.  1075 

word,  influenza  is  particularly  serious  in  the  very  young,  or  when  there 
are  pulmonary  complications,  hut  rarely  otherwise. 

Treatment. — The  communicability  of  the  disease  makes  it  desirable 
that  cases  of  influenza  should  be  isolated  whenever  practicable,  and  par- 
ticularly that  delicate  children,  or  those  prone  to  pulmonary  disease, 
should  not  be  exposed.  The  fumigation  of  apartments  after  attacks 
should  be  regularly  practised,  preferably  with  formalin  gas;  tliis  with 
isolation  will  do  much  to  control  house  epidemics. 

As  there  is  no  specific  for  influenza,  the  indications  are  to  sustain 
the  patient,  to  make  him  comfortable  during  the  attack,  and  to  prevent 
so  far  as  possible  the  occurrence  of  complications.  Every  child  with 
influenza  should  be  put  to  bed  and  kept  there  during  acute  symptoms. 
At  the  outset  the  bowels  should  be  opened  by  castor  oil  or  calomel.  A 
very  high  temperature  should  be  relieved  by  cold  sponging  or  the  cold 
pack,  precisely  as  in  pneumonia,  but  large  doses  of  antipyretic  drugs 
are  to  be  avoided.  The  nervous  symptoms — restlessness,  pain,  headache, 
and  other  disturbances — are  best  controlled  by  phenacetine  in  combina- 
tion with  codeine — e.  g.,  to  a  child  of  one  year,  phenacetine  gr.  j,  codeine 
gr.  ^,  every  three  or  four  hours.  Double  the  dose  may  be  given  to  a 
child  of  two  years.  Stimulants  are  required  whenever  the  pulse  shows 
signs  of  weakness.  They  should  be  given  according  to  the  same  rules  as 
in  pneumonia. 

The  cough  which  so  often  persists  after  influenza  is  best  controlled 
by  cod-liver  oil  and  creosote,  used  as  after  acute  bronchitis.  With  per- 
sistent bronchitis  which  resists  ordinary  remedies,  a  patient  should  be 
sent  to  a  warm,  dry  climate.  The  complications  of  influenza  are  to  be 
treated  as  they  arise,  in  the  same  manner  as  when  they  occur  under 
other  conditions.  In  all  cases  careful  feeding  in  accordance  with  the 
general  rules  laid  down  for  feeding  in  acute  diseases,  good  nursing,  and 
care  to  avoid  exposure  during  convalescence,  are  essentials  in  treatment. 
One  should  be  particularly  anxious  about  patients  who  have  a  strong 
tendency  to  tuberculosis,  and  such  cases  should  be  watched  with  the  great- 
est care. 

In  prolonged  or  constantly  recurring  attacks  nothing  is  of  much 
avail  except  a  removal  to  a  warm  climate.  If  this  is  impossible,  a  young 
or  delicate  child  should  be  kept  indoors  during  the  cold  season,  but  fre- 
quently moved  from  one  apartment  to  another. 


CHAPTER    XIII. 

MALARIA. 

Malaria  is  an  infectious  disease  due  to  the  presence  in  the  blood  of 
a  specific  organism  often  called  the  plasmodium,  but  more  exactly  the 


1076  THE  SPECIFIC   INFECTIOUS   DISEASES. 

hmnatocytozoon  malaria.  It  manifests  itself  in  children  by  the  ordinary 
acute  febrile  attacks  which  are  seen  in  adults  and  by  chronic  malarial 
poisoning.  Both  of  these  forms  may  present  certain  peculiar  symptoms 
dependent  upon  the  age  of  the  patient. 

Etiology. — The  malarial  organism  was  discovered  by  Laveran  in  1881 ; 
it  is  a  parasite  of  the  blood  and  belongs  to  the  group  of  protozoa.  It  is 
now  well  established  that  the  parasite  enters  the  blood  through  the  bite 
of  certain  forms  of  mosquito,  those  belonging  to  the  genus  Anopheles, 
and  probably  in  no  other  way.  For  this  knowledge  we  are  indebted 
chiefly  to  the  work  of  Ronald  Hoss,  in  India,  in  1897.  For  a  general 
discussion  of  the  malarial  parasite,  its  methods  of  staining,  etc.,  the 
reader  is  referred  to  works  on  clinical  medicine. 

Malaria  affects  all  ages,  even  the  newdy-born  infant.  We  must  accept 
with  some  allowance  the  statements  made  by  the  older  writers  upon  the 
subject  of  intra-uterine  infection,  but  in  the  following  case  occurring  in 
the  practice  of  my  former  associate.  Dr.  Crandall,  there  seems  little 
doubt  that  the  disease  was  contracted  in  utero:  For  ten  days  before  de- 
livery the  mother  had  suffered  from  a  tertian  intermittent  of  moderate 
severity.  Eighteen  hours  after  birth  the  child  was  noticed  to  have  cold 
hands  and  feet,  blue  lips  and  nails,  and  a  pinched  face.  These  symptoms 
lasted  about  half  an  hour  and  were  followed  by  a  distinct  fever.  Upon 
the  following  day  the  paroxysm  was  repeated.  Examination  of  the  blood 
of  both  mother  and  child  revealed  the  malarial  organisms  in  both  cases. 

Malaria  is  more  frequently  overlooked  in  young  children  than  in  later 
life,  from  the  fact  that  its  forms  are  more  irregular,  and  this  has  led  to 
the  belief  that  young  children  are  less  liable  than  adults  to  the  disease. 
I  believe,  however,  the  opposite  to  be  the  case.  In  a  large  nunil)er  of  in- 
stances where  families  have  been  exposed  to  malarial  poisoning  I  have 
noted  that  the  young  children  were  frequently  the  first  to  show  the 
symptoms  of  the  disease. 

Malaria  is  an  endemic  disease  prevailing  in  certain  localities.  Exact 
knowledge  regarding  the  mode  of  infection  has  cleared  up  many  obscure 
points  in  its  etiology.  The  role  of  the  mosquito  explains  the  greater 
liability  to  contract  malaria  after  sunset  and  during  the  night,  the 
danger  from  stagnant  ponds  and  pools  of  water,  the  peculiar  suscepti- 
bility of  infants  and  young  children,  and  the  greater  frequency  of  the 
disease  in  the  spring  and  summer.  Malarial  attacks  may,  however, 
occur  at  any  season,  since  the  organism  may  be  latent  in  the  body  for 
an  indefinite  time;  how  long  it  is  impossible  to  say,  but  there  seems 
to  be  conclusive  proof  that  it  may  he  for  many  months.  Attacks  of 
malaria  very  often  occur  when  the  general  health  has  been  reduced  by 
some  other  cause,  particularly  by  disturbances  of  digestion. 

Lesions. — Opportunities  for  a  study  of  the  peculiarities  of  the  lesions 
of  malaria  in  children  are  infrequent,  especially  in  New  York,  as  fatal 


MALARIA. 


1077 


cases  are  extremely  rare.  I  have  myself  seen  but  two.  As  observed  by 
others,  the  lesions  do  not  differ  in  any  marked  way  from  those  of  the 
adult  form  of  the  disease.  The  most  ini])ortant  changes  are  the  destruc- 
tion of  the  red  corpuscles  of  the  blood,  enlMrgement,  and  in  chronic 
cases  hyperplasia  with  pigmentation  of  the  spleen;  less  frequently  pig- 
mentation of  the  liver,  kidneys,  and  brain.  Pneumonia  and  gastro- 
enteritis are  occasional  complications. 


DAY 

1 

a 

3 

i 

0 

6 

^       1 

HOUR 

A.M. 

a     6    1 

P.M. 
0     2      6     10 

A.M. 
2      S     10 

2T,0 

A.M.       1        P.M. 
2       6     10  1  2       6     10 

A.M. 

2      6     10 

2T1O 

2      $     10 

2      6     10 

2     s  '10 

2^,0 

A.M. 
2       6    10 

P.M. 

106° 

105° 

104 

103 

102 

101 

100° 

99 

98 
97° 

11 

ll 

' 

1 

1 

1 

1 

X 

1 

A 

1 

\ 

1 

ft 

i 

1 

\ 

r 

1 

1 

\ 

\ 

\ 

\ 

/ 

\ 

\ 

' 

\ 

1 

1 

1 

\, 

1 

1 

\* 

1 

J 

" 

[N 

, 

\ 

\ 

1 

\ 

1 

A^ 

,» 

•^ 

1 

Vj 

,/ 

\( 

\^ 

i 

V 

l-- 

1 

/ 

\ 

/ 

\ 

/ 

) 

y 

i.' 

* 

... 

Fig.  219. — Typical  Malarial  Temperature,  Quotidian  Type,  in  a  Boy  Six  Years 
Old.  Each  paroxysm  preceded  by  a  chill.  It  will  be  noticed  that  the  temperature 
rose  higher  with  each  succeeding  paroxysm ;  X  marks  the  time  when  quinine  was  begun. 

Symptoms. — The  clinical  forms  of  malarial  fever  in  children  from  six 
to  ten  years  old,  do  not  differ  essentially  from  the  same  disease  in  adults. 
Both  intermittent  and  remittent  forms  occur,  the  former  being  the  type 
usually  seen.  Of  the  different  varieties  of  intermittent  fever,  the  quo- 
tidian (Fig.  219)  is  the  most  common,  although  the  tertian  (Fig.  220) 
is  fairly  frequent,  but  in  this  locality  the  quartan  is  extremely  rare.  The 
stages  of  the  paroxysm  are  generally  well  marked.  The  cold  stage  begins 
with  a  chill  or  vomiting,  with  headache,  lassitude,  and  general  pains. 


1078 


THE  SPECIFIC   INFECTIOUS   DISEASES. 


The  hot  stage  is  usually  characterised  by  a  higher  temperature  than  in 
adults,  and  this  is  followed  by  the  sweating  stage,  which  is  generally 
marked.  The  paroxysm  may  be  repeated  every  day  or  every  other  day 
until  controlled  by  quinine,  or  the  stages  may  become  less  and  less  dis- 


DAY 

1 

8 

3 

; 

5 

6 

'     1 

HOUR 

/■-■,o|, 

P.M. 
t     10 

A.M. 

s    e    10 

P.M. 
2      E     10 

!     e    10 

P.M. 
2       6     10 

2    e    10 

2%-iO 

2      8     10 

2     e    10 

2       6     10 

2      S     10 

2       6      10 

2       6      1o| 

105 
104 
103° 
108 
101 
100° 
M° 
98 
JO. 

A 

f 

1 

\ 

\ 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

V 

1 

\ 

1 

' 

s 

1 

/ 

s 

V 

s. 

1 

/ 

s^ 

\ 

s. 

/ 

' 

V, 

/ 

^ 

/ 

' 

V 

/ 

V 

"v 

/ 

\^ 

/ 

V 

/ 

S 

/ 

_ 

_ 

Fio.  220. — Typical  Malarial  Temperature,  Tertian  Type,  in  a  Boy  Five  Years  Old. 
Onset  with  vomiting  and  drowsiness,  but  no  chill.     This  was  an  anticipating  inter- 
•  mittent,  the  first  paroxysm  occurring  at  3  p.m.,  the  second  at  12  m.,  the  third  at   10 
A.M.;  X  marks  the  time  when  quinine  was  begun. 


tinct  as  the  disease  progresses  until  a  more  or  less  remittent  type  of  fever 
develops.  Less  frequently  the  fever  is  remittent  from  the  beginning  and 
the  constitutional  symptoms  are  of  greater  severity.  In  this  form  there 
is  marked  prostration,  the  tongue  is  thickly  coated,  there  are  often  ten- 
derness and  pain  in  the  region  of  the  liver,  and  occasionally  there  is 
slight  jaundice. 

In  infants  and  very  young  children  peculiar  types  of  malaria  are 
seen.  A  well-marked  intermittent  fever  with  distinct  stages  is  often 
absent,  many  eases  assuming  more  of  a  remittent  type  or  an  irregular 
form  of  intermittent  (Fig.  221).  The  onset  is  usually  abrupt  with  vom- 
iting, a  well-marked  chill  being  rare.    Malarial  chills  are  not  often  wit- 


MALARIA. 


1079 


nessed  in  children  under  five  years  old.  They  are  replaced  in  infants  by 
cold  hands  and  feet,  blue  lips  and  nails,  sometimes  slight  general  cyano- 
sis, pallor,  drowsiness,  and  prostration.  Vomiting  has  been  present  in 
two-thirds  of  my  own  cases.  Several  times  I  have  seen  a  malarial  attack 
ushered  in  by  convulsions. 

The  fever  is  relatively  higher  than  in  adults,  rising  rapidly  to  104°  or 
105°  F.,  occasionally  to  106°  or  106.5°  F.  This  continues  from  four  to 
twelve  hours  and  gradually  falls,  usually  to  normal.  The  other  constitu- 
tional symptoms  of  the  febrile  stage  are  much  less  severe  than  in  most 
diseases  with  the  same  elevation  of  temperature.  The  sweating  stage 
is  only  slightly  marked  and  is  often  absent  altogether.     With  the  fall 


DAY 

1 

2               1 

3 

i 

5 

6 

^      1 

HOUR 

2  *'6"'lO 

2      6 

A.M. 
10     2      6     10 

P.M.              A 
2      6     10     2 

M.              P.M. 
S     10     2      6    10 

2      6     10 

2      6 

10      2  *6"'lO 

P.M. 
2       6     10 

2      6    'lO 

2      6    10 

2      6     1 

02T10I 

105 
IM 
103 
102 
101 
100 
99 
98 

I 

L 

_J 

\ 

A 

A 

|i 

^ 

I 

/ 

A 

l\ 

/ 

1 

I 

/ 

\ 

\ 

'^ 

i 

\ 

\ 

/ 

\ 

/ 

1 

_ 

1                 t 

B 

th-     - 

1 

tt 

1 

I     ' 

1 

1 

T 

T 

4- 

1 

T 

4        U- 

T 

i      t- 

1 

T 

t 

/ 

1 

1 

t 

/ 

1 

j 

t 

/ 

\ 

1 

1 

f 

/ 

\ 

1 

r 

f 

\ 

/ 

1, 

^\ 

,  ^ 

t 

\ 

/ 

' 

; 

\ 

1 

I 

h 

•^ 

/ 

/ 

\, 

/\ 

1 

\ 

y 

\ 

\ 

/ 

J 

V 

\/ 

V 

1 

, 

^_ 

FiQ.  221. — An  Irregular  Malarial  Temperature  in  a  Child  Nine  Months  Old. 
The  paroxysm  on  the  fourth  day  was  accompanied  by  an  attack  of  acute  pulmonary 
congestion  which  came  near  being  fatal;  X  marks  the  time  when  quinine  was  begun. 
Although  the  course  of  the  temperature  is  irregular,  it  touched  the  normal  line  both 
on  the  second  and  fourth  days. 

in  the  temperature  there  is  a  gradual  subsidence  of  all  the  other  symp- 
toms of  the  febrile  stage. 

After  the  first  paroxysm  the  patient  may  be  quite  well  for  several 
hours  or  even  for  a  day,  when  the  second  paroxysm  occurs.  This  is  gen- 
erally not  so  well  marked  as  the  first  one,  the  third  may  be  even  less  so, 
and  the  case  may  resemble  more  and  more  one  of  continuous  fever  with 
wide  oscillations  in  the  'temperature.     In  some  cases  it  is  remittent  at 


1080  THE   SPECIFIC   INFECTIOUS   DISEASES. 

first  and  later  becomes  intermittent,  but  it  is  very  rare  under  any  cir- 
cumstances that  the  temperature  does  not  touch  the  normal  point  at  some 
time  in  the  twenty-four  hours.  In  infants  the  quotidian  has  been  in  my 
experience  very  much  more  frequent  than  any  other  type,  the  tertian 
being  uncommon  and  the  quartan  almost  unknown. 

Enlargement  of  the  spleen  is  present  in  the  great  majority  of  cases, 
and  usually  to  a  sufficient  degree  to  be  readily  appreciated  by  examina- 
tion. The  most  satisfactory  method  of  examination  is  by  palpation. 
A  spleen  which  can  be  easily  felt  below  the  ribs  (except  in  the  rare 
cases  in  which  the  organ  is  displaced  downward  by  some  condition  in 
the  thorax)  is  enlarged.  When  it  is  not  sufficiently  enlarged  to  be 
readily  felt  by  a  practised  observer  under  favourable  conditions  for  ex- 
amination, it  is  not  large  enough  to  be  of  any  diagnostic  importance. 
None  of  the  other  symptoms  occurring  in  malarial  fever  are  charac- 
teristic; they  are  quite  similar  to  those  which  are  seen  in  almost  all 
febrile  attacks.  They  are  anorexia,  coated  tongue,  constipation,  and 
restlessness. 

Masked  or  Irregular  Forms  of  Malaria. — These  are  quite  frequent  in 
young  children,  and  are  due  to  the  presence  of  certain  special  or  uncom- 
mon symptoms  which  may  readily  lead  to  a  mistake  in  diagnosis.  They 
are  more  often  seen  than  cases  of  true  malarial  cachexia. 

Among  the  most  frequent  of  the  irregular  forms  are  those  relating 
to  the  nervous  system.  Headache  is  exceedingly  common  and  is  usually 
frontal.  When  severe  and  associated  with  continuous  drowsiness,  vomit- 
ing, and  constipation,  it  may  lead  to  a  strong  suspicion  of  tuberculous 
meningitis.  Yertigo  is  not  a  frequent  symptom,  but  it  is  sometimes  very 
prominent.  Pains  in  various  parts  of  the  body  are  very  common.  A 
sharp,  severe  pain  at  the  epigastrium  is  frequent  at  the  beginning  of  a 
paroxysm.  It  is  often  associated  with  tenderness,  but  has  no  relation  to 
meals.  Less  frequently,  pain  is  localised  in  the  region  of  the  spleen 
or  liver.  Trifacial  neuralgia  of  malarial  origin  is  rare  in  childhood. 
Aching  or  dragging  pains  in  the  muscles  of  the  lower  extremities  are 
frequent  symptoms  during  acute  attacks,  but  they  are  of  short  duration, 
disappearing  with  the  fever.  They  are  to  be  distinguished  from  the 
acute  lancinating  pains  of  multiple  neuritis,  which  is  occasionally  seen 
as  a  result  of  malarial  poisoning.  I  have  seen  the  latter  in  young  chil- 
dren in  three  cases,  and  it  has  been  observed  by  otliers.  The  pain  is 
accompanied  by  tenderness  of  the  muscles  and  nerve  trunks,  and  by  loss 
of  power,  which  is  usually  partial.  Spasmodic  torticollis  I  have  seen  in 
eight  cases,  in  which  the  condition  seemed  very  clearly  to  depend  upon 
malaria. 

Accompanying  the  paroxysm  of  malaria  there  is  occasionally  seen, 
more  often  in  infants  than  in  older  children,  acute  pulmonary  congestion 
(Fig.  221),  which  may  give  rise  to  obscure  and  often  very  alarming 


MALARIA.  1081 

symptoms.  There  is  an  acute  onset  with  vomiting  and  prostration,  high 
temperature,  cough,  rapid  respiration,  and  often  slight  cyanosis.  On  ex- 
amination of  the  chest  there  is  found  feeble  or  rude  respiration  over  one 
lung,  or  over  both  lungs  behind,  and  sometimes  coarse  moist  rales ;  these 
signs  and  symptoms  may  disappear  in  the  course  of  a  few  hours  with  the 
fall  in  temperature,  to  return  with  the  next  paroxysm,  or  if  quinine  is 
given  they  may  disappear  entirely.^  This  group  of  syin})toms  has  some- 
times led  to  the  mistaken  opinion  that  the  disease  was  pneumonia,  which 
had  been  aborted  by  the  administration  of  quinine. 

Subacute  or  Chronic  Forms  of  Malaria. — The  most  constant  symp- 
toms are  anaemia,  enlargement  of  the  spleen,  and  slight  fever.  The 
anaemia  is  usually  marked,  often  being  extreme.  The  enlargement  of  the 
spleen  is  distinct,  easily  made  out  by  palpation,  and  sometimes  is  very 
great.  The  fever  is  often  so  slight  as  to  be  discovered  only  when  the 
temperature  is  taken  five  or  six  times  in  the  twenty-four  hours:  The 
other  symptoms  are  of  a  very  indefinite  character;  there  may  be  slight 
cedema  of  the  lower  extremities,  general  muscular  weakness,  so  that  the 
child  is  easily  fatigued,  loss  of  appetite,  coated  tongue,  constipation,  head- 
ache, muscular  pains,  and  often  cough  from  a  slight  bronchitis.  These 
symptoms  may  depend  upon  many  conditions  other  than  malaria,  even 
when  they  are  seen  in  a  malarial  district.  The  only  positive  evidence  of 
malaria  in  such  cases  is  the  presence  of  the  malarial  organisms  in  the 
blood.  Even  the  swollen  spleen,  anaemia,  and  slight  fever,  Avhich  are 
often  looked  upon  as  diagnostic,  may  be  present  in  cases  of  anaemia  with 
which  malaria  has  nothing  whatever  to  do. 

*  The  following  case  is  a  good  example  of  this  condition  in  its  more  severe  form, 
and  illustrates  the  difficulties  in  the  diagnosis  of  malaria  in  infancy:  A  fairly  nour- 
ished child,  nine  months  old,  who  had  been  under  observation  in  an  institution  for 
two  weeks,  was  suddenly  taken  with  vomiting  and  fever  (Fig.  221).  A  cathartic  was 
followed  by  a  large  undigested  stool,  and  as  the  temperature  then  fell  to  normal,  the 
attack  was  regarded  as  one  of  indigestion.  On  the  third  day  the  temperature  was 
again  high  and  accompanied  by  cough;  coarse  rales  were  found  throughout  the  chest, 
and  fine  rales  at  the  right  base;  it  was  then  thought  that  pneumonia  was  developing. 
On  the  fourth  day  all  the  symptoms  were  so  much  improved  that  the  infant  was 
regarded  as  convalescent.  At  6  p.  m.  the  temperature  was  normal,  and  the  infant  went  to 
sleep  quietly.  At  9.30  p.m.  he  awoke  with  a  temperature  of  104°  F.,  extreme  restlessness, 
and  marked  dyspncea.  In  half  an  hour  his  symptoms  had  increased  to  a  point  where  he 
seemed  likely  to  die.  He  became  cyanotic,  the  respirations  were  of  a  panting  char- 
acter and  rose  nearly  to  one  hundred  a  minute,  and  he  coughed  with  almost  every 
breath;  the  pulse  was  scarcely  perceptible.  The  severe  symptoms  continued  for  about 
an  hour,  then  passed  away  gradually,  and  at  the  end  of  two  and  a  half  hours  they 
had  completely  disappeared,  and  the  child  was  in  a  quiet  sleep  which  continued  until 
morning.  Malaria  was  now  suspected,  and  the  diagnosis  established  by  the  discovery 
of  the  Plasmodium  in  the  blood.  The  spleen  was  at  this  time  much  enlarged;  the 
signs  in  the  chest  were  those  only  of  bronchitis  of  the  large  tubes.  Quinine  was 
given  in  full  doses,  and  immediately  controlled  the  temperature  and  the  pulmonary 
symptoms. 


1082  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Diagnosis. — The  positive  diagnosis  of  malaria  rests  upon  the  demon- 
stration of  the  malarial  organisms  in  the  blood.  They  will  be  found  in 
nearly  all  the  eases  provided  a  careful  examination  is  made  a  few  hours 
before  the  paroxysm,  and  also  that  no  quinine  has  been  administered. 
When  their  number  is  small  they  may  be  missed  at  the  height  of  the 
fever,  although  they  may  readily  be  found  just  before  the  temperature 
begins  to  rise.  While  a  poiitive  result  is  conclusive,  a  negative  one  is  not 
always  so  because  of  the  impossibility  of  fulfilling  all  the  above  condi- 
•tions.  This  fact  and  lack  of  experience  in  blood  examinations  make  it 
necessary  for  a  large  part  of  the  profession  to  make  the  diagnosis  by  the 
other  symptoms.  These,  in  the  order  of  their  importance,  I  would  place 
as  follows:  Prompt  curability  (especially  in  cases  of  fever)  by  quinine; 
distinct  periodicity  in  the  symptoms;  enlargement  of  the  spleen;  and  a 
history  of  an  exposure  in  a  district  known  to  be  malarial.  Particular 
importance  is  to  be  attached  to  the  therapeutic  test.  Becent  experience 
emphasises  more  and  more  strongly  the  fact  that  quinine  has  very  little 
influence  upon  fevers  which  are  not  malarial,  and,  conversely,  that  a  fever 
immediately  and  permanently  controlled  by  quinine  is  pretty  certain  to 
be  malarial. 

The  cachexia  and  course  of  the  temperature  in  septicaemia,  pyaemia, 
broncho-pneumonia,  tuberculosis,  and  empyema,  may  cause  them  to  be 
mistaken  for  malaria.  The  fever  and  recurring  chills  of  pyelitis  are 
often  attributed  to  malaria;  as  are  also  the  heaviness,  lethargy,  head- 
ache, coated  tongue,  and  slight  fever  of  chronic  intestinal  indigestion. 
Many  conditions  accompanied  by  an  enlarged  spleen  may  be  confounded 
with  malaria,  especially  simple  anaemia,  leukaemia,  rickets,  and  syphilis. 
While  malaria  may  be  multiform  in  its  manifestations,  the  physician  can 
fall  into  no  more  serious  error  than  to  regard  all  ailments  with  obscure 
or  indefinite  symptoms  as  malarial,  neglecting  careful  physical  and  blood 
examinations,  by  which  means  alone  an  accurate  diagnosis  is  reached. 

Prognosis. — Although  it  is  seldom  fatal  in  itself,  an  attack  of  malaria 
in  a  young  child  may  so  undermine  his  constitution  that  he  may  suc- 
cumb to  some  other  acute  disease.  Cases  are  often  difficult  to  cure 
while  the  patient  remains  in  the  malarial  districts,  and  when  frequent 
reinfection  occurs.  Under  other  circumstances  and  with  proper  treat- 
ment the  prognosis  of  malaria  is  good. 

Treatment. — Prophylaxis. — More  exact  knowledge  regarding  the  eti- 
ology of  malaria  makes  it  possible  for  much  to  be  done  in  the  way  of 
prevention.  Besides  the  general  measures  proposed  for  the  extermina- 
tion of  the  mosquitoes  concerned,  emphasis  should  be  laid  upon  the  neces- 
sity, in  the  case  of  young  children,  of  protecting  them  against  the  bites 
of  mosquitoes  in  localities  which  are  or  which  may  possibly  be  malarial. 
This  can  be  done  by  a  more  thorough  use  of  mosquito  netting  and  by 
using  upon  exposed  parts  of  the  body  lotions  or  ointments  containing 


MALARIA.  1083 

menthol,  pennyroyal,  turpentine,  or  other  substances  which  keep  these 
pests  away.  The  general  treatment  is  symptomatic,  and  is  to  be  con- 
ducted as  in  all  acute  febrile  diseases.  Tn  the  cold  stage,  stimulants  or  a 
hot  bath  may  be  required ;  in  the  hot  stage,  ice  to  the  head  and  frequent 
sponging.  The  bowels  in  all  cases  should  be  freely  opened,  preferably 
by  calomel. 

Methods  of  Administration  of  Quinine. — For  infants  my  own  prefer- 
ence is  to  give  the  bisulphate  in  an  aqueous  solution,  one  or  two  grains 
to  the  teaspoonful,  according  to  the  age  of  the  patient.  Most  infants 
take  such  a  solution  with  less  difficulty  and  vomit  it  less  frequently  than 
the  combinations  with  the  various  vehicles  supposed  to  cover  its  taste. 
In  the  event  of  failure  by  this  method,  the  same  solution  may  be  given  per 
rectum  through  a  catheter.  It  should  then  be  more  largely  diluted  with 
some  bland  fluid  such  as  gruel,  and  in  double  the  dose.  This  is  necessary, 
not  only  because  absorption  is  less  certain  and  complete,  but  also  be- 
cause a  rectal  dose  can  seldom  be  repeated  oftener  than  every  five  or 
six  hours.  There  is  sometimes  an  advantage  in  giving  part  of  the 
quinine  by  the  mouth  and  part  of  it  by  the  rectum;  should  both  fail  it 
may  be  given  hypodermically.  For  this  purpose  the  bimuriate  of  quinine 
and  urea,  the  hydrobromate,  or  the  bisulphate  may  be  used.  All  are  more 
or  less  irritating  and  there  usually  follows  some  induration  at  the  site 
of  the  injection,  which  may  last  a  long  time.  While  the  hypodermic  use 
of  quinine  is  sometimes  invaluable  it  should  not  be  employed  in  infants 
except  in  serious  attacks  and  when  the  diagnosis  has  been  established. 
In  a  number  of  instances  both  in  hospitals  and  private  practice  I  have 
seen  sloughing  follow  the  use  of  nearly  all  the  preparations  generally 
employed.  The  occurrence  of  abscess  points  to  infection  at  the  time 
of  injection ;  but  necrosis  I  believe  may  be  due  simply  to  the  irritation  of 
the  quinine  upon  tissues  having  a  lowered  vitality,  as  in  the  case  of  young 
or  delicate  infants.  I  have  seen  this  happen  when  the  strictest  precau- 
tions against  infection  were  observed.  The  frequent  repetition  of  the 
hypodermic  injections  should  be  avoided ;  in  most  cases,  one  or  two  good 
doses  are  sufficient,  the  effect  being  continued  by  quinine  given  by  other 
methods. 

For  children  from  two  to  seven  years  old  the  taste  of  quinine  must 
be  concealed.  An  aqueous  solution  of  the  bisulphate  may  be  mixed  with 
the  syrup  of  sarsaparilla,  orange,  or  yerba  santa;  or  the  sulphate  may  be 
given  in  suspension  in  one  of  the  same  vehicles,  the  mixture  being  made 
just  before  the  dose  is  taken;  otherwise  the  partial  solution  of  the  drug 
will  render  the  whole  dose  exceedingly  bitter.  When  the  dose  required  is 
not  large,  as  in  the  milder  cases,  the  lozenges  of  the  tannate  of  quinine 
combined  with  chocolate  answer  the  purpose  admirably,  for  these  are  so 
nearly  tasteless  that  children  will  take  them  without  difficulty.  Each 
lozenge  usually  contains  one  grain  of  the  tannate,  which  is  equivalent  to 


1084  THE  SPECIFIC   INFECTIOUS   DISEASES. 

about  one-third  of  a  grain  of  tlie  sulphate  of  quinine.  A  similar  lozenge 
containing  one  grain  of  the  sulphate  may  be  made,  which  is  often  taken 
by  children  without  the  slightest  objection.  The  bisulphate  may  be  given 
in  solution  by  the  rectum,  or,  better,  at  this  age,  in  the  form  of  supposi- 
tories ;  but,  as  in  infancy,  with  very  urgent  symptoms,  it  is  better  to  resort 
at  once  to  the  hypodermic  method  in  case  of  failure  by  the  stomach. 

For  children  over  seven  years  old,  the  same  methods  of  administra- 
tion may  usually  be  employed  as  in  adults.  It  is  always  preferable  to 
give  quinine  in  solution,  or  if  not  so,  in  capsule,  but  not  in  pill  form. 

In  a  case  with  well-marked  paroxysms  the  quinine  should  if  possible 
be  given  in  the  interval,  with  the  largest  dose  about  four  hours  before 
the  expected  paroxysm.  With  infants  this  plan  is  sometimes  imprac- 
ticable, as  frequent  small  doses  are  usually  better  borne  by  the  stomach 
than  a  few  large  ones.  In  them  also  vomiting  seems  less  likely  to  occur 
when  it  is  given  on  an  empty  stomach.  For  this  reason  it  is  advantageous 
to  give  the  drug  at  regular  two-  or  three-hour  intervals  during  the  night, 
and  omit  all  medication  during  the  day. 

Dosage. — Relatively  much  larger  doses  of  quinine  are  required  for 
young  children  than  for  adults.  Except  for  its  tendency  to  disturb  the 
stomach,  quinine  is  borne  remarkably  well  by  little  patients.  Generally 
too  small  doses  are  given.  An  infant  of  a  year  with  a  sharp  attack  of 
malarial  fever  will  usually  require  from  eight  to  twelve  grains  of  the 
sulphate  (ten  to  fourteen  grains  of  the  bisulphate)  daily.  Occasionally 
I  have  found  it  necessary  to  give  double  the  quantity  referred  to,  and  I 
have  seen  no  unpleasant  cerebral  symptoms.  It  is  useless  to  expect  to 
control  an  acute  attack  of  malaria  by  such  doses  as  one  grain  three  or 
four  times  a  day.  Children  from  five  to  ten  years  old  require  almost  as 
large  doses  as  do  adults.  None  of  the  substitutes  for  quinine  are  to  be 
relied  upon  in  acute  cases. 

In  chronic  cases,  arsenic  and  iron  are  usually  required  in  combination 
with  smaller  doses  of  the  quinine  than  those  mentioned.  For  children 
over  seven  years  old,  Warburg's  tincture  may  -be  employed.  In  most 
chronic  cases  a  cure  can  be  effected  only  by  a  change  of  climate. 

The  masked  and  irregular  manifestations  of  malaria  are  to  be  treated 
in  the  same  manner  as  cases  of  malarial  fever. 


SECTION  X. 
OTHER  GENERAL  DISEASES. 

CHAPTER    I. 
RHEUMATISM. 

The  rheumatic  diathesis  manifests  itself  in  children  by  quite  a  dif- 
ferent group  of  symptoms  from  those  seen  in  adults ;  for  this  reason  the 
disease  was  formerly  supposed  to  be  a  rare  one  in  early  life.  It  is  only 
within  recent  years  that  its  frequency  and  its  peculiarities  have  come  to 
be  appreciated.  For  our  present  understanding  of  the  subject  we  are 
indebted  largely  to  the  work  of  Englisli  physicians,  especially  Cheadle, 
who  has  brought  out  more  fully  than  any  one  else  the  close  connection 
existing  between  many  conditions  formerly  not  regarded  as  rheumatic. 
One  who  has  in  mind  only  the  adult  types  of  articular  rheumatism,  and 
regards  arthritis  as  a  necessary  symptom  for  a  diagnosis,  will  overlook 
in  early  life  many  manifestations  which  are  clearly  tlie  result  of  the 
rheumatic  poison.  There  is  seen  at  this  period  a  group  of  clinical 
phenomena,  which  often  occur  in  combination  or  in  succession,  whose 
association  was  not  understood  until  they  were  all  discovered  to  be  related 
to  rheumatism.  Sometimes  one  member  of  the  group  and  sometimes 
another  is  first  seen,  but  when  one  has  appeared  others  are  likely  soon 
to  follow. 

Rheumatism  in  childhood,  then,  is  manifested  not  alone  by  arthritis 
with  acute  or  subacute  symptoms,  but  by  a  large  number  of  other  condi- 
tions which  are  not  to  be  regarded  in  the  light  of  complications,  but 
rather  as  forms  of  the  disease. 

Etiology. — It  is  not  in  the  province  of  this  work  to  discuss  the  vari- 
ous theories  regarding  the  nature  of  rheumatism  and  its  exciting  cause. 
The  drift  of  medical  opinion  to-day  is  strongly  toward  the  view  that 
acute  rheumatism  is  an  infectious  disease,  probably  of  microbic  origin. 
Although  the  character  of  the  micro-organism  is  not  yet  determined,  the 
latest  observations  of  Poynton  and  Paine  ^  point  to  a  diplococcus.  The 
excessive  formation  of  acids  in  the  system  may  be  regarded  as  a  result 
of  the  infection,  or  possibly  as  a  condition  necessary  for  the  activity  of 

»  Lancet,  May  4,  190L 

1085 


1086         .  OTHER  GENERAL  DISEASES. 

the  specific  poison.  Under  five  years  of  age  articular  rheumatism  is  not 
common,  and  in  infancy  it  is  extremely  rare.  I  once  saw,  however,  in 
a  nursing  infant,  a  typical  attack  of  rheumatic  fever  with  multiple  joint 
lesions.  The  condition  is,  however,  so  exceptional  that  one  sliould  be 
cautious  in  making  the  diagnosis  of  rheumatism  in  infancy.  Most  of  the 
cases  80  regarded  are  examples  of  scurvy.  After  the  fifth  year  both 
the  articular  and  the  other  manifestations  of  rlieumatism  become  very 
common,  and  occur  with  increasing  frequency  up  to  the  time  of  puberty. 

Heredity  is  a  very  important  etiological  factor,  and  in  fully  two- 
thirds  of  the  cases  that  have  come  under  my  care,  a  rheumatic  family 
history  was  obtained.  Of  the  other  important  causes,  the  most  frequent 
are  living  in  damp  dwellings,  direct  exposure  to  cold  and  wet,  poor 
hygienic  surroundings,  and  insufficient  food.  While  seen  among  all 
classes,  rheumatism  is  more  common  among  those  who  are  badly  housed. 
Attacks  of  rheumatism  occur  at  all  seasons,  but  are  much  more  frequent 
in  the  spring  months.  One  attack  strongly  predisposes  to  a  second,  and 
in  most  cases  there  is  a  history  of  a  large  number  of  attacks  of  greater 
or  less  severity.  Among  my  own  patients,  girls  have  been  affected  with 
greater  frequency  than  boys. 

Symptoms. — The  General  and  Articular  Manifestations. — The  clini- 
cal types  of  rheumatism  in  children  present  very  notable  contrasts  to 
those  seen  in  adults.  A  typical  attack  of  acute  articular  rheumatism  such 
as  is  seen  in  adult  life,  with  a  sudden  onset,  high  temperature,  severe 
inflammation  of  several  joints,  profuse  acid  perspiration,  and  occasional 
delirium,  is  rarely  seen  in  a  child  under  eight  or  ten  years  old.  In  most 
of  the  attacks  in  childhood  the  onset  is  not  very  acute,  the  temperature 
is  but  slightly  elevated — only  100°  or  101 . 5°  F. — the  swelling  and  pain 
are  moderate,  and  the  redness  is  often  absent.  The  number  of  joints  in- 
volved is  generally  small,  those  most  frequently  affected  being  the  ankles, 
the  knees,  the  small  joints  of  the  foot,  the  wrists,  or  the  elbows.  These 
symptoms  are  often  not  severe  enough  to  keep  the  patient  in  bed,  and 
only  the  pain  in  the  joints  of  the  lower  extremities  prevents  him  from 
walking.  The  duration  of  these  attacks  is  from  one  to  three  weeks,  and 
in  the  course  of  a  month  most  of  them  recover  even  without  treatment. 

Not  infrequently  the  symptoms  are  limited  to  a  single  joint,  usually 
the  hip,  knee,  or  ankle.  Possibly  the  joints  of  the  upper  extremity  are 
affected  oftener  than  would  appear,  but  disease  here  is  much  more  likely 
to  be  overlooked  than  when  lameness  is  present.  The  swelling  is  mod- 
erate and  may  not  be  evident  except  on  a  close  examination;  in  some 
cases  there  is  none.  There  is  stiffness  of  the  joint,  as  shown  by  lameness, 
and  there  may  be  so  much  pain  and  soreness  that  the  child  refuses  to 
walk  altogether.  Muscular  spasm  about  the  affected  joint  is  oftMi 
marked,  and  may  be  the  most  striking  objective  symptom.  The  tender- 
ness is  sometimes  localised,  but  it  may  affect  the  ligaments,  tendons,  and 


RHEUMATISM.  1087 

even  the  muscles.  These  symptoms  may  persist  for  two  or  three  weeks 
and  lead  to  a  suspicion  of  incipient  tuberculous  disease  of  the  joint. 
Eheumatism  is  distinguished  by  its  more  acute  onset  and  usually  by  the 
presence  of  slight  fever;  some  elevation  of  temperature  being  the  rule, 
though  it  is  not  often  much  over  100°  F.  A  family  history  of  rheu- 
matism, or  a  history  of  previous  similar  attacks  in  the  patient  affecting 
the  same  or  other  joints,  or  other  manifestations  of  rheumatism,  are  also 
of  assistance  in  the  diagnosis.  Occasionally  all  doubt  is  removed  by  the 
disease  extending  to  other  joints,  or  by  the  development  of  endocarditis. 
In  some  cases  the  symptoms  are  less  in  the  articulation  than  in  the 
muscles,  and  they  are  dismissed  as  simply  "  growing  pains,"  having  noth- 
ing characteristic  about  them  except  their  occurrence  in  damp  weather. 

Cardiac  Manifestations. — These  may  occur  wlien  the  articular  symp- 
toms are  very  mild,  and  in  some  cases  when  they  are  entirely  absent. 
The  most  frequent  is  endocarditis.  This  is  much  more  often  seen  in  the 
acute  rheumatism  of  children  than  of  adults,  and  probably  occurs  in  the 
majority  of  all  severe  cases;  if  it  does  not  come  in  tlie  first  attack,  it  is 
likely  to  be  seen  in  the  later  ones.  It  frequently  occurs  with  a  mild 
rheumatic  arthritis,  often  being  unnoticed  until  valvular  disease  of  con- 
siderable severity  has  developed.  Sometimes  there  is  only  high  fever 
with  severe  constitutional  symptoms  of  an  indefinite  character,  but  no 
arthritis,  and  no  suspicion  that  the  attack  is  rheumatic  until  endocar- 
ditis is  discovered.  Such  cases  are  not  infrequent.  If  the  patients  are 
kept  under  observation,  articular  symptoms  are  almost  certain  to  develop 
later,  and  often  there  are  other  manifestations  of  rheumatism,  especially 
chorea. 

Pericarditis  is  much  less  frequent  than  endocarditis,  and  usually  oc- 
curs in  children  over  seven  years  old.  It  is  often  associated  with  endocar- 
ditis. The  most  characteristic  form  of  inflammation  in  early  life  is  a  sub- 
acute, dry,  fibrous  form,  often  resulting  in  great  thickening  with  extensive 
adhesions,  and  frequently  in  obliteration  of  the  pericardial  sac.  When 
once  started  it  shows  a  strong  tendency  to  recurrence  and  persistence. 

The  heart  is  so  frequently  affected  in  the  rheumatism  of  childhood 
that  it  should  be  closely  watched  whenever  articular  symptoms  are  pres- 
ent, no  matter  how  mild  they  may  be;  and  not  only  in  these  cases,  but 
in  all  the  conditions  hereafter  enumerated  with  which  rheumatism  is 
likely  to  be  associated. 

Inflammations  of  other  serous  membranes — the  pleura,  peritonaeum, 
and  pia  mater — were  much  more  frequently  ascribed  to  rheumatism  in 
the  past  than  now.  There  is  little  doubt  that  on  rare  occasions  any  one 
of  these  may  be  due  to  rheumatism.  The  pleura  is  most  often  involved, 
but  even  this  is  rare  in  young  children. 

Torticollis  when  it  occurs  acutely  is  frequently  rheumatic.  This 
form  is  characterised  by  its  sudden  development,  continuous  spasm,  the 


1088  OTHER  GENER.\L  DISEASES. 

great  amount  of  muscular  soreness,  the  moderate  pain,  and  the  fact  that 
it  usually  disappears  spontaneously  after  a  few  days.  Other  manifesta- 
tions of  muscular  rheumatism  are  less  characteristic  and  usually  affect 
the  muscles  of  the  extremities. 

AncBmia  is  almost  invariahly  seen  in  rheumatic  patients,  both  during 
and  between  the  attacks.  The  effect  of  the  rheumatic  poison  upon  the 
blood  resembles  that  of  malaria.  The  presence  of  anaemia  is  so  evident 
and  its  degree  often  so  marked,  that  one  may  have  great  difficulty  in 
distinguishing  cardiac  murmurs  which  are  haemic  from  those  due  to 
endocarditis. 

Chorea. — In  the  article  upon  Chorea  I  have  already  discussed  the 
association  of  that  disease  with  rheumatism  and  expressed  my  own  belief 
in  a  very  close  relationship  existing  between  them.  Xot  very  infre- 
quently chorea  is  the  first  manifestation  of  a  rheumatic  diathesis,  to 
be  followed  soon  by  articular  symptoms  or  by  endocarditis  without  such 
symptoms.  In  other  cases  chorea  and  actite  endocarditis  occur  together 
without  articular  symptoms,  or  all  three  may  be  associated.  Whichever 
of  the  three  conditions  is  first  seen,  the  physician  should  always  be  on 
the  lookout  for  the  others.  The  frequency  of  rheumatism  in  choreic 
patients  has  been  variously  estimated  by  different  observers;  in  my  own 
cases  over  fifty-six  per  cent  gave  unmistakable  evidence  of  a  rheumatic 
diathesis. 

TonsiUitis. — The  association  of  tonsillitis  and  phar}Tigitis  with  rheu- 
matism appears  in  many  cases  to  be  a  close  one.  Children  who  are  the 
subjects  of  frequent  attacks  should  be  regarded  as  possibly  rheumatic, 
and  closely  watched  for  other  signs  of  that  disease.  Acute  tonsillitis 
often  ushers  in  an  attack  of  rheumatic  arthritis,  and  occasionally  acute 
endocarditis  without  articular  symptoms.  The  nature  of  the  relationship 
is  not  3'et  fully  explained;  by  many  the  tonsils  are  regarded  as  the  struc- 
tures through  which  the  rheumatic  poison  is  absorbed. 

Suhcutaneous  Tendinous  Nodules. — General  attention  was  first  drawn 
to  these  as  a  manifestation  of  rheumatism  by  Barlow  and  AYarner,  in 
1881,  who  described  them  as  "  oval,  semi-transparent,  fibrous  bodies  like 
boiled  sago  grains."  They  are  most  frequently  found  at  the  back  of  the 
elbow,  over  the  malleoli,  at  the  margin  of  the  patella;  occasionally  on 
the  extensor  tendons  of  the  hands,  fingers,  or  toes,  or  over  the  spinous 
processes  of  the  vertebrse  or  the  scapulae.  They  are  composed  of  fibrin, 
cells,  and  fibrous  tissue,  and  vary  in  size  from  a  large  pin's  head  to  a 
small  bean,  sometimes  being  as  large  as  an  almond.  The  nodules  may 
come  in  crops,  lasting  for  a  few  weeks  and  then  disappearing,  or  they 
may  last  for  months.  An  eruption  of  nodules  is  usually  coincident  with 
other  rheumatic  manifestations.  These  nodules  are  better  felt  than 
seen,  although  they  may  be  visible  if  the  skin  is  tightly  drawn.  They  are 
certainly  not  common  in  this  country;  and  although  I  have  made  it  a 


RHEUMATISM.  1089 

rule  to  examine  rheumatic  patients  for  them,  I  have  seen  them  but 
seldom,  and  they  have  been  prominent  in  only  two  or  three  cases.  This, 
I  think,  has  also  been  the  experience  of  most  observers  in  New  York. 
From  published  reports,  however,  they  appear  to  be  much  more  frequent 
in  England.  There  can  be  no  doubt  regarding  the  connection  of  these 
nodules  with  rheumatism. 

Erythema. — The  connection  between  rheumatism  and  the  various 
forms  of  erythema — marginatum,  papulatum,  and  nodosum — has  been 
very  clearly  shown  by  Cheadle.  None  of  these  are  frequent  conditions  in 
childhood,  but  when  seen  they  should  always  suggest  rheumatism. 

Purpura.  —  The  association  of  purpura  with  rheumatism  is  so 
frequent  that  there  can  be  little  doubt  of  the  close  connection  be- 
tween the  two  conditions.  Rheumatic  purpura,  however,  is  quite 
distinct  from  the  other  forms  of  purpura,  and  is  a  much  less  frequent 
disease. 

Diagnosis. — In  order  to  recognise  rheumatism  in  a  child,  one  must 
free  his  mind  from  preconceived  notions  of  the  disease  drawn  from  its 
manifestations  in  adults,  as  very  few  cases  correspond  to  the  adult  type 
of  acute  rheumatism.  In  early  life  the  disease  is  recognised  not  by  any 
one  or  two  special  symptoms,  but  by  the  association  or  combination  of  a 
number  of  conditions  which  may  appear  unrelated.  In  determining 
whether  or  not  any  given  set  of  symptoms  is  due  to  rheumatism,  one 
should  consider:  (1)  The  family  history,  since  in  early  life  heredity  is 
so  important  an  etiological  factor;  (2)  the  previous  history  of  the  pa- 
tient, not  only  as  regards  articular  pains  and  swelling,  the  slight  joint- 
stiffness  without  swelling,  the  indefinite  wandering  pains  in  damp 
weather,  and  the  so-called  growing  pains,  but  also  the  previous  existence 
of  chorea,  frequent  attacks  of  tonsillitis,  torticollis,  or  erythema;  (3) 
the  examination  of  the  patient,  which  should  include  a  careful  search 
for  tendinous  nodules,  as  well  as  a  thorough  examination  of  the  heart 
for  signs  of  endocarditis  or  pericarditis,  and,  in  cases  which  are  at  all 
acute,  the  temperature.  In  doubtful  cases  with  monarticular  symptoms 
much  importance  is  to  be  attached  to  the  presence  of  slight  fever,  the 
abrupt  onset,  and  tenderness  of  the  neighbouring  muscles  and  tendons — 
all  occurring  without  a  history  of  traumatism.  Eheumatism  is  more 
often  overlooked  than  confounded  with  other  diseases ;  although  in  child- 
hood multiple  neuritis  and  tuberculous  and  syphilitic  bone  disease  are 
often  mistaken  for  it,  and  in  infancy  the  same  is  true  of  scurvy.  The 
extreme  infrequency  of  rheumatism  during  the  first  two  years  of  life 
should  always  make  one  sceptical  regarding  it.  In  an  infant,  when  the 
symptoms  are  confined  to  the  legs  and  are  not  accompanied  by  fever,  they 
are  almost  certain  to  be  due  to  scurvy,  even  though  the  gums  are  normal 
and  ecchymoses  have  not  yet  appeared.  Multiple  gonococcus  arthritis  has 
often  been  diagnosticated  rheumatism. 
70 


1090  OTHER  GENERAL  DISEASES. 

Prognosis. — Rheumatism  in  a  child  is  in  itself  seldom  if  ever  danger- 
ous to  life.  In  the  great  majority  of  cases  the  articular  symptoms  soon 
disappear,  even  without  special  treatment.  The  danger  from  the  disease 
consists  in  its  cardiac  complications.  One  attack  of  rheumatism  is  almost 
certain  to  he  followed  by  others,  and  when  once  the  heart  has  been 
affected  its  lesions  are  likely  to  increase  with  each  recurrence  of  the 
disease. 

Treatment. — Rheumatism  in  children  derives  its  chief  importance 
from  its  relation  to  cardiac  disease.  Cardiac  complications  are  so  fre- 
quent and  so  serious  that  everything  possible  should  be  done  to  avert 
rheumatism  from  those  who  by  inheritance  are  especially  predisposed  to 
it,  to  prevent  its  recurrence  in  a  child  who  has  once  had  the  disease,  and 
during  an  attack  to  prevent  the  heart  from  becoming  involved.  The 
relation  of  diet  to  rheumatism  is  very  imperfectly  understood.  The  best 
opinion  at  the  present  time  is  that  there  is  no  very  close  connection 
between  the  two.  The  underclothing  should  be  of  flannel  during  the 
entire  year,  in  summer  the  lightest  weight  being  worn.  The  feet  should 
be  carefully  protected,  and  exposure  in  damp  weather  avoided.  Indoor 
occupations  should  be  chosen  for  rheumatic  boys. 

The  tendency  to  recurrence  is  so  strong  in  this  disease  that  a  child  of 
rheumatic  antecedents,  who  has  shown  in  the  various  ways  mentioned  a 
marked  predisposition  to  rheumatism,  and  who  has  had  an  attack,  even 
though  a  mild  one,  should,  if  possible,  spend  the  winter  and  spring  in 
some  warm,  dry  climate,  or  even  remain  there  permanently.  Otherwise 
in  most  such  children,  it  is  only  a  question  of  time  when,  with  the  re- 
peated attacks,  the  heart  will  become  involved. 

To  avert  the  danger  of  cardiac  complications  during  an  attack  of 
rheumatism,  or  to  limit  their  extent,  there  are  two  things  which  sliould 
invariably  be  insisted  on :  First,  to  confine  to  the  house  and  in  a  warm 
room  every  child  with  rheumatic  pains,  no  matter  how  mild ;  secondly, 
if  fever  is  also  present,  to  keep  the  child  in  bed  while  it  continues,  even 
though  it  may  never  be  above  100°  F.  Absolute  rest  and  the  equable 
temperature  thus  secured  are  unquestionably  of  more  importance  than 
anything  else  in  protecting  the  heart  during  a  rheumatic  attack.  With 
these  precautions  must  be  combined  an  early  diagnosis.  In  very  many, 
perhaps  in  most  cases,  the  harm  is  done  before  the  true  nature  of  tlie 
disease  is  suspected,  the  symptoms  being  dismissed  as  of  slight  impor- 
tance because  the  articular  manifestations  are  not  very  severe.  Children 
who  have  once  had  rheumatism  should  be  closely  watched  during  chorea 
and  other  diseases  related  to  rheumatism,  the  heart  should  be  frequently 
examined,  and  the  physician  should  be  on  the  alert  for  the  first  articular 
symptoms. 

Aside  from  the  measures  just  mentioned,  the  treatment  of  rheuma- 
tism in  childhood  is  to  be  conducted  very  much  like  that  of  adult  life. 


DIABETES  MELLITUS.  1091 

In  the  most  acute  attacks  either  salicylate  of  soda  (gr.  v  every  three  hours 
to  a  child  of  five  years),  oil  of  wintergreen,  aspirin,  or  salicin  should 
be  given;  as  the  majority  of  cases  are  not  very  acute,  marked  improve- 
ment is  by  no  means  always  obtained  by  these  drugs.  Alkalies  should  be 
given  in  all  cases  in  combination  with  the  specific  remedies,  but  par- 
ticularly in  those  in  which  there  is  hyperacidity  of  the  urine.  Either  the 
acetate  or  citrate  of  potassium  or  the  bicarbonate  of  sodium  may  be  used, 
a  sufficient  quantity  being  administered  to  render  the  urine  alkaline. 

Quite  as  important  as  these  drugs  is  the  use  of  general  tonics,  partic- 
ularly iron  and  cod-liver  oil.  These  should  be  given  not  only  between 
attacks  to  fortify  patients  against  their  recurrence,  but  also  in  subacute 
cases  which  are  sometimes  influenced  very  little  or  not  at  all  either  by 
salicylates  or  alkalies. 

CHAPTER    II. 
DIABETES  MELLITUS. 

In  this  chapter  will  be  attempted  only  a  description  of  the  peculiar 
features  which  diabetes  presents  when  affecting  young  patients.  It  is 
a  very  infrequent  disease  in  children.  Of  1,360  cases  of  diabetes  col- 
lected by  Pavy,  only  eight  were  under  ten  years  of  age.  In  a  series 
of  700  cases  collected  by  Prout,  only  one  case  was  under  ten  years.  In 
a  series  of  380  cases  collected  by  Meyer,  only  one  case  was  under  ten 
years  of  age. 

Etiology. — Stern,  in  a  series  of  117  collected  cases  of  diabetes  in  chil- 
dren, states  that  47  were  females  and  31  males,  the  sex  in  the  other 
cases  not  being  given.  Although  extremely  rare,  cases  have  been  ob- 
served during  the  first  two  years,  and  even  during  the  first  year  of  life. 
Statistics  on  this  point  are  not  altogether  trustworthy,  since  some  cases 
of  temporary  glycosuria  have  certainly  been  included. 

Among  the  etiological  factors,  heredity  is  one  of  the  most  important. 
Pavy  reports  the  case  of  a  child  dying  of  diabetes  at  two  years  in  whose 
family  the  disease  had  existed  for  three  generations.  .  Instances  have 
been  recorded  of  the  occurrence  of  diabetes  in  four  or  five  children  of 
the  same  family.  Inherited  gout,  insanity,  and  nervous  diseases  gen- 
erally, may  be  looked  upon  as  factors  in  the  production  of  diabetes.  Sev- 
eral of  the  cases  reported  in  children  have  been  preceded  by  injuries 
received  upon  the  head.  In  a  nvimber  of  my  own  cases  the  disease  has 
followed  the  consumption  of  large  quantities  of  sugar  for  a  long  time. 
Often  no  adequate  cause  can  be  found. 

Symptoms. — The  most  important  early  symptoms  are  thirst,  polyuria, 
and  wasting;  their  development  is  often  quite  rapid.  The  thirst  is 
intense,  often  leading  children  to  drink  four  or  five  pints  of  fluid  a  day. 


1092  OTHER  GENERAL  DISEASES. 

The  amount  of  urine  passed  varies  from  one  to  eight  quarts  daily.  The 
specific  gravity  is  from  1.026  to  l.OiO,  and  the  usual  amount  of  sugar 
is  from  three  to  five  per  cent,  rarely  more.  Albumin  is  not  infrequently 
present.  Incontinence  of  urine  is  an  important  symptom,  and  often  one 
of  the  earliest  to  be  noticed.  The  wasting  is  usually  quite  rapid,  so  that 
a  child  may  lose  as  much  as  six  or  eight  pounds  in  a  month.  It  is  gen- 
erally accompanied  by  anaemia.  The  appetite  may  be  poor;  at  times, 
however,  it  is  voracious.  Other  symptoms  of  less  importance  are  a  dry 
mouth,  scanty  perspiration,  irregular  sleep,  occasional  epistaxis,  furuncles 
and  abscesses,  decayed  teeth,  and  genital  irritation. 

The  course  of  the  disease  is  much  more  rapid  in  children  than  in 
adults,  and,  as  a  rule,  the  younger  the  child  the  more  rapid  its  progress. 
The  majority  of  the  cases  prove  fatal  in  from  two  to  four  months  from  the 
time  the  symptoms  are  sufficiently  marked  to  make  the  diagnosis  possible. 
Very  few  last  more  than  six  months;  occasionally,  however,  one  of  the 
milder  type  may  be  prolonged  from  one  to  two  years. 

The  progress  of  the  disease  is  marked  by  continuous  wasting,  which 
may  result  in  a  marked  degree  of  marasmus,  and  prove  fatal.  Some  are 
carried  off  by  intercurrent  pneumonia  or  tuberculosis,  but  the  majority 
die  comatose.  When  coma  develops,  the  case  may  be  considered  hopeless, 
and  death  is  likely  to  be  postponed  but  a  few  days.  The  cause  of  diabetic 
coma  has  not  yet  been  satisfactorily  explained,  but  it  is  usually  believed 
to  be  due  to  the  presence  of  the  acetone  bodies  in  the  blood. 

Diagnosis. — Diabetes  is  apt  to  be  overlooked,  because  of  the  common 
neglect  of  urinary  examinations  in  children.  The  prominent  symptoms 
— thirst,  polyuria,  and  wasting — when  associated,  should  always  attract 
attention.  Incontinence  of  urine,  accompanied  by  marked  wasting,  is 
always  suspicious.  In  some  cases  genital  irritation  may  be  the  most 
prominent  early  symptom.  A  positive  diagnosis  is  made  only  by  an 
examination  of  the  urine. 

Prognosis. — In  few  diseases  is  the  prognosis  so  bad  as  in  diabetes  in 
children.  So  high  an  authority  as  Senator  declares  that  diabetes  in 
children  is  hopeless  and  all  treatment  is  useless.  From  a  study  of  sev- 
enty-seven cases.  Stern  reaches  the  same  conclusion.  There  are,  how- 
ever, cases  on  record  in  which  recovery  is  believed  to  have  taken  place. 
The  cases  which  I  have  seen  have  all  terminated  unfavourably.  In  a 
given  case  the  prognosis,  as  to  the  duration  of  the  disease,  is  rendered 
much  worse  by  the  presence  in  the  urine  of  large  amounts  of  diacetic 
and  j3-oxybutyric  acids.  This  condition  is  even  more  serious  than  is  a 
high  percentage  of  sugar ;  that  the  patient  will  then  live  more  than  three 
months  is  highly  improbable. 

Treatment. — The  indications  for  treatment  are  the  same  in  children 
as  in  adults:  first,  diet;  secondly,  general  hygienic  measures.  From 
the  use  of  drugs  nothing  can  be  expected. 


INDEX. 


Abdomen,  examination  of,  38;  growth  of, 
24;    in    rickets,    255. 

Abscess,  alveolar,  267;  cerebral,  731; 
symptoms,  732;  treatment,  734;  cere- 
bral, in  acute  otitis,  899;  Ischio-rectal, 
431 ;  mammary,  114  ;  hepatic,  437  ;  peri- 
toneal, 443  ;  peritonsillar,  300  ;  psoas,  in 
spinal  caries,  858 ;  retro-cesophagoal, 
306;  retro-pharyngeal.  In  Pott's  disease, 
287,  855;  retro-pharyngeal,  of  infancy, 
305;    subphrenic,    453. 

Abscess,    multiple,    in   newly  born,   84. 

Acetonurla,    604. 

Achondroplasia  (see  Chondro-dtstro- 
PHY),    760. 

Acid,  hydrochloric,  increased  by  lavage, 
334;  hydrochloric,  in  gastroenteric  in- 
toxication, 359;  hydrochloric,  in  stom- 
ach digestion,  309 ;  in  chronic  gastric 
Indigestion,   334. 

Adenitis,  acute,  836;  acute  axillary, 
836;  acute  cervical,  836;  acute  in- 
guinal, 836 ;  cervical.  In  diphtheria, 
976;  in  influenza,  1073;  in  measles, 
938;  retro-oesophageal,  306;  retro- 
pharyngeal, 284;  simple  acute,  836; 
simple  chronic,  839 ;  syphilitic,  840 ; 
tuberculous,    840;    treatment,    846. 

Adenoid  vegetations  of  pharynx,  288,  457; 
symptoms,  290  ;  treatment,  292  ;  asthma 
from,  485;  causing  chronic  nasal  ca- 
tarrh, 457;  chronic  laryngitis  with,  469; 
in   rickets,   256;    with   adenitis,   839. 

Adenoma    of    umbilicus.    111. 

Agenesis,  cortical,  747. 

Airing,    when  allowed   out   of   doors,   8. 

Air-space   required   by   Infants,    10. 

Alalia,   686. 

Albumin    water,    preparation   of,    160. 

Albuminuria,  orthostatic  or  cyclic,  600  ;  in 
chronic  cardiac  disease,  585;  in  chronic 
nephritis,  619;  in  measles,  938;  in  scar- 
let  fever,   917. 

Alcohol,  as  stimulant,  51;  as  tonic,  52; 
effect  on  breast  milk,  172;  use  of.  In 
diet   of   nurse,    136. 

Amaurotic    family    idiocy,    759. 

Amyloid  degeneration,  in  chronic  bone 
disease,  854;  of  the  intestines,  389;  of 
the  liver,   389;  of  the   spleen,   389. 


Anaemia,  cardiac  murmurs  in,  593;  fol- 
lowing diphtheria,  982;  pernicious,  818; 
pseudo-leukaemic,  of  infancy,  816;  treat- 
ment, 820;  simple,  813;  treatment,  820; 
in  rickets,  256  ;  in  scurvy,  238  ;  in  tu- 
berculosis, 1043  ;  preceding  tuberculo- 
sis,   1031. 

Auiesthesia,  partial,  in  multiple  neuritis, 
803. 

Anaesthetics,  those   best   for   children,   66. 

Anasarca,  general,  in  acute  diffuse  ne- 
phritis, 614;  in  chronic  cardiac  disease, 
585. 

Aneurism,    595. 

Antipyretic    drugs,    51. 

Antipyretics,  49;  in  acute  broncho-pneu- 
monia,   518. 

Antlpyrlne,  in  chorea,  674;  in  catarrhal 
croup,  464;  In  pertussis,  964;  scarla- 
tiniform   rash   from,    922. 

Antitoxine,  in  the  treatment  of  tetanus, 
91;  eliminated  by  human  milk,  137. 

Anuria,   604. 

Anus,  fissure  of  the,  428;  imperforate, 
115. 

Aorta,  abnormal  origin  of,  571;  aneurism 
of,  595;  atheroma  of,  595;  congenital 
narrowing  of.  In  chlorosis,  815  ;  hypo- 
plasia  of,  595;    thrombosis   of,    595. 

Aortic   insufliciency,    587;    stenosis,    588. 

Aphasia,  functional,  686;  In  acquired 
cerebral  paralysis,  754;  after  typhoid 
fever,  1014;  motor.  In  cerebral  tumour, 
737,    738. 

Aphonia,    hysterical,    682. 

Appendicitis,  415;  lesions,  416;  symp- 
toms, 416 ;  diagnosis,  418  ;  leucocyte 
count  an  aid  in,  419;   treatment,  419. 

Arm,  paralysis   of,    at   birth,    108. 

Arsenic,  as  a  tonic,  52;  dosage  in  chorea, 
674. 

Arteries,  hypogastric,  in  foetal  circula- 
tion, 564;  hypoplasia  of,  594;  umbilical, 
in  foetal   circulation,   564. 

Arthritis,  acute,  of  Infants,  850;  acute 
suppurative,  syphilitic,  867 ;  gonococ- 
cus,  634,  639,  851;  rheumatic,  1086. 

Arthrogryposis    (see  Tetany),  656. 

Artificial  feeding,  178 ;  versus  wet-nurs- 
ing, 165. 

1093 


1094 


INDEX. 


Ascaris  lumbrlcoides  (see  Worms,  Intes- 
tinal), 422. 

Ascites,  452;  chylous,  452;  In  acute  dif- 
fuse uephrltls,  Cll;  In  cirrhosis  of 
liver,  43i);  with  chronic  peritonitis,  445; 
with  tuberculosis  of  the  peritonaeum, 
447. 

Asphyxia,  death  from,  in  young  children, 
47;  from  overlying,  46;  fi*om  aspiration 
of  food,  46;  from  enlarged  thymus,  46; 
in  convulsions,  6.54;  in  retro-pharyngeal 
ab.'»cess,  286;  in  the  newly  born,  69; 
from  tuberculous  bronchial  lymph 
nodes,  1045;  methods  of  resuscitation, 
72;  sudden,  in  retro-oesophageal  ab- 
scess, 307. 

Aspiration   of  chest   In   empyema,  560. 

Asthma,  485;  etiology,  485;  symptoms, 
485;  diagnosis,  487;  prognosis.  487; 
treatment,  488 ;  catarrhal,  486 ;  with 
adenoids,  291;  simulated  by  tuberculous 
bronchial   glands,   104.5. 

Ataxia,  Friedreich's,  794 ;  in  multiple 
neuritis,  803. 

Atelectasis,  acquired,  545;  from  compres- 
sion, 545;  from  obstruction,  545;  in 
delicate  infants,  546;  causing  sudden 
death,   46 ;   congenital,   73. 

Atheroma,   595. 

Athetoid  movements,  675;  in  acquired 
cerebral  paralysis,  754  ;  in  birth  paral- 
ysis, 751. 

Athetosis,    675. 

Atresia   anl,   341. 

Atrophy,  infantile  (see  Marasmus),  227; 
muscular,  facial  type,  799;  in  multiple 
neuritis,  803 ;  juvenile  form,  799 ;  pro- 
gressive muscular,  hand  type,  796 ; 
peroneal   type,   797. 

Babcock's  centrifugal  machine,  145. 

Bacillus  of  diphtheria,  969,  990;  dis- 
tribution in  the  body,  972;  in  milk, 
140 ;  in  healthy  throats,  991 ;  in  laryn- 
geal diphtheria,  991 ;  non-virulent, 
991;  of  dysentery  (Shiga)  in  ileo- 
colitis, acute,  366;  in  gastro-intestinal 
intoxication,  acute,  .349;  of  Eberth,  in 
typhoid  fever,  1009:  Klebs-Loeffler  (see 
B.  Diphtheria),  969;  lactis  aerogenes, 
311 ;  of  Pfeiffer,  in  influenza,  1070 ; 
pseudo-diphtheria,  295;  of  tuberculosis. 
1017;  in  acute  broncho-pneumonia,  491. 

Backwardness,   760. 

Bacteria,  etiology  of  diarrhoea,  349;  in 
human  milk,  137;  in  cow's  milk,  139, 
144,  151,  153;  means  of  reducing  the 
number  In  cow's  milk,  143;  intestinal, 
311. 

Bacterium  coll  communis,  311;  in  appen- 
dicitis,  416;   in   peritonitis,   443. 

Bacterium    lactis    aerogenes,    311. 

Balanitis.  634. 

Band,   abdominal,   1,    3. 

Barley  water,  directions  for  making,  160; 
use  during   first    year,   200. 


Barlow's  disease  (see  ScoRBUTrs),  2.33. 

Bath,  at  birth,  1,  2  ;  cold,  50 ;  in  acute 
broncho-pneumonia,  518  ;  in  asphyxia  of 
newly  born,  71;  evaporation,  50;  hot, 
56;  hot  air,  56;  vapour,  56;  mustard, 
57;  bran,  57;  tepid,  57;  shower,  57; 
cold  sponge,  57;  hot.  in  asphyxia,  of 
newly  born,  71  ;   in  typhoid  fever,  1017. 

Bed-wetting,   641. 

Beef    broth,     160;     extracts,     1.59;    juice, 

'  159;  preparations  of,  159;  raw  scraped, 
160. 

Belladonna,  54  :  elimination  of.  In  milk, 
137;    scarlatiuiform   rash,    907. 

Bile,    physiological    a<'tiou    of,   310. 

Bile-ducts,  congenital  malformations  of, 
77. 

Birth  paralyses,  104;  cerebral,  104; 
spinal,    104;    peripheral,    104. 

Bladder,  control  acquired,  641;  exstrophy 
of,  6.33;  haemorrhage  from,  in  newly 
born,  102;  stone  in,  646;  training  to 
control,   4. 

Bleeders,  823. 

Blindness,  hysterical,  681;  stigma  of  de- 
generation, 771;  transient,  in  pertussis, 
960. 

Blood,  circulation  of,  in  early  life,  5t'>4; 
corpuscles,  red,  809,  corpuscles,  white, 
809;  diseases  of,  809;  haemoglobin, 
978 ;  in  empyema,  .557,  811  :  in  Icuk.-p- 
mia,  820  ;  in  measles,  939 ;  in  pernicious 
ansemia,  818 ;  in  pneumonia,  811  ;  in 
pseudo-leuksemic  anaemia,  817  ;  in  scar- 
latina, 919 ;  in  simple  anaemia.  814 ; 
leucocytes  of,  varieties  of,  810 ;  leu- 
cocytosis,  811  :  Plasmodium  malarise  in, 
1075,   1082 ;    specific   gravity.   809. 

Blood-vessels,  diseases  of,  595  :  aneurism, 
595  ;  arterial  hypoplasia,  595  ;  athero- 
ma, 595  ;  embolism,  595  ;  thrombosis, 
595. 

Boil   (see  Furunculosis),  887. 

Bone-marrow   in    leukaemia,    821. 

Bones,  diseases  of,  850;  in  hereditary 
syphilis,  1054;  in  late  syphilis,  1063; 
lesions  of,  in  rickets,  243;  microscopical 
changes  of,  in  rickets,  240;  syphilitic 
diseases  of,  867;  tuberculous  diseases 
of,   852;    etiology,   852;    lesions,   853. 

Bothriocephalus  latus,  420. 

Bottles,   nursing,  choice  and  care  of,  198. 

Bowels,  haemorrhages  from  (see  ILf.mor- 
RHAGE,  Intestinal)  ;  movements  of.  Ir- 
regularity in  times  for,  403 ;  training 
to    control    movements,    4. 

Bow-legs    in    rickets,   254. 

Bradycardia,    594. 

Brain,  diseases  of,  694 ;  abscess  of,  731  ; 
atrophy  and  sclerosis  of,  749 ;  atrophy 
and  sclerosis  of,  in  acquired  cerebral 
paralysis,  752;  cysts  of,  in  infantile 
cerebral  paralysis,  749;  malformations 
of,  694;  tuberculosis  of,  1029;  tumour 
of,  731;  weight  of,  647. 
Bran  bath,   57. 


INDEX. 


1095 


Breast,    abscess   of,    lu   newly    boru,   118. 

Breast-feeding,    166;    schedule    for,    KiS. 

Breast  milk   (see  Milk,  Woman's). 

Breath,  offensive,  in  ulcerative  stomatitis, 
273. 

Breathing,  noisy,  with  adenoids,  200; 
strldulons,  in  diseases  of  the  larynx, 
463,  466,  469;  in  retro-oBSophageal  ab- 
scess,   306. 

Breck's   feeder,   13. 

Bright's  disease    (see   Nephuitis),  611. 

Bromides,    elimination    of,    in    milk,    137. 

Bronchi,  catarrhal  spasm  of,  486;  diph- 
theria of,  97.">;  foreign  bodies  in,  471; 
lesions  of,  in  acute  broncho-pneumonia, 
494;  lymph  nodes  of,  in  tuberculosis, 
1021,   1027  ;    tube   casts  of,  482. 

Bronchial  glands  (see  also  Lvmph  Xode.s, 
Bronchial),  enlarged,  cause  of  asthma, 
485;  in  acute  broncho-pneumonia,  500; 
reflex   cough    from,   484. 

Bronchitis,  acute  catarrhal,  475;  symp- 
toms, 476;  diagnosis,  478;  treatment, 
479  ;  prophylaxis,  480  ;  asthma  follow- 
ing, 485 ;  capillary  (see  Broncho- 
pneumonia, Acute),  492,  502;  attacks 
of  asthma  resembling,  486 ;  chronic, 
482;  etiology,  482;  symptoms,  483; 
diagnosis,  483;  treatment,  483;  chronic, 
bronchiectasis  in,  483;  chronic,  in 
rickets,  248;  diphtheritic,  broncho-pnen- 
monla  in,  512;  fibrinous,  481;  treat- 
ment, 482;  in  pertussis,  959;  in  typhoid 
fever,  1013;  spasmodic  (see  Asthma), 
486;   tuberculous,    1036. 

Bronchiectasis  in  chronic  bronchitis,  483; 
in    broncho-pneumonia,    chronic,    540. 

Broncho-pneumonia,  acute,  492;  bacteri- 
ology, 493;  complications,  513;  com- 
plicating influenza,  512  ;  diphtheria, 
978;  measles,  512;  pertussis,  959;  rick- 
ets, 248;  diagnosis,  514;  etiology,  493; 
lesions,  494;  associated,  in  the  lung, 
500;  physical  signs,  illustrated,  508; 
protracted  or  persistent  form,  510;  sec- 
ondary pneumonia  with  measles,  512; 
ileocolitis,  513;  Influenza,  512;  per- 
tussis, 511;  diphtheria,  512;  prognosis, 
515;  protracted  cases,  510;  symptoms, 
501;  temperature  charts  of,  505;  ter- 
minations, 499;  treatment,  517;  prophy- 
laxis, 517. 

Broncho-pneumonia,  chronic,  540;  lesions, 
540;  symptoms,  541;  physical  signs, 
541  ;    treatment,   542. 

Broncho  -  pneumonia,  tuberculous,  1035, 
1036 ;  rapid  cases,  1089 ;  protracted 
cases,  1089  (see  also  Tuberculous 
Pneumonia). 

Broths,   directions  for   making,   160. 

Buhl's  disease,   91. 

Buttermilk,    156,    206,    382. 

Calamine   lotion,    885. 

Calculi,  biliary,  441;  renal,  627;  pyelitis 
with,    628;    vesical,   646. 


Calories,  required  dally  by  healthy  In- 
fauts,  178;  method  of  calculating,  178; 
value  of  different  food  stuffs  in,  127, 
179. 

t'ancrum  oris  (see  Stomatitis,  Gan- 
cuENoi.s),   279. 

Carbohydrates,    function   of,    in    diet,    125. 

Carcinoma  of  brain,  734;  of  kidney,  622; 
of  stomach,   3.'5S. 

Carrel's  apparatus  for  inflating  the 
lungs,    72. 

Casein,    147,    181. 

Caselnogen,    147. 

Casts  in   urine   of   chronic   nephritis,   618. 

Catarrh,  Eustachian,  in  hypertrophy  of 
tonsils,  302;  gastric,  331;  nasal  acute, 
454;  prophylaxis,  456;  chronic,  457; 
with  adenoid  growths,  290;  foreign 
bodies  In  nose,  457;  nasal  polypi,  4.58; 
rhinitis,  simple  chronic,  458;  syphilitic, 
4.59;  rhlno-pharyngeal,  with  adenoids, 
290. 

Catheters,  sizes  required  for  Infants,  598. 

Cellulitis  of  abdominal  wall  with  perito- 
nitis, 443;  of  neck,  In  scarlet  fever, 
916. 

Cephalhaematoma,  external,  95;  Internal, 
96. 

Cereals,  160;  allowed  from  third  to  sixth 
year,    213. 

Cerebellum,  abscess  of,  731;  tumours,  734. 

Cerebral  paralysis,  747 ;  from  haemor- 
rhage, 104;  etiology,  104;  lesions,  108; 
symptoms,  105 ;  prognosis,  106 ;  treat- 
ment, 106. 

Cerebro-splnal  menlntritis  (see  Menin- 
gitis,   Acute   Cerebuo-spinal),    701. 

Cerebrum,   abscess  of,   731;   tumour,  734. 

Chest,  circumference  of,  20;  development 
of,  23;  "funnel"  chest,  24:  In  rickets, 
251  ;  lateral  depressions  of,  in  adenoids, 
290. 

Cheyne-Stokes  respiration  in  cerebro- 
spinal meningitis,  706;  in  tuberculous 
meningitis,    724. 

Chicken-pox    (see  Varicella),  946. 

Chloral,    dosage   and    administration,   53. 

Chlorosis,  815;  etiology,  815;  lesions, 
815;  symptoms,  815;  prognosis,  816; 
diagnosis,    816;    treatment,    820. 

Cholera  infantum,  361;  symptoms,  362; 
treatment,  364. 

Chondrodystrophy,   762. 

Chorea,  669;  acute  endocarditis  in,  584; 
diagnosis,  584 ;  endocarditis  in,  672 ; 
etiology,  669;  following  birth  paralysis, 
751;  typhoid  fever,  1014;  heart  mur- 
murs in,  672;  prognosis  of,  673;  hys- 
terical, 682;  with  adenoids,  291;  In 
rheumatism,  670,  1088;  pathology,  671; 
posthemiplegic,  676;  in  cerebral  palsy, 
751;  prognosis,  673;  relation  to  rheuma- 
tism, 670;  speech  in,  672,  686;  symp- 
toms,   671;   treatment,   673. 

Circulation,  changes  in,  at  birth,  565; 
foetal,    565;   in    early    life,    565. 


1096 


INDEX, 


Circulatory  system,  diseases  of  the,   565. 

Citrate   of   soda,    208. 

Claw-hand,    796. 

Cleft  palate,  262. 

Clothing  at  birth,  2;  In  summer,  3;  at 
night,    3;    In    summer    diarrhoea,    356. 

Club-foot   with   spina   bifida,    775. 

Codeine,    dosage   of,    53. 

Cod-liver  oil  as  tonic,  52. 

Cold,  as  an  antipyretic,  49;  ice  cap,  49; 
sponging,  49  ;  pack,  50 ;  bath,  50 ;  Irri- 
gation of  the  colon,  50;  In  the  head, 
with  adenoids,  290;  therapeutics  of,  56. 

Cold   sores,   263. 

Colic,  habitual,  197;  intestinal,  400;  renal, 
627. 

Colitis,  acute  (see  Ileo-cohtis,  Acute), 
365;  amoebic,  389;  membranous,  372; 
membranous   gastritis    with,    329. 

Collapse,  in  acute  broncho-pneumonia, 
treatment  of,  519;  in  acute  peritonitis, 
467  ;  in  ulcer  of  stomach,  337. 

Collapse,  pulmonary  (see  Atelectasis, 
Acquired),   545. 

Colles's  law,   1054. 

Colon,  abnormal  position  of,  342;  con- 
genital atresia  of,  114 ;  dilatation  of, 
407;  in  rickets,  255;  follicular  ulcers  of, 
370;  hypertrophy  of,  407;  irrigation  of, 
50,  65;  In  gastroenteric  intoxication, 
359;  in  acute  ileocolitis,  382;  In  Intes- 
tinal Indigestion,  388;  membranous  in- 
flammation of,  373. 

Colostrum,  128;  corpuscles  of,  128;  com- 
position  of,   128. 

Coma,   in  diabetes  mellltus,   1091. 

Compression-myelitis  (see  Myelitis), 
780. 

Condensed  milk,  cause  of  rickets,  241; 
composition  of,  155;  dilution  of,  for  in- 
fants,  155;  fresh,   155. 

Congenital,  Ichthyosis,  875;  myotonia, 
677;  rickets,  257;  syphilis,  1057;  tuber- 
culosis, 1019. 

Conjunctiva,  catarrhal  inflammation  of. 
In  measles,  932 ;  haemorrhage  from,  in 
newly   born,    102. 

Constipation,  In  rickets,  255;  chronic,  401; 
treatment  of,  403 ;  dilatation  of  colon 
In,  407 ;  anal  fissure  from,  428 :  early 
symptom  of  rickets,  248 ;  from  defi- 
cient fat  in  food,  196 ;  In  intussuscep- 
tion, 413. 

Contractures,    hysterical,   681. 

Convulsions,  649;  symptoms,  651;  diag- 
nosis, 652;  prognosis,  654;  treatment, 
654;  causing  death  without  other  symp- 
toms, 47;  chloral  in,  655;  epileptic,  664; 
hysterical,  682;  In  acquired  cerebral 
paralysis,  753;  In  cerebral  haemor- 
rhages, 105;  in  congenital  atelectasis, 
75;  In  pertussis,  960;  In  rickets,  2.56; 
morphine  in,  655;  in  status  lymphat 
lens,   832. 

Cord,  spinal,  diseases  of,  772;  malforma- 
tions of,  772;  meningitis,  778;  myelitis. 


778;  pressure-paralysis  of,  780;  tumours 
of,   793;   weight  of,   647. 

Cord,  umbilical,  care  of,  1;  separation 
of,  2. 

Cornea,  ulcers  of,  in  chronic  ileo-colitis, 
387. 

Corpuscles    of    blood,    809. 

Coryza,  454;  early  symptoms  of  measles, 
931;    syphilitic,    459,    1059. 

Cough,  hysterical,  682;  refiex,  483;  from 
pharyngeal  irritation,  484;  elongated 
uvula,  484;  from  pharyngeal  mucus, 
484;  from  aural  Irritation,  484;  from 
cardiac  disease,  484;  of  puberty,  484; 
periodical,  at  night,  484;  from  Pott's 
disease,  484  ;  spasmodic.  In  retro-oesoph- 
ageal  abscess,  307;  In  tuberculous 
bronchial  glands,  1045;  whooping  (see 
Pertussis),   954. 

Counter-irritants,   54. 

Cow's  milk  (see  Milk),  138. 

Cranio-tabes,  early  symptom  in  rickets, 
249. 

Cranium,   syphilitic  nodes  on,   870. 

Cream,  147;  to  secure  different  percent- 
ages of,  148,   149. 

Cream-gauge,    132,    145. 

Credo's  method  of  preventing  ophthalmia 
neonatorum,  1:  treatment  of  ophthal- 
mia,  88. 

Cretinism,   sporadic,   765. 

Croup,  bronchial,  481;  catarrhal,  462; 
kettle,    60;    spasmodic,    462. 

Croupous   tonsillitis,  295. 

Cry,  causes  and  varieties  of,  34;  in  dis- 
eases,  34;    in    colic,    401. 

Cryptorchidism,   633. 

Cups,    dry.    Indications  for,  55. 

Cyanosis,  In  acute  broncho-pneumonia, 
501,  503 ;  In  acute  inanition,  218 ;  in 
chronic  cardiac  disease,  585;  in  congen- 
ital atelectasis,  75;  in  congenital  dis- 
ease of  heart,  571;  in  diphtheritic  pa- 
ralysis, 806;  in  malaria,  1079,  1081; 
of  face,  from  pressure  at  root  of  lung, 
1045. 

Cyclic  vomiting,   321. 

Cyst,  of  brain,  734;  of  brain  in  Infantile 
cerebral   paralysis,   749. 

Cysticerci,    420. 


Dactylitis,  syphilitic,  873;  tuberculous, 
865. 

Deaf-mutism,  771;  stigma  of  degenera- 
tion, 771. 

Deafness  following  mumps,  968 ;  with 
adenoids,  290:  with  hypertrophy  of  ton- 
sils, 302;  sudden,  in  late  syphilis,  1064. 

Death,  most  frequent  causes  of.  at  differ- 
ent  ages,   43;    sudden,    causes  of.   44. 

Deformities,  hysterical,  681;  in  rickets, 
2.50. 

Degeneration,    stigmata   of,    770. 

Deltoid,   paralysis  of,    at  birth,   108. 

Dental   caries,   266. 


INDEX. 


1097 


Dentition,  27;  eruption  of  first  teetli,  28; 
eruption  of  permanent  teeth,  29;  de- 
layed, 28;  before  birth,  28;  difficult, 
268;   in   rickets,   255. 

Dermatitis,  exfoliative,  of  newly  born, 
875;    gangrenous,   886. 

Development,  conditions  interfering  with, 
30;    muscular,    25;   of  body,    15. 

Dew's  method  of  inducing  artificial  res- 
piration,  71. 

Dextro-cardla,    571. 

Diabetes   insipidus,   605. 

Diabetes    mellltus,    1091. 

Dlacetonurla,    604. 

Diagnosis,    general    considerations    in,    31. 

Diapers,   3. 

Diaphragm,    hernia    through,    115. 

DiarrhcEa,  general  consideration  of,  343; 
deaths  from  In  New  York  in  five  years, 
343;  prevalence  during  summer,  345; 
Impure  milk  as  a  cause,  344;  observa- 
tions of  The  Rockefeller  Institute  on 
association  of  feeding  Impure  milk  and 
diarrhoeal  disease  ;  345  et  seq.  ;  Inflam- 
matory (see  iLEO-coLiTis,  Acute). 
365 ;  in  chronic  intestinal  Indigestion, 
394 ;  in  intestinal  tuberculosis,  392  ; 
summer,  348. 

Diet  (see  also  Feeding),  as  cause  of 
chronic  constipation,  402;  cause  of 
rickets,  241;  in  acute  gastro-enteric  in- 
fection, 357;  in  acute  gastric  Indiges- 
tion, 327;  in  chronic  constipation,  404; 
in  chronic  gastric  indigestion,  334;  In 
dental  carles,  267 ;  in  eczema,  883 ;  in 
intestinal  Indigestion,  398  ;  In  malnutri- 
tion, 225;  in  rickets,  2.59;  in  scurvy, 
241;   of  nurse,   effect  on  milk,   136. 

Dietary    of    the    Infant,    127. 

Digestion,  gastric,  308  ;  duration  of,  310  ; 
in  infancy,   309;  intestinal,  310. 

Digestive  system,   diseases  of  the,   262. 

Digitalis,  dosage,  52;  in  cardiac  disease, 
580,  591. 

Dilatation   of   the   stomach,    335. 

Diphtheria,  969 ;  bacillus  (see  Bacillus 
OF  Diphtheria),  969;  broncho-pneu- 
monia in,  512,  978,  986;  blood  in, 
978;  cardiac  failure  in,  988;  cardiac 
thrombi  in,  977  ;  catarrhal,  973,  979 ; 
complications  and  sequelae,  986;  diag- 
nosis, 988;  bacteriological,  990;  clinical, 
988;  from  pseudo-diphtheria,  991;  dis- 
infection after,  995;  distribution  and 
mode  of  communication,  970;  etiology, 
969;  fibrinous  bronchitis  in,  481;  Im- 
munization, 994;  ileo-colltls  in,  987;  in- 
cubation, 971  ;  lesions,  972  ;  membrane, 
973;  membranous  gastritis  in,  329; 
proctitis  in,  429;  myocarditis  in,  591, 
988;  nasal  syringing  In,  996;  nephritis 
in,  977,  985;  of  oesophagus,  304;  otitis 
in,  986  ;  paralysis  after,  987  ;  paralysis 
in,  804 ;  prognosis,  992 ;  prophylaxis, 
993;  quarantine,  993;  simulated  after 
tonsillotomy,       304;       symptoms,       978; 


thrombosis  in,  986;  toxins  of,  972; 
treatment,  995;  local,  996;  serum,  997; 
of  children  exposed,  994;  of  suspected 
cases,  994;  laryngeal,  979,  983,  1003; 
nasal,  981,  985;  psoudo  (see  1'seudo- 
Diphthekia),  295;  scarlatinal,  904; 
scarlatiniform  erythema  in,  922  ;  ton- 
sillar,  980. 

Diphtheria  antitoxine,  dosage  of,  998  ; 
immunizing  dose  of,  994;  Influence  on 
mortality  of  cities,  1001  ;  local  and 
general  effects  of,  999;  other  treat- 
ment with,  995,  996;  real  and  alleged 
dangers  from,  1000;  strength  of,  997; 
time  of  administration,  998. 

Diplegia,  in  birth  paralysis,  750;  In 
meningeal  haemorrhage,  106 ;  spastic, 
747. 

Disease,  peculiarities  of,  in  children,  29; 
etiology,  29;  symptomatology  and  diag- 
nosis, 30  ;  pathology,  40  ;  prognosis,  42  ; 
prophylaxis,   47;   therapeutics,  48. 

Diverticulum,    Meckel's,    111. 

Dover's    powder,    dosage    of,    53. 

Dropsy  (see  also  Q-^dema)  ;  in  acute  dif- 
fuse nephritis,  611,  612;  in  chronic  car- 
diac disease,  580;  In  chronic  nephritis, 
619;  in  tuberculosis,  1040;  without 
renal   disease,   231. 

Drugs,  administration  of,  48;  antipyret- 
ics, 49;  elimination  of,  in  breast  milk, 
137  ;  well  borne,  54 ;  not  well  borne, 
54. 

Duct,    amphalo-mesenteric.    111,    115. 

Ductus  arteriosus,  closure  of,  564;  In 
foetal  circulation,  564;  patent,  570; 
venosus,  closure  of,  565;  in  foetal  cir- 
culation,  564. 

Duodenum,    congenital   atresia    of,    114. 

Dura  mater,  haematoma  of,  698;  throm- 
bosis of  the  sinuses  of,   729. 

Dysentery    (see   Ileo-colitis,  Acute),  365. 

Dysphagia,  hysterical,  682;  in  retro- 
pharyngeal  abscess,  285. 

Dyspnoea,  evidence  of,  36;  from  tubercu- 
lous bronchial  lymph  nodes,  1047;  In 
acute  catarrhal  laryngitis,  467;  in  ca- 
tarrhal spasm  of  larynx,  463;  In  chronic 
cardiac  disease,  585;  inspiratory,  in 
retro-oesophageal  abscess,  307 ;  from 
pressui-e  of  abscess  on  pneumogastrlc, 
307 ;   spasmodic,    in  asthma,  486. 


Ear,  anomalies  of,  as  stigmata  of  degen- 
eration, 771;  middle,  inflammation  of 
(see  Otitis),  894;  in  measles,  938;  In 
scarlet   fever,   916. 

Ecchymoses  in  purpura,  825;  in  scurvy, 
238;    in    leuksemia,    822. 

Echinococcus  of  liver,   441. 

Eclampsia    (see   Convulsions),    649. 

Ecthyma  gangrenosa,  888. 

Ectocardia,   571. 

Eczema,  879;  etiology,  879;  diagnosis, 
882 ;    treatment,    883 ;    intertrigo,    882. 


1098 


INDEX. 


Emboli,  infectious,  in  malignant  endo- 
carditis,   592. 

Embolism,  595;    in    diphtlieria,   986. 

Empliysema,  547;  symptoms,  548;  acute, 
in  bronciiitis  of  infants,  476;  in  acute 
broncho-pneumonia,  500 ;  in  pertussis, 
959. 

Empyema,  554;  lesions,  554;  symptoms, 
556;  diagnosis,  557;  treatment,  560;  in 
acute    broncho-pneumonia,    500. 

Encephalocele,  694  ;  symptoms,  696 ; 
treatment,    696. 

Endarteritis,  syphilitic,  of  brain,  1056; 
tuberculous,   721. 

Endocarditis,  acute  simple,  582;  lesions, 
583  ;  symptoms,  583  ;  treatment,  589  ; 
in  chorea,  582 ;  chronic  (see  also 
Heart,  Valvular  Disease),  584 ;  foe- 
tal, 568 ;  in  chorea,  672 ;  in  rheuma- 
tism, 1088  ;   malignant,  591. 

Enemata,  65;  nutrient,  65;  drugs  by,  65; 
astringent.  In  chronic  ileo-colitis,  388; 
in  chronic  constipation,  406;  in  colic, 
401;    injuries  to    rectum    from,    429. 

Enuresis,  641;  etiology,  641;  symptoms, 
642;  treatment,  643;  stigma  of  degen- 
eration,   771. 

Ependymltis,  acute,  in  hydrocephalus, 
743. 

Epidermis,  exfoliation  of,  in  congenital 
ichthyosis,  876;  exfoliation  of,  in  newly 
born,   875. 

Epilepsy,  663  ;  diagnosis,  667  ;  hysterical, 
682;  in  acquired  cerebral  paralysis,  754; 
in  birth  paralysis,  751;  insanity  fol- 
lowing, 757  ;  Intestinal  putrefaction  in, 
663;  Jacksonian,  in  cerebral  tumour, 
737;  mental  condition  in,  666;  pathol- 
ogy, 664;  prognosis,  667;  status  epi- 
leptlcus,  667;  stigma  of  degeneration, 
771;    symptoms,    664;    treatment,    668. 

Epiphyseal  separation  in  acute  arthri- 
tis, 851;  in  scurvy,  238;  in  syphilis, 
867. 

Epiphyses,  enlargement  of,  in  ricliets, 
253;  in  syphilis,  868. 

Epiphysitis,  acute  (see  Arthritis, 
AciTTE),  850;  syphilitic,  867,  1055. 

Epispadias,   632. 

Epistaxis,  460;  in  ansemia,  814;  in  per- 
tussis, 958;  in  purpura,  827;  in  scurvy, 
238. 

Epitroehlear  lymph  nodes  in  syphilis, 
1065. 

Erb's  paralysis,  109. 

Erysipelas  in  newly  born,  85. 

Erythema,  following  diphtheria  antitox- 
ine,  1000  ;  in  influenza,  1073  ;  intertrigo, 
882;  in  intestinal  indigestion,  397;  in 
rheumatism,  1089;  of  the  buttocks  in 
marasmus,  231;  scariatiniform,  causes, 
922. 

Estlander's  operation,  563. 

Eustachian  tube  in  acute  otitis,  895;  ob- 
struction of,  in  hypertrophy  of  tonsils, 
302. 


Examination  of  sick  child,  33. 

Exercise,  importance  of,  7;  caution  re- 
garding, in  heart  disease,  590;  in  anae- 
mia, 820. 

Exstrophy  of  bladder,   633. 

Eye,  anomalies  of,  as  stigmata  of  degen- 
eration, 771;  keratitis,  interstitial,  in 
syphilis,  1063;  care  of.  at  birth,  1,  3; 
diphtheritic  paralysis  of,  806 ;  early 
use,  25;  ectropion  of,  in  congenital 
ichthyosis,  875;  inflammation  of,  in 
newly  born,  87  ;  in  measles,  938  ;  nys- 
tagmus, 676. 

Face,  asymmetry  of,  as  stigma  of  degen- 
eration, 771;  expression  of,  in  disease, 
34;  cyanosis  and  oedema  of,  from  pres- 
sure at  root  of   lung,   1045. 

Facial  paralysis  at  birth,  107;  acquired, 
peripheral,  807  :  in  otitis.  900. 

Faeces,  311  ;  of  milk  diet,  311  :  of  mixed 
diet,    312;    incontinence   of,    4.32. 

Fat,  determination  of,  in  milk,  133;  in 
the  faeces,  311;  lack  of,  a  cause  of 
rickets,  241  ;  in  woman's  milk,  131 ; 
percentages  of,  in  modification  of  cow's 
milk,  182,  186,  188 :  symptoms  from 
deficiency  of,  in  food,  196 ;  symptoms 
from  excess  in  food,  195,  197  ;  function 
of,   in   diet,    124. 

Fatty  degeneration  of  the  newly  born, 
91. 

Feeding,  artificial,  principles  of,  178; 
rules  for,  190,  199;  schedule  for  first 
year,  190 ;  versus  wet-nursing,  165 ; 
breast,  schedule  for,  168;  other  than 
milk,  first  year.  199:  difficult  cases, 
first  year,  201 ;  Finkelstein's  classifica- 
tion, 208 :  dally  dietary  from  four- 
teen to  eighteen  months,  210 :  for 
healthy  Infants,  second  year,  209;  diffi- 
cult cases,  second  year,  211;  from  tliird 
to  sixth  year,  212 ;  articles  allowed, 
212;  articles  forbidden,  213;  during 
acute  illness,  214;  in  infants,  214; 
older  children,  214 ;  during  periods  of 
excessive  heat,  355 :  by  gavage,  in 
acute  illness,  215 ;  nasal,  63 :  in  acute 
intestinal  indigestion  and  Intoxication, 
357 ;  methods  of,  in  etiology  of  diar- 
rhoea, 344  ;  mixed,  indications  for,  177  ; 
simple    rules    in,    214. 

Feet,  anomalies  of,  as  stigmata  of  degen- 
eration, 771. 

Fever  from  insufficient  nourishment,  169; 
inanition,  118  (see  also  Temperature). 

Finger   (See  Dactylitis). 

Fingers,  clubbing  of,  in  congenital  heart 
disease,  572. 

Finkelstein's  classification  of  nutritional 
disturbances,  208;  "  food  intoxication," 
361. 

Fissure  of  the  anus,  428. 

Fistula,   congenital,   of  the  neck,   304. 

Flatulence,  cause  of  colic,  400;  in  Intes- 
tinal indigestion,  396. 


INDEX. 


1099 


Flexner's  serum  for  cerebrospinal  menin- 
gitis,  712  et  8eq. 

Foetal   circulation,   564;    endocarditis,   568. 

Foetus,   evidences  of   syphilis   in,   1054. 

Follicles,  solitary    (see  Limph  Nodules). 

Follicular  ulceration  of  intestine,   376. 

Fontanel,  bulging  of,  in  cerebro-spiaal 
meningitis,  709;  bulging  of,  in  menin- 
geal haemorrhage,  106 ;  bulging  of,  in 
tuberculous    meningitis,    724;    in    hydro- 

■  cephalus,  745;  closure  of,  22;  in  cretin- 
ism, 766;   in   rickets,  251. 

Food,  constituents,  123;  protein,  123; 
fats,  124;  carbohydrates,  125;  mineral 
salts,  126;  water,  126;  farinaceous,  a 
cause  of  eczema,  883;  in  chronic  indi- 
gestion, 334;  second  year,  209;  im- 
proper In  etiology  of  diarrhoea,  344 ; 
of  dental  caries,  207;'  regurgitation  of, 
causes  and  treatment,   195. 

Food   diseases,   233. 

Foods,  Infant,  161;  milk,  162;  malted, 
162;  farinaceous,  162;  proprietary,  dan- 
gers of,  122;  cause  of  rickets,  241; 
cause  of  scurvy,  234  ;  uses  of,  in  chron- 
ic  constipation,    404. 

Foramen  ovale,  closure  of,  565;  function 
of,    in   foetal   life,    564;   patent,    569. 

Foreign  bodies,  swallowing  of,  339;  in  the 
larynx,   471. 

Fractures,  green-stick,  in  rickets,  244, 
253. 

Freeman's  pasteurizer,  152. 

Friedreich's    ataxia,    794. 

Fruit,  best  time  for  giving,  211;  during 
second  year,  211;  allowed  during  third 
to  sixth  year,  213;  forbidden  during 
third   to  sixth  year,  213. 

Furunculosis,  887  ;  in  diabetes  mellitus, 
1092. 


Gangrene,  of  the  face,  280  ;  of  Intestine, 
in  intussusception,  410 ;  of  lung,  544  ; 
in  acute  broncho-pneumonia,  500;  in 
lobar  pneumonia.  522;  in  scarlet  fever, 
920;   In   measles,  938. 

Gangrenous  stomatitis,  279. 

Gastralgla,  324;  in  malaria,  1080;  in 
spinal    carles,    856. 

Gastritis,  acute,  327 ;  etiology,  327 ; 
lesions,  327;  symptoms.  329;  treat- 
ment, 3.'il  ;  chronic,  331  ;  ulcers  In,  366  ; 
toxic    (see   Ga.stritis,   Corrosive),   329. 

Gastro-enterltls  (see  Acute  Intestinal 
Indigestion  and  Intoxication),  348; 
In   newly   born,    83. 

Gavage,  62 ;  in  acute  illness,  215 ;  in 
acute  Inanition,  220;  in  diphtheria, 
995 ;    in    premature    Infants,    13. 

Genital   irritation,  645. 

Genital  organs,  diseases  of,  631  ;  anom- 
alies of,  as  stigmata  of  degeneration, 
771;  care  of,  in  newly  born,  4;  malfor- 
mations of,  631;  female,  gangrene  of, 
279;   females,   diseases  of,   636;   hasmor- 


rhage  from,  in  newly  born,  102;  males, 

diseases   of,   634. 
Gingivitis,    in  dental    caries,   267;    hsemor- 

rhagic,    in    scurvy,    236,    237. 
Glands,     bronchial     (see     Lymph     Nodes, 

BUONCHIAL). 

Glands,  lymphatic  (see  Lymph  Nodes), 
830. 

(Glioma  of  brain,  735  ;  of  spinal  cord,  793. 

(Uio-sarcoma   of  brain,   735. 

Glossitis,   265. 

Glottis,    oedema   of   the,  468. 

Gonococcus,  differentiation  of,  638;  In 
gonorrhoeal  stomatitis,  278  ;  in  specific 
urethritis,     634;     vaginitis,     637. 

Gout,  its  relation  to  eczema  in  children, 
879. 

Grippe    (see   Influenza),   1070. 

Growing   pains,    rheumatic,    1086. 

Growth,  conditions  interfering  with,  30; 
of  body,   15;  extremities,  21;   trunk,  21. 

Gumma,  syphilitic  (see  Syphilis  Le- 
sions), 1055;  in  syphilitic  bone  dis- 
ease, 871  ;  of  brain,  735. 

Gums,  abscess  of,  267;  bleeding  in  ulcer- 
ative stomatitis,  273;  inspection  of,  38; 
lancing,  270;  spong.v  and  bleeding,  in 
scurvy,  2.36,  237;  in  ulcerative  stomati- 
tis,   273. 

Habit-spasm,    675. 

Habits,    injurious,   689. 

Hsematemesis,    338. 

Ha'matoma    of    the    sterno-mastoid,    94. 

Ilsematuria,  601;  in  newly  born,  102;  In 
purpura,  826;  in  pyelitis,  626;  in 
scurvy,  238;  in  tumours  of  kidney,  622. 

Haemoglobin,    809. 

Haemogiobinuria,  602;  epidemic,  91;  par- 
oxysmal,  602. 

Haemophilia,   823. 

Haemoptysis  in   tuberculosis,   1089. 

Haemorrhage,  from  stomach,  338  ;  In 
haemophilia,  823 ;  intra  -  alveolar,  in 
acute  broncho-pneumonia,  496;  internal, 
causing  sudden  death,  46;  intestinal, 
from  tuberculous  ulcer,  392;  in  typhoid 
fever,  1013;  meningeal,  causing  birth 
paralysis,  747;  in  acquired  cerebral 
paralysis,  751;  in  acute  broncho-pneu- 
monia, 513;  in  convulsions,  651;  men- 
ingeal, in  pertussis,  958;  meningeal, 
in  purpura,  825 ;  nasal,  in  diphtheria, 
986;  pulmonary,  in  cardiac  cases,  585; 
rectal,  from  ulcer,  430 ;  In  leukaemia, 
822;  in  measles,  939;  in  pertussis,  957; 
In  pernicious  anaemia,  819;  in  purpura, 
825;  in.  the  newly  born,  94;  visceral, 
97;  in  scurvy,  233,  235;  in  syphilis, 
1061. 

Haemorrhaglc  diseases  of  the  newly  born, 
98. 

Hiemorrhoids,  432;  in  chronic  constipa- 
tion,  403. 

Hair,  anomalies,  stigmata  of  degener- 
tlon,  771;   in  the  stomach,   340. 


1100 


INDEX. 


Hand,  progressive  muscular  atrophy  of, 
796. 

Hands,  anomalies,  stigmata  of  degenera- 
tion, 771. 

Harelip,  262. 

Hay  fever,   487. 

Head,  circumference  of,  21;  closure  of 
sutures,  22 ;  closure  of  fontanels,  22 ; 
shape  of,  22;  in  rickets,  250;  examina- 
tion of,  34;  hydrocephalic,  characteris- 
tics of,  744  ;  rotary  and  nodding  spasm 
of,   676;   sweating  of,   in   rickets,   248. 

Headache,  frequent,  with  adenoids,  291; 
varieties,  684;  diagnosis,  684;  treat- 
ment,   084. 

Head-banging,  963. 

Hearing,   when  developed,  26. 

Heart,  diseases  of,  564;  aneurism  of,  592; 
aortic  disease,  congenital,  570;  area  of 
absolute  cardiac  dulness,  567;  of  rela- 
tive dulness,  566  ;  auscultation  of,  38  ; 
diphtheritic  paralysis  of,  806;  examina- 
tion of,  567;  hypertrophy  of,  in  valvu- 
lar diseases,  583 ;  in  measles,  938 ;  in 
scarlet  fever,  919;  malformations  of, 
568;  peculiarities  of,  in  early  life,  504; 
persistent  foetal  conditions,  568;  posi- 
tion of  apex  beat,  566;  in  infancy,  560; 
size  and  growth  of,  565;  sounds  of  re- 
duplication, 567  ;  sudden  failure  of,  in 
diphtheria,  988;  thrombus  of,  ante-mor- 
tem, 595;  transposition  of,  571;  con- 
genital anomalies  of,  567;  functional 
disorders  of,  594  ;  murmurs  of,  586  ;  dif- 
ferential diagnosis  of,  574,  575;  acci- 
dental, 593;  in  congenital  diseases,  573; 
in  chorea,  671;  In  marasmus,  231; 
valves,  aortic  InsuflBclency,  587;  aortic 
stenosis,  587;  mitral  insufficiency,  586; 
mitral  stenosis,  587;  congenital  ab- 
sence of  valves,  571;  tricuspid  insuffi- 
ciency, 588;  valvular  diseases  of  (see 
also  Endocabditis),  582;  chronic  val- 
vular disease  of,  584;  ventricle,  left, 
signs  of  dilatation,  586;  signs  of  hyper- 
trophy, 587;  right,  signs  of  hypertro- 
phy, 587. 

Height,  19;  from  birth  to  sixteenth  year, 
20. 

Hemichorea,    672. 

Hemiplegia  in  acquired  cerebral  paral- 
ysis, 751;  in  birth  paralysis,  747;  in 
meningeal  hseraorrhage,  100;  in  cerebral 
tumour,    737;    spastic,    749. 

Hepatitis,  interstitial,  77;  suppurative, 
437. 

Hermaphroditism,    false,    632. 

Hernia,  cerebri,  695  ;  diaphragmatic,  115  ; 
umbilical,   112. 

Herpes  lablalis,   263. 

Herpetic    stomatitis,    271. 

Hiccough,  677;  in  acute  peritonitis,  444; 
in  hysteria,   682. 

Hip,  articular  ostitis  of,  8.59. 

Hip-Joint  disease  (see  Hip,  Articular 
Ostitis  of),  859. 


History-taking.    31. 

Hives   (see  L'rticaria),  890. 

Hoarseness  with  adenoids,  291:  in  ca- 
tarrhal spasm  of  larynx,  462;  in  syph- 
ilis,   1059. 

Hodgkin's  disease,  847. 

Holding-breath    spells,    001. 

Home  modification  of  milk  (see  Milk, 
Modification  of,  at  Home),  186. 

Hookworm,  425. 

Hutchinson's  teeth  in  late  hereditary 
syphilis,  1062. 

Hydatids  of  liver,  441. 

Hydrencephalocele,    694. 

Hydrocele,   635. 

Hydrocephalus,  740;  in  chronic  basilar 
meningitis,  728;  with  spina  bifida,  742, 
775 ;  acute  (see  Meningitis,  Tuber- 
culous), 720—727;  chronic  external, 
741  ;  internal,  740 ;  congenital,  697  ; 
intrauterine,   696  ;  syphilitic,    1056. 

Hydronephrosis,  (507;  traumatic,  628; 
with  malformations  of  kidney,  607; 
with   renal   calculi,   627. 

Hydromyelus,    793. 

Hygiene  of  infancy,   1. 

Hypersesthesia,  general,  in  cerebro-spinal 
meningitis,  707;  In  acute  poliomyelitis, 
787;  hysterical,  (581;  in  multiple  neu- 
ritis, 803 :  in  scurvy,  230 ;  in  spinal 
meningitis,  778. 

Hj-permetropia,  stigma  of  degeneration, 
771. 

Hypertrophy,    muscular    pseudo-,    797. 

Hypodermic  medication,  66;  dosage  for, 
52. 

Hypodermoclysis,    indications    for,    (56. 

Hypospadias,    (532. 

Hysteria,  ($80;  symptoms,  (580;  diagnosis, 
682  ;  treatment,  683. 

Hystero-epilepsy,   (582. 

Ice,   bag,   56;   cap,  49,   56;   coil,  56. 

Ichthyosis,    congenital,    875. 

Icterus,  459;  in  epidemic  haemoglobinuria, 
91;  varieties  in  newly  born,  76;  in  mal- 
formation of  the  bile  ducts,  77  ;  inter- 
stitial hepatitis,  77;  physiological  or 
idiopathic,  78;  differential  diagnosis,  80. 

Idiocy,  750;  Mongolian,  758;  amaurotic 
family,    7.59;    cretinoid,    759. 

Ileo-colitis,  acute,  305;  etiology,  305;  le- 
sions, .300 ;  in  catarrhal,  307  ;  in  follicu- 
lar, 370;  in  membranous,  372;  associ- 
ated lesions,  374  ;  symptoms,  catarrhal 
form,  374;  with  follicular  ulceration, 
.370 ;  membranous  form,  372 ;  diagnosis, 
380 ;  prognosis,  381  ;  treatment,  381  et 
fieq.;  broncho-pneumonia  complicating, 
513 ;  in  diphtheria,  987 ;  in  influenza, 
1073;    in   measles,   937. 

Ileocolitis,  chronic,  384;  lesions,  384; 
symptoms,  380;  diagnosis,  387;  differ- 
ential diagnosis,  387;  prognosis,  388; 
treatment,    388. 

Ileum,  congenital   atresia   of,   114. 


INDEX. 


1101 


Imbecility,  756. 

Impetigo,  bulbous,  in  newly  born,  92 ; 
contagiosa,  889. 

Inanition,    acute,    217. 

Inanition   fever,   118. 

Incubators,    12. 

Indican,  in  urine  of  chronic  constipation, 
403 ;  of  chronic  intestinal  indigestion, 
397. 

Indicanuria,  603. 

Indigestion,  acute  gastric,  323;  etiology, 
325 ;  symptoms,  326 ;  diagnosis  from 
gastritis,  326;  treatment,  320;  vomiting 
in,  319;  chronic  gastric,  332;  etiology, 
331;  lesions,  332;  symptoms,  in  in- 
fants, 332  ;  in  older  children,  333  ;  prog- 
nosis, 332;  treatment  in  infants,  334; 
acute  intestinal,  and  intoxication,  348 ; 
etiology,  348;  symptoms,  351;  diagno- 
sis, 355 ;  prognosis,  355 ;  prophylaxis, 
355 ;  treatment,  3.')6 ;  Finkelstein's 
"  food    intoxication,"    359. 

Indigestion,  chronic  intestinal,  393  ;  In 
young  infants,  393;  symptoms,  394; 
prognosis,  395;  treatment,  395;  in  older 
children,  396;  symptoms,  396;  treat- 
ment, 398. 

Infant,  care  of  newly  born,  1;  when 
premature   or  delicate,    10. 

Infant   feeding,    163. 

Infant  foods,   161. 

Infantilism,    intestinal,    397. 

Infarctions,   uric   acid,    in    kidney,    610. 

Infectious    diseases,    the    specific,    903. 

Influenza,  1070;  etiology,  1070;  lesions, 
1070;  symptoms,  1070;  with  broncho- 
pulmonary complications,  1072 ;  pro- 
tracted cases,  1075 ;  complications  and 
sequela;,  1073 ;  ansemia  in,  1073 ;  diag- 
nosis, 1073  ;  prognosis,  1074  ;  treatment, 
1075 ;  broncho-pneumonia,  512,  1072 ; 
epidemic,  acute  otitis  In,  895  ;  scarlatin- 
iform  erythema  in,  1073 ;  nephritis  in, 
1073. 

Inhalations,    59 ;    in    bronchitis,   467. 

Inheritance  a  factor  in  disease,  29. 

Injections,  rectal,  in  ileo-colitis,  382; 
subcutaneous,  of  saline  solution  in  chol- 
era infantum,   364. 

Insanity,  769 ;  symptoms,  769 ;  following 
typhoid   fever,    1014. 

Intermittent    fever,    malarial,    1078. 

Intertrigo,   882;  treatment,  886. 

Intestinal  obstruction  in  newly  born,  114; 
acute,  from  Intussusception,  407. 

Intestines,  diseases  of,  341;  amyloid  de- 
generation of,  389;  bacteria  of,  311; 
digestion  in,  310;  haemorrhage  from,  in 
newly  born,  101 ;  In  typhoid,  1013 ;  in 
tuberculosis,  392;  length,  310;  mal- 
formations of,  341;  obstruction,  con- 
genital of,  114 ;  perforation  of,  in  tu- 
berculous ulcers,  390;  in  typhoid  fever, 
1013;  tuberculosis  of,  390,  1030;  eti- 
ology, 390;  lesions,  391;  symptoms,  392; 
treatment,  393. 


Intoxication,  acute  intestinal,  348;  etiol- 
ogy, 348;  lesions,  350;  symptoms,  mild 
form,  351;  relapses,  353;  cases  with- 
out diarrhoea,  354  ;  diagnosis,  355 ; 
prognosis,  355  ;  prophylaxis,  355  ;  treat- 
ment, hygienic,  356 ;  dietetic,  357 ; 
medicinal  and  mechanical,  358  ;  chol- 
era infantum,  361  ;  etiology,  362 ; 
symptoms,  362  ;  prognosis,  364  ;  treat- 
ment, 364. 

Intubation,  in  acute  catarrhal  laryngitis, 
464;  in  syphilitic  laryngitis,  470;  in  per- 
tussis, 964. 

Intussusception,  407  ;  etiology,  408 ;  le- 
sions and  mechanism,  409;  symptoms, 
410;  diagnosis,  414;  prognosis,  414; 
treatment,  415;  laparotomy,  415;  in  the 
dying,  408. 

Invagination  of  intestine  in  intussuscep- 
tion,  410. 

Iodides,  elimination  of,   in  milk,  137. 

Iritis,    syphilitic,    1057. 

Iron,    preparations   of,   52. 

Irrigation,  intestinal,  in  chronic  indiges- 
tion, 399;  as  antipyretic,  50;  of  the 
colon,    method   of,   65. 

Ischio-rectal  abscess,   431. 

Jaundice  (see  also  Icterus),  76;  ca- 
tarrhal, 435  ;  chronic  family,  434. 

Jaw,  necrosis  of,  from  alveolar  abscess, 
268;  in  gangrenous  stomatitis,  280;  in 
ulcerative   stomatitis,   273. 

Jejunum,    congenital    atresia    of,    114. 

Joints,  diseases  of,  850;  liysterlcal  affec- 
tions of,  681;  in  scarlet  fever,  918; 
rheumatism  of,  1086;  suppuration  of, 
in  newly  born,  84;  swelling  of,  in 
scurvy,  237;  ecchymoses  about,  in 
scurvy,  236 ;  tuberculous  diseases  of, 
852. 

Junket,   158. 

Kernig's    sign,    707. 

Keratitis,  interstitial,  in  late  syphilis, 
1057,   1063. 

Kidney,  diseases  of,  606;  acute  degen- 
eration of,  611;  calculi  in,  627;  chronic 
congestion  of,  610;  cystic,  607;  mov- 
able, 609;  granular  (see  Nephritis, 
Chronic),  618;  hsemorrhage  from,  in 
newly  born,  102;  in  scurvy,  238;  horse- 
shoe, 607;  hydronephrosis,  607;  trau- 
matic, 628  ;  malformations  and  malpo- 
sitions of,  606;  malignant  tumours  of, 
622;  nephritis,  acute  diffuse,  611;  acute 
exudative,  611;  chronic,  618;  perine- 
phritis, 629 ;  pyelitis,  624 ;  pyoneph- 
rosis, 626 ;  single,  607  ;  tuberculosis 
of,  621,  1030;  uric-acid  infarction,  610; 
in  diphtheria,  977;  in  scarlet  fever,  917. 

Klebs-Loeffler  bacillus  (see  Bacillus  of 
Diphtheria),   969,   991. 

Knee,  articular  ostitis  of,  863;  symptoms, 
866;  treatment,  867;  subluxation  of, 
in    poliomyelitis,    789;    swelling    of,    in 


1102 


INDEX. 


scurvy,    237;     white    swelling    of    (see 

Knee,  Abticulak  Ostitis). 
Knee-jerk,  In  acquired  cerebral  paralysis, 

754;    In    birth    paralysis,    751;    lost.    In 

diphtheritic   paralysis,   806;   in   multiple 

neuritis,    803;    in   tetany,   658. 
Knee-joint  disease    (see  Knee,  Abticulak 

Ostitis). 
Knock-knee  in  rlcket.s,  254. 
Koplik's  sign   in  measles,  931. 
Kumyss,    157. 
Kyphosis  in   rickets,  252  ;   treatment,  260  ; 

In   spinal    caries,   854. 

Lactalbumin,    131,    146,   150. 

Lactation,  care  of  breasts  during,   166. 

Lactic   acid    milk,    157. 

Lactometer,    author's,    132. 

Landry's    paralysis,    795. 

Laparotomy,  in  acute  peritonitis,  445;  In 
chronic  peritonitis,  with  ascites,  446 : 
In  Intussusception,  415  ;  in  tuberculous 
peritonitis,   451. 

Laryngismus  stridulus,  659;  in  rickets, 
2.56;    with   tetany,    656. 

Laryngitis,  acute  catarrhal,  465;  catar- 
rhal, in  measles,  936;  chronic,  468; 
with  adenoid  vegetations  of  pharynx, 
469;  tuberculous,  469;  syphilitic,  469; 
with  new  growths  of  larynx,  470;  spas- 
inodle,  462;  submucous  (oedema  of  glot- 
tis).   468. 

Laryngeal  diphtheria,  983;  antltoxine  in, 
998;  Intubation  In,  1003;  symptoms  of, 
983. 

Laryngotomy  for  foreign  body  in  larynx, 
471. 

Larynx,  diseases  of,  462;  catarrhal  spasm 
of,  462;  from  long  uvula,  284;  with 
adenoids,  292  ;  diphtheria  of,  983  ;  for- 
eign bodies  in,  471 ;  intubation  of, 
1003;  in  measles,  936;  new  growths  of, 
470 ;  spasm  of,  659 ;  stenosis  of,  sim- 
ulated by  tuberculous  glands,  1047 ; 
syphilis  of,  469,  470,  1059 ;  tubercu- 
losis of,  469. 

Lassar's  paste,  885. 

Lavage    (see   Stomach   Washing). 

Leukemia,   820. 

Leucocytosis,  811;  diagnostic  value,  812; 
In  diphtheria,  978;  In  acute  meningitis, 
711. 

Lewi's  method  for  examination  of  wom- 
an's milk,   133. 

Lichen  urticatus  (see  Ueticabia),  890; 
tropicus,  877. 

Limewater,  In  modification  of  cow's  milk, 
183. 

Lip,  eczema  of,  264;  perleche,  264;  dis- 
eases of,  263;  herpes  of,  263;  malfor- 
mations of,  262. 

Lisping,  686. 

Liver,  diseases  of,  433;  abscess  of,  437; 
acute  yellow  atrophy  of,  437;  amyloid 
degeneration  of,  439;  biliary  calculi. 
441 ;   cirrhosis  of.   438 ;   congestion   of. 


437;  Interstitial  hepatitis,  77;  enlarged, 
in  congestion,  437  ;  in  abscess,  438 ; 
in  cirrhosis  (early),  439;  in  chronic 
cardiac  disease,  581;  fatty,  440;  in  ma- 
rasmus. 229 ;  functional  disorders  of, 
436;  hydatids  of,  441;  in  rickets,  256; 
in  syphilis,  10."»5,  KXJS;  in  tuberculosis, 
10.30;  lardaceous,  4.39;  malformations 
and  malpositions  of,  4.34  ;  size  and  po- 
sition of,  39,  433;  tuberculosis  of,  1029; 
waxy,  439  ;   weight  of,  in  infancy,   43.3. 

Lumbar   puncture,   711. 

Lung,  diseases  of,  472;  abscess  of,  543; 
abscesses  of,  in  acute  broncho-pneu- 
monia, 500;  acute  congestion  of,  in 
malaria,  1077;  calcareous  nodules  in, 
1027;  caseous  degeneration  of,  1025; 
collapse  of,  from  compression,  545; 
from  obstruction,  545 ;  in  acute  bron- 
cho-pneumonia. 495  ;  congenital  atelec- 
tasis of,  73  ;  emphysema  of.  547  ;  acute, 
in  Ijronchitis  of  infants,  476;  gangrene 
of,  544;  gangrene  of,  in  lobar  pneu- 
monia, 522;  haemorrhages  into,  in  new- 
ly born,  99 ;  Inflation  of,  72 ;  Carrel's 
method  of,  72  :  miliary  tuberculosis  of, 
1033 ;  peculiarities  In  disease,  474 :  in 
Infancy  and  early  childhood,  472  :  phys- 
ical examination  of,  473  ;  structure  of, 
473. 

Lymph  nodes,  diseases  of,  830 :  calcare- 
ous cervical,  843  ;  bronchial,  1044  :  early 
Infection  In  tuberculosis,  1021;  enlarged 
In  Hodgkin's  disease,  847;  in  malnutri- 
tion, 222;  frequency  of  disease  of,  41; 
inflammation  of  (see  Adenitis),  8.36; 
in  late  hereditary  syphilis,  1063 ;  in 
measles,  9.38 ;  pseudo-diphtheria,  295 ; 
In  scarlet  fever,  916 ;  simple  hyperpla- 
sia of,  8.39 ;  situation  and  drainage 
areas  of  the  groups  of  head  and  neck, 
832;  syphilitic  disease  of,  840;  tuber- 
culous bronchial,  1027 ;  lesions,  1021, 
1027 ;  symptoms,  1031 ;  cervical,  tuber- 
culosis of,  841  :  mesenteric,  .390.  1030 ; 
in  diphtheria,  976 :  in  rickets,  2.56 ;  in 
tonsillitis,  296 ;  epitrochlcar,  in  syphi- 
lis, 1063 ;  mesenteric,  often  enlarged, 
in  marasmus,  229 ;  In  typhoid  fe.ver, 
1010 ;  tuberculosis  of,  840 ;  retro-phar- 
yngeal,  abscess  of,  284. 

Lymph  nodules  of  Intestines,  ulceration 
of,   376. 

Lymphadenoma    of    stomach,    338. 

Lymphangioma    of    tongue,    263. 

Lymphatism  (see  Status  Lymphaticus), 
832. 

Lymphocytes,  809. 

Malaria,  1075;  etiology,  1076;  lesions, 
1076;  symptoms,  1077;  diagnosi.s,  1082; 
prognosis,  1082;  prophylaxis.  1082; 
treatment,  1082;  quinine,  methods  of 
administration,  1083;  acute  pulmonary 
congestion  in,  1077 ;  contracted  in 
utero,  1076;  spleen  in,  849. 


INDEX. 


1103 


Malformations  as  cause  of  sudden  death, 
46. 

Malnutrition,  220 ;  etiology,  220 ;  symp- 
toms in  infants,  221;  symptoms  in  older 
children,  222;  diagnosis,  223;  nervous 
factor  in,  227;  prognosis,  224;  treat- 
ment in  infants,  225;  treatment  in  older 
children,    226. 

Malnutrition,  marasmus,  227. 

Malt  extracts,  use  of,  in  diet  of  nurse, 
136. 

Maltose,  substitute  for  milk  sugar,  125, 
205,    207. 

Malt  soup,  use  of,  with  difficult  feeding 
cases,  207. 

Mania,  769;  acute,  following  typhoid 
fever,    1014. 

Marasmus,  227;  etiology,  228;  lesions, 
228  ;  symptoms,  230  ;  diagnosis,  231  ; 
from  tuberculosis,  232,  1035 ;  prog- 
nosis, 2.32;  treatment,  232;  fatty  liver 
in,  440;  general  oedemii  in,  231;  tuber- 
culosis   resembling,    1031. 

Massage,  66;  in  chronic  constipation,  405; 
in  malnutrition,  226;  of  breasts  to  in- 
crease  milk,   172. 

Mastitis    in    the    newly    born,    113. 

Mastoid  disease,  cerebral  abscess  follow- 
ing,  899;   in   acute  otitis,  898. 

Mastoiditis,  etiology,  898;  symptoms,  898; 
treatment,  901;  dangers  from  opera- 
tion,   901. 

Masturbation,    690. 

Matzoon,    157. 

Measles,  927  ;  broncho-pneumonia  compli- 
cating, 512;  complications  and  sequelae, 
936;  desquamation,  933;  diagnosis,  939; 
digestive  system,  937 ;  diphtheria  in, 
937;  duration  of  infective  period,  929; 
ears  in,  894,  938 ;  eruption,  931 ;  etiol- 
ogy, 928 ;  eyes  in,  938 ;  German  ( see 
Rubella),  943;  hsemorrhage  in,  939; 
hsemorrhagic,  932 ;  heart  in,  939 ;  ileo- 
colitis, 937  ;  incubation,  929  ;  invasion, 
931 ;  kidneys  in,  939 ;  larynx  in,  936 ; 
lesions.  930 ;  lungs,  936 ;  lymph  nodes, 
9,38  ;  mode  of  infection,  930  ;  mortality, 
940 ;  nervous  system  in,  938 ;  other  in- 
fectious diseases  in,  939 ;  otitis,  938 ; 
predisposition,  928 ;  prognosis,  940 ; 
prophylaxis,  941 ;  pseudo-diphtheria  in, 
937 ;  quarantine  in,  941  ;  skin  in,  938 ; 
symptoms,  931 ;  throat,  937  ;  treatment, 
942  ;   tuberculosis  following,   939. 

Meats,  allowed  from  third  to  sixth  year, 
212;  forbidden  from  third  to  sixth 
year,   213. 

Meckel's   diverticulum,    111,    342. 

Meconium,    composition   of,   311. 

Mediastinum,  anterior,  abscess  of,  1046 ; 
tumour  of,  due  to  tuberculous  lymph 
nodes,   1046. 

Mediastinitis,   577. 

Melancholia,    770. 

Melsena,    101. 

Membrane,    in   diphtheria,    973. 


Meningeal  hiemorrhage,   104,  698,   747. 
^Meninges,   diseases   of,    694. 
Meningitis,     acute,      700 ;     cerebrospinal, 
701;     complications    and     sequelaj,     710; 
course,    duration   and    termination,    709; 
etiology,  702;  lesions,  702;  lumbar  punc- 
ture in,   711,   716;   symptoms,   704;   diag- 
nosis,   711;    prognosis,    710;    treatment, 
712. 
Meningitis,  acute,  from  other  causes  than 
the  meningococcus,   717  ;   pneumoeoccus, 
717;  influenza,  719;  septic,  719;  in  newly 
born,    83  ;    from    otitis,    899 ;    in    pneu- 
monia, 513,  532  ;  rare,  in  typhoid  fever, 
1014. 
Meningitis,    chronic    basilar,    727;    spinal, 

778;    syphilitic,    1050. 
Meningitis,  tuberculous,  720;  lesions,  720; 
etiology,   721;   symptoms,   723;   duration, 
725;      diagnosis,      725;     prognosis,      727; 
treatment,     727;     lumbar     puncture    in, 
725. 
Meningocele   of   brain,    694;  of   cord,   773. 
Meningo-encephalitis,    748. 
Meningo-niyelocele,    774. 
Menstruation,   effect   on   breast   milk,   135. 
Mental    defects,    756;    classilication,    750; 

diagnosis,   760;   treatment,    702. 
Mercury,     elimination    of,     in    milk,     137; 
ulcerative     stomatitis     from,     273  ;     in 
syphilis,    1008. 
Microcephalus,    697. 
Micro-oi'ganisms    in    cow's    milk,    139;    see 

also  Bacteria. 
Micturition,   difficult  or  painful,    646;   fre- 
quency of,   598. 
Miliaria,    877;    papulosa,    877;    treatment, 

878;  rubra,  877. 
Milk,  cow's,  138;  average  percentages  of, 
181  :  bacteriological  standard  for,  141  ; 
handling  and  transportation  of,  143, 
144 ;  composition  of,  144  ;  average 
percentages  in,  from  different  breeds, 
144,  145  ;  examination  of,  145  ;  cream, 
137  ;  contaminated,  cause  of  diar- 
rhcea,  344  ;  differences  from  woman's 
milk,  146 ;  dried  milk,  156 :  essen- 
tials of,  for  Infant  feeding,  138  ;  formu- 
las from  diluting,  188  seq. ;  formulas 
reduced  to  percentages,  194  ;  micro-or- 
ganisms in,  139;  modification  of,  per- 
centage or  American  method  of,  180, 
190  ;  at  home,  186  ;  top-milk,  148  ;  for- 
mulas from  top-milk,  188  seq.;  sched- 
ule of  percentages  for  first  year,  186 ; 
schedule  showing  quantities  and  in- 
tervals of  feeding,  180  ;  rules  for  vary- 
ing percentages,  190 ;  modifications  re- 
quired by  particular  symptoms,  195  ;  in 
difficult  cases,  205 ;  in  summer  diar- 
rhoea, 357  ;  in  acute  gastric  indigestion, 
327 ;  in  chronic  constipation,  404 ;  pas- 
teurisation of,  150;  pasteurisation  of, 
at  150°  F.,  151  ;  protein  of,  123  ;  sterili- 
sation of,  at  212°  F.,  152;  sterilised, 
scurvy    ascribed    to,    234 ;    tubercle    ba- 


1104 


INDEX. 


cllll  in,  1020;  typhoid  contamination 
of,  140;  condensed  (see  Condensed 
Milk),  154;  fermented,  157,  206;  pro- 
tein, 157;  sljlmmed,  206,  235,  398;  pep- 
tonised,  154 ;  peptonlsed,  use  of,  154 ; 
dangers   from   prolonged   use  of,   154. 

Milk-laboratories,    184. 

Milk-sugar,  125,  182,  189;  solution,  how 
to  prepare,    199. 

Milk,  woman's,  127;  physical  characters 
of,  127;  colostrum  of,  128;  daily  quan- 
tity of,  128;  average  quantity  at  one 
nursing,  130;  composition  of,  131;  pro- 
tein, 131,  134,  146;  fat,  131;  sugar, 
132;  salts,  132;  reaction,  133;  specific 
gravity,  133,  134;  average  percentages 
of,  181;  conditions  affecting  composi- 
tion of,  134;  menstruation,  135;  diet, 
135  ;  drugs,  137  ;  pregnancy,  137  ;  elim- 
ination of  antltoxine  and  other  protec- 
tive substances,  l.'?7 ;  nervous  Impres- 
sions, 137;  examination  of,  132;  varia- 
tions in  quality,  1.34;  apparatus  for  ex- 
amining, 1.32,  133 ;  secretion,  when  es- 
tablished, 127  ;  how  to  modify  quantity 
and  quality,  171,  172 ;  indications  of 
scanty    supply,    169. 

Modified  milk,  from  milk  laboratory,  184; 
schedule  for  feeding  from  birth,  190 ; 
made  at  home  (see  Milk,  Modifica- 
tion OF,  AT  Home). 

Mongolian  Idiocy,  758. 

Monoplegia,  In  birth  paralysis,  749 ;  in 
cerebral  haemorrhage,  104;  In  cerebral 
tumour,    738. 

Morbus  coxarlus  (see  Hip,  Articular 
Ostitis   of),  859. 

Morbus  maculosus   (see  Purpura),  824. 

Morphine,  dosage  of,  53;  dosage  in  con- 
vulsions, 655;  hypodermlcally  in  cholera 
infantum,  3(34;  In  gastro-lntestlnal  In- 
toxication,  360. 

Mortality  at  different  ages,  42,  43. 

Mouth,  diseases  of  (see  also  Stomatitis), 
270  seq. ;  applications  to,  278  ;  care  of, 
at  birth,  1,  3;  haemorrhage  from.  In 
newly  born,  102;  haemorrhages  from.  In 
scurvy,  238;  malformations  of,  262; 
mucous  patches,  in  syphilis,  278,  1060 ; 
"  tapir,"  799  ;   syringing  of,  59. 

Mouth-breathing,  with  hypertrophy  of 
tonsils,  302;  with  adenoids,  291;  with 
retro-pharyngeal  abscess,  285. 

Mucous  membranes,  frequency  of  Involve- 
ment  In   childhood,  40;   In   rickets,   256. 

Mucous  patches,   syphilitic,  278,  1060. 

Mumps,  965 ;  complications  and  sequelae, 
967;  diagnosis,  968;  etiology,  966;  In- 
cubation, 966;  pathology  and  lesions, 
965;  prognosis,  968;  quarantine  in,  969; 
symptoms,   966;    treatment,   969. 

Murmurs,  cardiac  (see  Heart  Mur- 
murs). 

Muscles,  atrophy  of,  796;  In  multiple, 
neuritis,  803  ;  In  myelitis,  779  ;  In  polio- 
myelitis,  787  ;   contractures  of,    hyster- 


ical, (>81;  In  acquired  cerebral  paralysis, 
754 ;  In  birth  paralysis,  750 ;  develop- 
ment  of,   25. 

Muscular  atrophies,  different  types  of, 
796. 

Muscular   pseudo-hypertrophy,    79S. 

Mustard  bath,  57  :  paste,  54  ;   pack,   55. 

Myelitis,  778  ;  symptoms,  779  ;  treatment, 
780;  compression,  from  Pott's  disease, 
780;   diffuse,  779;   transverse,    779. 

Myelocytes  In  leukaemia,  821;  in  diph- 
theria,   978. 

Myocarditis,  592;  aneurism  In,  593;  toxic, 
In  diphtheria,  807,  986;  in  scarlet  fever, 
919;  in  syphilis,  1056. 

Myotonia,  congenital  (Oppenhelm's  dis- 
ease),   800. 

Myotonia,  congenital  (Thomsen's  dis- 
ease),   677. 

Nail-biting,   693. 

Nails   In  syphilis,    1061. 

Neck,  cellulitis  of,  in  scarlatina,  916 ;  con- 
genital fistula  of,  304  :  wry  (see  Torti- 
collis). 

Necrosis  of  bone  In  syphilis,  870,  871. 

Nematodes  (see  Worms,  Intestinal), 
422. 

Nephritis,  acute  diffuse,  611;  etiology, 
611;  lesions,  612;  symptoms,  613;  prog- 
nosis, 615;  treatment,  616;  in  broncho- 
pneumonia, 513;  acute  parenchymatous 
type,   613. 

Nephritis,  chronic,  618  ;  etiology,  618 ; 
lesions,  618 ;  symptoms,  619 ;  of  the 
parenchymatous  type,  (JIO:  of  the  in- 
terstitial type,  619 ;  diagnosis,  620 ; 
prognosis,  620  ;  treatment,  620  ;  chronic 
diffuse,  with  hydronephrosis,  609; 
chronic  Interstitial,  syphilitic,  1057  ;  in 
diphtheria,  977:  interstitial  (see  Neph- 
ritis, Chronic),  619;  post-scarlatinal, 
917. 

Nerves,  peripheral,  diseases  of,  800. 

Nervous  impressions,  effect  of,  on  breast 
milk,    137. 

Nervous  system,  diseases  of,  (547  ;  general 
hygiene  of,  5 ;  peculiarities  of.  In 
childhood,   647. 

Neuritis,  multiple,  800;  after  diphtheria, 
804;  in  malaria,  1080;  optic,  in  acute 
meningitis,  708;  in  cerebral  tumour, 
738;   with  cerebral   abscess,   733. 

Newly  born,  diseases  of.  68 ;  acute  in- 
fectious diseases  of,  80;  acute  pyogenic 
diseases  of,  81:  atelectasis,  congenital, 
73;  asphyxia  of,  (58;  blood  In,  peculi- 
arities of,  809;  care  of,  1;  diseases  or 
accidents  at  birth,  30;  dermatitis  ex- 
foliativa In,  875;  facial  paralysis  In. 
107;  fatty  degeneration  of,  92;  haemor- 
rhages In,  94;  hsemorrhaglc  disease  of. 
98;  hyperpyrexia  in,  118:  Inanition 
fever  In,  118;  Icterus  In,  76;  infection 
of,  30 ;  malformations  of,  30  :  mastitis 
in,  113 ;  ophthalmia  of,  87  ;  pemphigus 


INDEX. 


1105 


In,  92:  peritonitis  in,  442;  scleremti  in, 
117;  sliin  of,  875;  ulcer  of  stomacli  in, 
336. 

Nightmare,    688. 

Night-terrors.  688. 

Nipples,  care  of,  during  lactation,  166 ; 
fissure  of.  haematemesis  from,  338;  rub- 
ber,  choice  of.   198;   care  of,   198. 

Nodding  spasm  of  head,  676. 

Nodes,    lymph    (see  Lymph   Nodes),   830. 

Nodules,  subcutaneous  tendinous,  in  rheu- 
matism.   1088. 

Noma  of  face  (see  Stomatitis,  Gangre- 
nous),  279;   of  vulva,   640. 

Nose,  diseases  of,  454;  deformities  of. 
in  hereditary  syphilis,  460;  diflQculty  in 
blowing,  with  adenoid.s,  290;  diphtheria 
of,  979;  discharge  from,  with  adenoids, 
290;  foreign  bodies  in,  457;  haemorrhage 
from,  460 ;  in  newly  born,  101  ;  in 
scurvy.  238  ;  in  hereditary  syphilis,  459, 
1056 ;  in  late  syphilis,  1064 :  polypi  in, 
458 ;  pseudo-diphtheria  of,  295 ;  sprays 
for,    58 ;   syringing,   58. 

Nurse,  requisite  qualities  in,  10;  wet  (see 
Wet-nurse). 

Nursery,  temperature  and  ventilation 
of,  9. 

Nursing,  during  acnte  illness,  214;  dur- 
ing first  days  of  life,  167;  hours  for. 
In  newly  born,  167;  during  illness,  176; 
importance  of  good  habits  of,  167  ;  un- 
successful, symptoms  of,  168 ;  mater- 
nal,  contra-indications  for,  166. 

Nursing-bottles,  choice  of,  198;  care  of, 
198. 

Nutrient,    enemata,    65. 

Nutrition,  derangements  of,  216;  acute 
inanition.  217:  malnutrition,  220;  ma- 
rasmus, 227;  faulty,  diseases  due  to, 
233;    importance    in   pjediatrics,    122. 

Nystagmus.  676:  in  cerebral  haemorrhage, 
106;  in  hydrocephalus,  745;  in  tuber- 
culous meningitis,  723;  stigma  of  de- 
generation. 771;  with  tumour  of  crura 
cerebri,   738. 


Oatmeal  water,   161. 

O'Dwyer's  intubation   set,   1003. 

Oldema.  in  acute  diffuse  nephritis,  613, 
614  :  in  anaemia,  814  ;  in  chronic  neph- 
ritis, 619 :  in  cardiac  disease,  572 ;  in 
leulisemia,  822:  of  face  from  pressure  at 
root  of  lung.  1045;  general,  in  maras- 
mus,   231. 

QDdema  glottidis,  468;  rare  in  acute  ca- 
tarrhal laryngitis,  465;  in  corrosive 
oesophagitis,   305;  in  quinsy,  301. 

(Esophagitis.  acute,  305;  catarrhal,  305; 
corrosive,    305. 

<Esophagus,  diseases  of,  304  ;  abscess  be- 
hind. .305;  congenital  narrowing  of. 
304;  congenital  obstruction  in,  304; 
diphtheria  of.  975:  malformations  of, 
304 ;  stricture  of,  304 ;  thrush  in,  304. 
71 


Oil  enemata,  65  :  in  chronic  constipation, 
4fX>. 

Omphalitis   in   newly   born,    82. 

Omphalomesenteric  duct.    111,   342. 

Onychia,    syphilitic,    1059. 

Ophthalmia,  gonorrhceal,  87;  in  newly 
born,    87;    treatment,    88. 

Opisthotonus,  cervical,  678;  hysterical, 
682:  in  cerebro-spinal  meningitis,  705; 
in  birth  paralysis,  750;  in  meningeal 
haemorrhage,  10(5:  In  chronic  basilar 
meningitis,  728;  in  marasmus,  231;  in 
tuberculous    meningitis,   724. 

Opium,  elimination  of,  in  milk,  137;  in 
acute  Intestinal  indigestion  and  in- 
toxication, .S60.  .364  ;  in  bronchitis,  481 ; 
preparations   and   dosage  of,   53. 

Oppenheim's  disease,  800. 

Optic  nerve,  atrophy  of,  in  cerebral  tu- 
mour,   736. 

Orchitis,  in  mumps,  9(58;  in  specific  ure- 
thritis. 635;  syphilitic,  1057;  tubercu- 
lous,  1030. 

Orthopnoea,  in  chronic  valvular  disease, 
585;  in  functional  disorders  of  the 
heart,   594. 

Osteo-myelitis,  acute  (see  Arthritis, 
Acute),  850;  in  newly  born,  84;  tuber- 
culous, 865;  symptoms,  866;  diagnosis, 
867;    treatment,    867. 

Osteo-periostitis,    chronic,    syphilitic,    869. 

Ostitis,  primary,  followed  by  joint  dis- 
ease, 853;  simulated  by  scurvy,  239. 

Otitis,  acute,  894;  etiology,  894;  lesions, 
895;  symptoms,  896;  complications  and 
sequelae,  898;  treatment,  900;  cerebral 
abscess  in,  732,  899;  thrombosis  of 
lateral  sinus  in,  899:  facial  paralysis 
in,  900;  labyrinth  in,  899;  mastoid  dis- 
ease in,  898;  meningitis  in,  899; 
chronic,  in  late  syphilis,  1064;  reflex 
cough  from,  484;  frequent  attacks  of, 
with  adenoids,  291;  in  influenza,  1075; 
in  scarlet  fever,  916;  in  syphilis,  1057; 
in   typhoid   fever,    1014. 

Overlying,  causing  death  by  asphyxia,  46. 

Oxyuris  vermicularis  (see  Worms,  Intes- 
tinal), 423. 

Ozaena,   syphilitic,  460,  1064. 

Pachymeningitis,  acute,  698;  chronic  (in- 
ternal), 698;  syphilitic,  1056;  meningeal 
haemorrhage  from,  699;  haemorrhagic, 
698;    pseudo-membranous,    698. 

Pack,   cold,  49;   hot,  56;   mustard,  55. 

Palate,  cleft,  262;  deformities  of,  stig- 
mata of  degeneration,  771;  diphtheritic 
paralysis  of,  805;  hard,  ulceration  of, 
275;  in  late  syphilis,  1064;  soft,  lesions 
of,  in  hereditary  syphilis.  460. 

Pancreas,  ferments  of,  310:  syphilis  of, 
1057;    tuberculosis    of,    1030. 

Paracasein,  formed  from  casein  in  stom- 
ach  digestion,    147. 

Paralysis,  ascending,  795;  atrophic  (see 
Poliomyelitis),  782;  birth,  104,  747; 


1106 


INDEX. 


atrophy  and  sclerosis  following,  749; 
meningo  -  encephalitis,  748:  secondary 
degenerations  following,  749 ;  symp- 
loms,  749;  Erb's,  109;  facial,  107,  807; 
in  acute  otitis,  900;  hysterical,  682;  in 
compression-myelitis,  780;  in  multiple 
neuritis,  802;  in  myelitis,  779;  Landry's, 
795;  of  face  in  newly  born,  107;  of  the 
upper  extremity  in  newly  born,  109; 
peripheral,  104  (see  also  Xeukitis, 
Multiple),  800;  post  -  diphtheritic, 
987  ;  pseudohypertrophic,  797  ;  simu- 
lated by  scurvy,  237. 

Paralysis,  Infantile  cerebral,  104,  747; 
acute  acquired,  751;  birth,  747;  of 
Intra-uterine  origin,  747;  varieties  and 
symptoms,  747,  749,  753 ;  prognosis, 
754;  diagnosis,  755;   treatment,  755. 

Paralysis,  infantile  spinal  (see  Polio- 
myelitis),  782. 

Paraplegia,  Pott's  (see  Myelitis,  Com- 
pression), 780;  spastic,  747. 

Paregoric,  dosage  of,  53. 

Parotitis,   epidemic   (see   Mumps),   965. 

Pasteurised   milk,    150. 

Pathology,   general  considerations  of,   40. 

Pavor  nocturnus,  688. 

Pellosis  rheumatica,   829. 

Pelvis,  deformities  of,  in  rickets,  252. 

Pemphigus,  gangrenosa,  888;  syphilitic, 
1057;  in  newly  born,  92. 

Pepsin  in  stomach  secretion,  309. 

Peptonised  milk,  preparation  of,  154. 

Percentages,  formulas  reduced  to,  194; 
of  ingredients  in  milk  formulas,  how  to 
calculate  them,   187  aeq. 

Pericarditis,  576;  acute,  in  broncho-pneu- 
monia, 513;  chronic,  with  adhesions, 
581;  diagnosis,  579;  dry,  577;  external, 
577;  in  newly  born,  83;  in  rheumatism, 
577,  578,  1087;  mediastinal,  577;  prog- 
nosis, 579;  purulent,  577;  sero-flbrinous, 
577;  tuberculous,  577;  with  effusion, 
577;  with  eflfusion  of  blood,  577;  with 
lobar  pneumonia,  523,  532;  with  pleuro- 
pneumonia, 538;  with  transudation  of 
serum,  576. 

Pericardium,  congenital  absence  of,  571; 
tuberculosis  of,   1029. 

Perinephritis,  629;  acute  peritonitis  com- 
plicating, 443. 

PeritonsBum,  diseases  of,  441;  hsemor- 
rhage  into,  in  newly  born,  98;  in  tuber- 
culosis,  1030. 

Peritonitis,  acute,  442;  etiology,  442; 
lesions,  443;  symptoms,  444;  treatment, 
445;  chronic,  non-tuberculous,  445; 
with  ascites,  445;  foetal,  cause  of  mal- 
formations, 342;  in  intussusception, 
414  ;  in  newly  born,  82  ;  in  suppurative 
appendicitis,  416;  pelvic,  from  gonor- 
rhoea, 638;  tuberculous,  447;  miliary, 
with  general  tuberculosis,  447;  miliary, 
with  ascites,  447;  fibrous  form,  448; 
with  intestinal  nlcers,  391;  with  lobar 
pneumonia,   532. 


Perspiration    (see  Sweating),  875. 

Pertussis,  954;  broncho-pueuruonia  in 
9.")9;  complications,  958;  convulsions, 
960;  diagnosis,  961;  etiology,  955 
haemorrhages  in,  958;  ileo-colitis  in 
960;  incubation,  956:  infective  period 
956;  lesions,  956;  leucocyto.sls  in,  961 
paralysis  in,  960;  predisposition  to 
955 ;  prognosis,  961  ;  prophylaxis,  962 
symptoms,   956;    treatment,    962. 

Peyer's  patches,  in  typhoid  fever,  1010 
swollen,  in  acute  ileocolitis,  367;  tuber 
culosis  of,  391;  ulceration  of.  in  ileo 
colitis,    370. 

Pharyngitis,  acute,  282:  uvulitis  in,  283 
chronic   catarrhal,    syphilitic.    1056. 

Pharynx,  diseases  of,  282;  adenoid  vege 
tations  of  vault,  288,  457;  with  ade 
nitis,  836;  diphtheria  of,  973;  diph 
theritic  paralysis  of,  805:  lesions  of,  in 
hereditary  syphilis,  459;  reflex  cough 
from,  484;  retro-pharyngeal  abscess, 
294;  syphilitic  ulceration  of,  1056; 
syringing   of,    59. 

Phimosis,  631;  reflex  phenomena  from, 
632. 

Phlebitis,   of  dural   sinuses,  730. 

Phosphorus   in   rickets,   260. 

Photophobia,  in  influenza,  1071:  in  mea- 
sles, 931  ;  in  tuberculous  meningitis, 
723. 

Phthisis,   chronic,   1027.    1044. 

Physical  examination  of  the  child,  33. 

Pica,   693. 

Pick's  paste,   886. 

Pinworms  (see  Worms,  Intestinal), 
423  ;    proctitis  from,   429. 

Plasmodium    malariae,    1076. 

Pleura,  effusion  into,  in  acute  nephritis, 
614;   tuberculosis  of,    1023,    1029. 

Pleurisy,  549;  dry,  549;  in  acute  broncho- 
pneumonia, 500 ;  purulent  (see  Empy- 
ema), 554;  tuberculous,  dry  form,  549; 
with  lobar  pneumonia,  501 :  with  serous 
effusion,  551;   Grocco's  sign  iu,  5.52. 

Pleuropneumonia,  537;  pericarditis  in, 
576,   578. 

Pneumococcus,  in  broncho-pneumonia,  491, 
492;  lobar  pneumonia,  491:  peritonitis, 
443;  diphtheria,  972,  985;  empyema, 
554 ;  acute  meningitis,  717 :  malignant 
endocarditis,   591 ;   pericarditis,   .576. 

Pneumonia,  489;  anatomical  varieties  and 
classifications  of,  489;  broncho-  (see 
Broncho -pneumonia.  Acute),  492; 
catarrhal  (see  Broncho  -  pneumonia. 
Acute),  492;  chronic  interstitial  (see 
Broncho-pneumonia,  Chronic),  540; 
in  newly  born,  80;  in  typhoid  fever, 
1013 ;  sources  of  infection.  492 :  varie- 
ties, classification,  492;  hypostatic, 
539;  in  marasmus,  229;  lobular  (see 
Broncho  -  pneumonia,  Acute),  492; 
pleuro-  (see  Pleuro-pneumonia),  537 ; 
syphilitic,  1055;  tuberculous.  1035 
(see  also  Tuberculosis,   Pneumonia)  ; 


INDEX. 


1107 


course,  duration,  termination,  1035; 
diagnosis,  1036;  physical  signs,  1036; 
chronic,    1041. 

Pneumonia,  lobar,  520;  etiology,  520;  fre- 
quency of,  491,  520;  complicating  influ- 
enza, 1072;  complications,  531;  course, 
523;  abortive,  524;  cerebral,  524;  diag- 
nosis, 532 ;  lesions,  521  ;  lysis,  fre- 
quency of,  527  ;  pathological  differen- 
tiation from  broncho-pneumonia,  490 ; 
physical  signs,  529  ;  prognosis,  534  ; 
symptoms,  523 ;  cerebral,  528 ;  termi- 
nation,  523  :    treatment,  5,35. 

Pneumothorax  in  pulmonary  tuberculosis, 
1029. 

Pock,   in   vaccinia,    951;    in   varicella,    947. 

Poisons,   gastritis   from,   327,   329. 

Poisoning,  stomach-washing   in,    62. 

Poliencephalitis,  acute,  causing  cerebral 
paralysis,    752. 

Poliomyelitis,  acute,  782;  etiology,  783; 
lesions,  785;  diagnosis,  790:  extent  and 
distribution  of  primary  paralysis,  789; 
electrical  reactions,  789  ;  prognosis,  791 ; 
treatment,   792. 

Polydipsia  in  diabetes  Insipidus,  605; 
mellitus,   1091. 

Polypi,   nasal,    458;    rectal,   432. 

Polyuria,  605;  hysterical,  682;  in  diabetes 
insipidus,    605;   mellitus,    1091. 

Porencephalus,    697. 

Pott's  disease  (see  Spine,  Caries  of), 
854 ;  cervical,  causing  torticollis,  679 ; 
reflex   cough   in,   484. 

Powders    for    sliin,    4. 

Praecordia,    bulging   of,    566,    587. 

I'rtgnaucy,  effect  on  woman's  milk,  135, 
137;  effect  on  nursing  child,   175. 

I'remature  infants,  management  of,  12; 
results  with.    14. 

Prematurity,   cause  of  marasmus,  228. 

Prepuce,    adherent,    631. 

Prickly    heat,    877. 

Proctitis,    429. 

Prognosis,  general  consideration  of,  42. 

Progressive  muscular  atrophy,  hand  type, 
796;  peroneal  type,  797. 

Prolapsus  anl  (see  also  Rectum,  Pro- 
lapse OF),  426;  from  proctitis,  430: 
In  ileo-colitis,  375  ;  in  membranous  ileo- 
colitis,  379. 

Prophylaxis,  general  consideration  of,  47. 

Protein,  determination  of,  in  milk,  1.34; 
function  in  diet,  123;  In  the  faeces,  312; 
of  woman's  milk,  131  ;  of  cow's  milk, 
146:  percentages  of,  in  modification  of 
cow's  milk,  188,  193;  vegetable,  124. 

Protein  milk,  157. 

Pseudo-diphtheria  (see  Membranous  Ton- 
sillitis,   295). 

Pseudo-hypertrophic  paralysis,   797. 

Pseudo-paralysis  in  rickets.  2.55;  in  scurvy, 
237;    in   s.vphilis,   868,   1061, 

Psoas  abscess  in  spinal  caries,  858. 

Puberty,  delayed,  stigma  of  degeneration, 
771;    in    cretins,    706;    in   syphilis,    1065; 


effect  of,,  on  heart  in  valvular  disease, 
585,  588;  reflex  cough  of,  484, 

Pulse,  examination  of,  35;  in  early  life, 
5(]ij. 

Purpura,  824;  arthritic,  829;  blood  in,  826; 
fulminaus,  828;  gangrenous,  828;  ha;m- 
atemesis  in,  827;  haemorrhagica,  827; 
Henoch's,  828 ;  primary,  825 ;  rheumat- 
ica,  829:  simplex,  824,  827;  symptomatic, 
824;  cachectic,  824;  infectious,  824;  neu- 
rotic,  825;    mechanical,   825;   toxic,    825. 

P.vaeniia,  in  newly  born,  81;  of  bone  (see 
Akthritis,   Acute),  850. 

Pyelitis,   624. 

Pyeio-cystitis,   624. 

I'yelo-nephritis,    603. 

Pylephlebitis,  437;  cause  of  hepatic  ab- 
scess,   437. 

Pylorus,  hypertrophic  stenosis  of,  313; 
etiology,  313;  symptoms,  313;  diagnosis, 
316;  treatment,  317;  dilated  stomach  in, 
335. 

Pyogenic  diseases,  acute,  in  newly  born, 
81;  general  symptoms,  85;  prophylaxis, 
86;   treatment,   87. 

Pyonephrosis    following   pyelitis,    624. 

I'yopneumothorax  in  pulmonary  tubercu- 
losis,  1029. 

Pyuria,   602;   in  pyelitis,   625. 

Quincke's   lumbar  puncture,  711. 
Quinine,  dosage,  1084;  methods  of  admin- 
istration, 1083;  scarlatlnlform  rash,  922. 
Quinsy,    300. 

Rachitis    (see    Rickets),    241. 

Reaction  of  degeneration,  in  Erb's  paral- 
ysis, 110 ;  in  facial  paralysis,  108 :  in 
multiple  neuritis,  803 ;  in  poliomyeli- 
tis.   789,    792. 

Rectal  injections  (see  Enemata,  65)  ; 
astringent,    383;    oil,    406;    saline,    383. 

Rectal   polypus,    432. 

Rectum,  diseases  of,  426;  administration 
of  drugs  by,  65;  atresia  of,  341;  con- 
genital obstruction  of,  114  ;  feeding  by, 
(55 :  haemorrhage  from  ulcers  of,  430 ; 
inflammation  of  (see  Proctitis),  429; 
malformations  of,  341 ;  prolapse  of, 
426;    ulcers    of,    430, 

Regurgitation  of  food,  causes  of,  in  young 
infants,  195;  nasal.  In  diphtheria,  806, 
981,   989. 

Remittent  fever,  malarial,   1077. 

Renal  calculi,   027;   renal  colic,  628. 

Rennet,   ferment   in   digestion,    309. 

Respiration,  artificial,  methods  of,  71,  72; 
Cheyne-Stokes,  in  cerebro-spinal  menin- 
gitis, 709;  In  meningitis,  tuberculous, 
723;  noisy  at  night  with  adenoids,  290; 
paralysis  of,  in  diphtheria,  806;  rapid- 
ity and  characteristics  of,  472  ;  In  pul- 
monary   tuberculosis,    1042. 

Respiratory  system,  diseases  of,   454. 

Rheumatism,  1085  ;  symptoms,  1086 ;  di- 
agnosis, 1089  ;  treatment,  1090  ;  chorea 


1108 


INDEX. 


In,  670,  1088 ;  endocarditis  In,  582, 
1087  ;  erythema  in,  1089  :  purpura  In 
829,  1089;  scarlatinal,  918;  simulated 
by  scurvy,  239  ;  subcutaneous  tendinous 
nodules,  1088;  tonsillitis  in,  299,  1088 
torticollis  in,  679,  1087. 

Rhinitis,  chronic,  457;  simple,  458;  syphil 
itic,  459;  hypertrophic,  cause  of  asthma 
485. 

Rhino-pharyngitis,  acute,  454;  in  influ 
enza,    1072;    with   adenoids,   290. 

Rhino-pharynx,  diphtheria  of,  974,  reflex 
cough  from  irritation  of,  484 ;  simple 
catarrh   of,    in    acute   otitis,    895. 

Ribs,  beading  of,  early  symptoms  in  riclc- 
ets,  251;  resection  of,,  in  empyema,  561. 

Rice   water,   161. 

Rickets,  241;  etiology,  241;  lesions,  243; 
symptoms,  248;  course  and  termination, 
256;  acute,  257  (see  also  Scorbutus), 
233 ;  congenital,  257 ;  convulsions  in, 
248 ;  diagnosis,  257 ;  from  scurvy,  2.39, 
258 ;  prognosis,  2.'58  ;  treatment,  2.59  ;  of 
deformities,  260 ;  dilatation  of  stom- 
ach in,  335;  late,  257;  spleen  in,  248, 
849. 

Ringworm  of  scalp,  893. 

Rotheln   (see  Rubeli>a),  943. 

Roundworms  (see  Worms,  Intestinal), 
422. 

Rubella,  943;  diagnosis,  945;  eruption, 
944;  incubation,  944;  symptoms,  944; 
treatment,    946. 

Rubeola    (see   Measles),  927. 


Saccharomyces  albicans  in  thrush,  275. 

Saline  solution,  as  rectal  injection,  382; 
subcutaneous  injection  of,  in  cholera  In- 
fantum, 364  ;  In  acute  inanition,  219. 

Saliva,   308. 

Salivation,  in  mumps,  967 ;  in  ulcerative 
stomatitis,    273. 

Salvarsan,    1069. 

Salts,  inorganic,  in  modification  of  cow's 
milk,  183;  mineral,  function  of,  in  diet, 
126;  of  cow's  milk,  147;  of  woman's 
milk,   132. 

Sarcoma,  of  brain,  735;  of  kidney,  622; 
of  spinal  cord,  793 ;  of  stomach,  337. 

Scabies,   891. 

Scalp,  pustular  eczema  of,  886;  ringworm 
of,  893  ;  seborrhoea  of,  878. 

Scarlatina    (see    Scarlet   Fever),   902. 

Scarlatiniform    erythema,   causes   of,   922. 

Scarlet  fever,  902;  albuminuria  in,  917; 
angina  in,  914;  blood  in,  919;  cellulitis 
in,  916;  complications  and  sequelse,  914; 
desquamation,  909;  diagnosis,  921;  diph- 
theria in,  915,  920;  disinfection  after, 
924;  duration  of  infective  period,  905; 
eruption,  907;  etiology,  904;  heart  in, 
919;  incubation  of,  905;  invasion,  907; 
joints  in,  918;  kidneys  in,  917;  lesions, 
908;  lymph  nodes  In,  916;  mode  of  in- 
fection, 905  ;  mortality  in,  922  ;  myocar- 


ditis in,  919;  nervous  system  in,  920; 
other  infectious  diseases  with,  OliO  ;  oti- 
tis in,  916  ;  predisposition  to,  904  :  prog- 
nosis, 922;  prophylaxis,  923;  quarantine 
in,  923;  relapses,  recurrences,  and  sec- 
ond attacks,  914;  symptoms.  907,  914; 
surgical,  913;  throat  in,  914;  treatment, 
925. 

Schultze's  method  of  inducing  artifleial 
respiration,   71. 

Sclerema,    117;    in   cholera    infantum,   .303. 

Scorbutus,  233 ;  etiology,  233  ;  lesions, 
235  ;  symptoms,  236  :  diagnosis,  239  ; 
treatment,  240  ;  rickets  with,  239  ;  sto- 
matitis   in,    274. 

Scrofula  (see  Adenitis,  Tuberculous), 
840;   (see  Tuberculosis). 

Scurvy   (see  Scorbutus),  233. 

Seborrhoea,    878. 

Senses,   special,   development   of,   25. 

Sepsis   in   newly    born,    81. 

Serous  membranes,  frequency  of  disease 
of,    40. 

Serum-therapy   of   diphtheria,    997. 

Serum-therapy  of  cerebro-spinal  meningi- 
tis,   712,  seq. 

Shiga  bacillus  (sec  Bacillus  of  Dysen- 
tery),  349,   366. 

Shower    bath,    57. 

Sight,   when  developed,  25. 

Singultus,  677. 

Sinuses  of  dura  mater,  thrombosis  of, 
729;    lateral,    in   otitis,   899. 

Skin,  diseases  of,  875;  anomalies  of,  as 
stigmata  of  degeneration,  771;  of  newly 
born,  875;  care  of,  in  newly  l)orn,  4. 

Skull,  asymmetry  of,  in  birth  paralysis, 
751  ;  in  rickets,  249 ;  sutures,  separa- 
tion of,  in  hydrocephalus,  743 ;  syphi- 
litic  nodes   on,   872. 

Sleep,  disorders  of,  686;  disturbed,  7, 
688;  with  hypertrophy  of  tonsils,  .302; 
in  intestinal  indigestion,  396:  in  rick- 
ets, 248;  with  adenoids,  290;  excessive, 
689  ;  Inspection  during,  33  proper  peri- 
ods of,   5. 

Sleeplessness,  C86. 

Smallpox,  protection  against  (see  Vac- 
cination), 948. 

Smegma,   631,   634. 

Smell,   sense  of,   when  developed,   27. 

Snoring,  with  adenoids,  290;  with  hyper- 
trophled  tonsils,  302. 

Snuffles,    syphilitic,   4.^9,   1058. 

Spasm,  carpo-pedal  (see  Tetany),  656  ;  of 
larynx,  659;  habit,  675:  nodding,  of  the 
head,  676;  rotary,  of  the.  head,  076; 
vesical,    645. 

Speech,  disorders  of,  685:  when  acquired, 
27. 

Spina  bifida,  773  ;  with  consi^ital  hydro- 
cephalus,  742. 

Spinal  cord    (see  Cord,   Spinal),  772. 

Spine,  angular  curvature  of.  in  caries, 
857;  caries  of,  854;  symptoms,  855; 
physical     examination,     856;     diagnosis. 


INDEX. 


1109 


858;  treatment,  859;  causing  compres- 
sion of  cord,  780;  curvature  of,  in  liip 
disease,  862  ;  hysterical  affections,  ref- 
erable to,  681  ;  in  ricliets,  2'y2  ;  lateral 
deviation  of,  858;  Pott's  disease  of  (see 
Spine,    Cakies    of),    854. 

Spirochseta  pallida,  in  syphilis,  1052. 

Spleen,  diseases  of,  848;  amyloid  degen- 
eration of,  850;  enlargement  of,  849; 
In  acute  disease,  897;  in  chronic  car- 
diac disease,  581;  in  chronic  disease, 
849;  in  cirrhosis  of  liver,  438;  in  leu- 
kaemia, 821;  in  malaria,  1080;  in  pseudo- 
leuksemic  anaemia,  817  ;  in  rickets,  248, 
849;  in  simple  anaemia,  814;  in  typhoid 
fever,  1011 ;  with  amyloid  liver,  4,39  :  in 
diphtheria,  977;  in  hereditary  syphilis. 
1055;  in  late  syphilis,  10C5;  in  tuber- 
culosis, 1040;  new  growths  and  tumours 
of,  850;  position  and  methods  of  exami- 
nation,  848;   weight,   848. 

Sponge  bath,   cold,   57. 

Sponging,   cold,   49. 

Spray,    nasal,    58;    steam,    60. 

Sprue    (see  Thrush),  275. 

Sputum,  means  of  obtaining,  for  examina- 
tion, 1043. 

Stammering,   685. 

Staphylococcus,  in  furunculosis,  887 ,  in 
acute  broncho-pneumonia,  591  ;  in  diph- 
theria, 972;  in  empyema,  5.54. 

Starch,  In  the  faeces,  test  for,  312;  ob- 
jections to,  as  food  of  young  infants, 
125. 

Status  iymphaticus,  46,  832. 

Stenosis,  laryngeal,  in  acute  catarrhal 
laryngitis,  465;  in  syphilitic,  470;  of 
pylorus,  319;  dilated  stomach  in,  3.35. 

Stercoraceous  vomiting,  in  intussuscep- 
tion,  411. 

Sterilisation  of  milk,  149;  changes  pro- 
duced by,  149;  at  212°  F.,  150;  at  low 
temperature,  151;  indications  for,  153; 
limitations  of,   153;  methods  of.   1.52. 

Sterno-mastoid,  haematoma  of,  94  ;  spasm 
of  (see  Torticollis). 

Stigmata  of  degeneration,  771. 

Stimulants,  52;  alcoholic,  .51;  indications, 
51;  contraindications,  51;  administra- 
tion,  51. 

Stomach,     diseases     of,     308;     absorption 
from,    310;    bacteria    of,    310;    capacity 
of,    309 ;    congestion    of,    in    acute   intes- 
tinal  indigestion  and   intoxication,  350 ; 
development  of,  309  ;  digestion  in,  309  : 
digestion    in,   309 ;    dilation    of,   335 ;    in 
chronic     gastric     indigestion,     332 ;     in 
rickets,    255 ;     haemorrhage    from,    338 
in  newly  born,  101  ;  in  scurvy,  238  ;  in 
flammation    of     (see    Gastritis),    328 
malformations      and      malpositions      of, 
312  ;   round  ulcer  of,   In  chlorosis,  815 
tuberculosis  of,  1030  ;  tumours  of,  337 
ulcer    of,     336 ;    in    newly    born,    336 
from  acute  gastritis,   337  ;   tuberculous, 
337  ;   round,  perforating,  337. 


Stomach  washing,  in  acute  gastritis,  331; 
In  acute  indigestion,  32(5;  in  chronic  in- 
digestion, 3.'14  ;  in  acute  intestinal  indi- 
gestion and  intoxication,  358 ;  method, 
<)2  :    indications   for,  (53. 

Stomatitis,  aphthous  (see  Herpetic  Sto- 
matitis), 271;  catarrhal,  270;  in 
measles,  9.37 ;  diphtheritic,  278,  975 ; 
follicular  (see  Herpetic  Stomatitis), 
271  ;  gangrenous,  279  ;  gonococcus,  278  ; 
herpetic,  271  ;  in  newly  born,  84  :  para- 
sitic (see  Thrush),  275;  syphilitic, 
278  ;  ulcerative,  272 ;  vesicular  (see 
Herpetic  Stomatiti.si,  271. 

Stone,  in  the  kidney,  627;  in  the  bladder, 
640. 

Stools,  blood  in,  from  ulcer  of  stomach, 
337;  in  catarrhal  ileo-colitis,  374,  376; 
in  membranous  ileo-colitis,  379;  in  in- 
tussusception, 414;  in  purpura,  827;  fat 
in,  197,  .351;  green,  explanation  of,  351; 
in  acute  intestinal  indigestion  and  in- 
toxication, .351,  3.53;  in  cholera  infan- 
tum, 362;  in  acute  ileocolitis,  374,  376, 
377,  379;  indication  of  improper  feed- 
ing, 197;  mucus  in,  in  malnutrition, 
223. 

Strabismus,  in  tuberculous  meningitis, 
724  ;  stigma  of  degeneration,  771 ;  with 
tumour  of   crura   cerebri,   738. 

Streptococcus,  angina  (see  Membranous 
Tonsillitis),  295;  pyogenes,  in  acute 
broncho-pneumonia,  491;  in  complica- 
tions of  scarlet  fever,  915;  in  derma- 
titis gangrenosa,  888;  in  diphtheria,  972, 
976,  985;  in  empyema,  5.54;  in  measles, 
937;  in  peritonitis,  acute,  443;  in  pseudo- 
diphtheria,  295;  in  scarlet  fever,  904. 

Stridor,  in  catarrhal  spasm  of  larynx, 
463;  in  acute  catarrhal  laryngitis,  466; 
congenital,   116. 

Strophulus  (see  Mili.vria  Rubra),  877; 
(see  Urticaria),   890. 

Stupe,    turpentine,   54. 

Stuttering,   685. 

Sucking,. 308;  as   a   bad   habit,   689. 

Sudamina,  877. 

Sudden  death,  chief  causes  of,  44. 

Sugar,  cane,  derivatives  in  digestion,  311; 
substitute  for  milk-sugar,  125,  182;  milk, 
determination  of,  134;  percentage  of, 
in  woman's  milk,  132;  milk,  derivatives 
In  digestion,  311;  percentages  of,  in 
modification  of  cow's  milk,  182;  solu- 
tions, rules  for  making,  187,  188;  stools 
In  difl5cult  digestion  of,  395  :  symptoms 
of  excess  of,   in  food,  195,   197. 

Summer  diarrhoea,  348. 

Suppositories,  In  chronic  constipation, 
405;  medicated,  405;  proctitis  from  long 
use  of,    429. 

Suprarenal  capsules,  in  syphilis,  1057;  in 
tuberculosis,  1030;  haemorrhage  into.  98. 

Sutures,  closure  of,  22;  premature  ossifi- 
cation of,  23;  separation  of,  in  hydro- 
cephalus,  743. 


1110 


INDEX. 


Sweating,  in  Infants,  875;  of  head  In 
rickets,   248;   In   tuberculosis,   1039. 

Symptomatology,  general  considerations, 
31. 

Synovitis,  acute  purulent  (see  Arthbiti.s, 
Acute),  830;  scarlatinal,  918. 

Syphilis,  1052;  acute  epiphysitis  In,  867; 
acute  osteo-myelitis  In,  868;  bone  le- 
sions in,  867;  chronic  osteo-perlo.stitis 
In,  869;  dactylitis  in,  873;  of  larynx, 
469;  pseudo-paralysis  in,  868;  spleen  In, 
849;   acquired,   1052. 

Syphilis,  hereditary,  1053;  adenitis  in,  840; 
bones,  1054 ;  CoUes's  law,  1054 ;  com- 
munlcability  of,  1054  ;  diagnosis,  1065  ; 
etiology,  1053 ;  evidences  of,  in  foetus, 
1057;  haemorrhages,  1061;  lesions,  1054; 
prognosis,  1066;  prophylaxis,  1067;  pseu- 
do-paralysis, 1061;  rhinitis  of,  459; 
spleen,  1055;  symptoms,  1057;  at  birth, 
77,  1057;  treatment,  1068;  salvarsan, 
1069;  late  hereditary,  1063;  bones,  1063; 
skin,  1064;  liver,  1055:  spleen,  1065; 
teeth,  1062;  tertiary,  chronic  laryngitis 
In,  469;  intubation  for,  470. 

Syringe,  nasal,  58  ;   for  antitoxine,  998. 

Syringing,  nasal,  58;  of  mouth  and 
pharynx,  59. 

Syringomyelia,   793. 

Syringo-myelocele,   775. 


Tachycardia,   594. 

Ttenia,  cucumerina  or  elllptica,  420;  nana, 
420  ;  saginata  or  medio-carnellata,  420  ; 
solium,    420. 

Tapeworms,  420. 

Taste,  when  developed,  27. 

Teeth,  27;  eruption  of  first  set,  28;  per- 
manent set,  29;  presence  of,  at  birth, 
28 ;  care  of,  3 ;  decayed  ( see  Dental 
Caries.  266)  ;  cause  of  adenitis,  836 ; 
delayed,  in  rickets,  255 ;  grinding  of, 
in  intestinal  indigestion,  396;  Hutch- 
inson's,  in   syphilis,   1062. 

Temperature,  at  birth,  35;  in  childhood, 
36;  subnormal,  36;  raised  by  artificial 
heat,  36;  variations  of.  in  health,  36; 
general  consideration  of,  49;  of  nursery, 
9. 

Tenesmus,  from  proctitis.  429:  in  intus- 
susception, 413;  in  membranous  ileo- 
colitis,  379;   treatment  of,   283. 

Tent  for  Inhalation  and  vapourisation,  59. 

Testicle,  retraction  of.  with  renal  calculi, 
627;  syphilis  of,  10.57;  tuberculosis  of, 
1030;    undescended,    &33. 

Tetanus,   in  the  newly  born,  89. 

Tetany,   656. 

Therapeutics,  general  consideration  of, 
48. 

Thomsen's  disease,   677. 

Thoracoplasty,   563. 

Thorax,  description  of,  472 ;  measure- 
ments of,  20,  24  ;  causes  of  deformity 
of,  24. 


Threadworms  (see  Wokms,  Intestinal), 
423. 

Throat,  diseases  of  (see  Phaktnx  and 
Tonsils)  ;  Importance  of  inspection  of, 
38. 

Thrombosis.  595  ;  cachectic,  of  dural  si- 
nuses, 729  ;  In  diphtheria,  977,  986  ;  In 
Infectious  diseases,  597 ;  Inflammatory, 
of  dural  sinuses,  730 ;  of  internal 
jugular  vein,  .597 ;  of  lateral  sinus  in 
acute  otitis,  899 ;  of  sinuses  of  dura 
mater,  730 ;  of  the  aorta,  597  :  of  the 
vena  cava,  597 ;  septic,  of  dural  si- 
nuses,   731. 

Thrush,    275. 

Thymus,  abscess  of,  syphilitic,  1057 ; 
enlargement  of.  causing  convulsions, 
47  ;  In  status  lymphaticus,  832  ;  tuber- 
culosis of.    1030. 

Thyroid  extract  in  cretinism,  767. 

Thyroid  gland,  congenital,  absence  of,  In 
cretinism,  768. 

Tibia,  deformities  of,  in  rickets,  254 ; 
enlarged  epiphyses  in  rickets,  244 ; 
sabre-blade  deformity  in  syphilis, 
870. 

Tinea   tonsurans,   893 :    treatment,   893. 

Toes,  clubbing  of,  in  congenital  heart  dis- 
ease, 572. 

Tongue,  diseases  of,  264  ;  bifid,  263  ;  con- 
genital hypertrophy  of,  263  ;  epithelial 
desquamation  of,  265 ;  geographical, 
265  ;  inflammation  of,  265 ;  malfor- 
mations of,  263 ;  ulcer  of  frenum, 
266. 

Tongue-sucking,   693. 

Tongue-swallowing,  266. 

Tongue-tie,  263. 

Tonics,  52. 

Tonsils,  diseases  of,  294 ;  anatomy  of, 
294 ;  chronic  hypertrophy  of,  301  ; 
diphtheria  of,  975,  981  ;  hypertrophy 
of,  cause  of  asthma,  485  ;  hypertrophy 
of,  in  rickets,  256  ;  removal  advised  in 
tuberculous  adenitis,  846 ;  with  ade- 
nitis, 839 ;  membrane  upon,  in  scarlet 
fever,  912. 

Tonsillitis,  membranous  (Pseudo-  diph- 
theria :  streptococcus  angina  :  crou- 
pous tonsillitis),  293;  diagnosis,  296; 
prognosis,  297  ;  treatment,  297 ;  bron- 
cho-pneumonia in,  296  :  follicular,  299  ; 
diagnosis,  300 ;  treatment,  300 ;  in 
rheumatism,  1088  ;  phlegmonous,  300 ; 
ulcero-membranous  (Vincent's  angina), 
298. 

Tonsillotomy,   303. 

Top-milk.    148. 

Torticollis,  678 ;  congenital,  679 ;  from 
cervical  I'ott's  disease,  679,  8.55 ; 
from  hsematoma  of  sterno-mastoid,  95  ; 
hysterical,  682 ;  in  phlegmonous  ton- 
sillitis, 301  ;  in  retropharyngeal  ab- 
scess, 305 ;  malarial,  679  :  rheumatic, 
679  ;  spasmodic,  678. 

Touch,  when  developed,   26. 


INDEX. 


nil 


Toxsemia,  In  intestinal  indigestion,  cliron- 
ic,  395  ;  vomiting  in,  320  ;  in  acute  gas- 
tric indigestion,  326. 

Toxins,   of  diphtiieria,  972,   997. 

Tractieotomy,  for  foreign  body  in  larynx, 
471  ;  in  laryngeal  diptitheria,  1003 ;  in 
retro-CBSophageal  abscess,    307. 

Trismus,   in   tetanus,   89. 

Trypsin,  310. 

Tubercle  bacilli  (see  Bacillus  of  Tuber- 
culosis),  1021. 

Tuberculin  test  in  herds,  139 :  in  diag- 
nosis, 1047. 

Tuberculosis,  1017 ;  age,  1018 ;  bacillus 
of  (see  Bacillus  of  Tubekculosis). 
1017 ;  in  milk,  139 ;  bronchial  lymph 
nodes  in,  1026 ,  clinical  forms  of, 
1031  ;  broncho-pneumonia,  1024.  1035  ; 
chronic  phthisis,  1044  ;  chronic  pul- 
monary, 1041  ;  congenital,  1019  ;  diag- 
nosis of  pulmonary,  1042 ;  of  bron- 
chial glands,  1044  ;  general,  1031  ; 
etiology,  1017  ;  following  measles,  939  ; 
following  pertussis,  962  ;  frequency, 
1017  ;  general,  in  infants,  1031  ;  in 
older  children,  1031  ;  haemoptysis, 
1039  ;  incipient,  symptoms  in,  1031  ; 
intestines,  390,  1030 ;  intra-uterine  in- 
fection, 1019;  kidney,  621,  1030:  le- 
sions, 1022  ;  mesenteric,  390  ;  miliary, 
of  the  lungs,  1033  ;  mode  of  infection, 
1019  ;  of  larynx,  469  ;  of  lymph  nodes, 
cervical,  840 ;  paths  of  infection, 
1021  ;  pericarditis  in,  577  ;  physical 
signs,  1041  ;  pleura  in,  550,  1029  ;  pre- 
disposing causes,  1018 ;  prognosis, 
1049 ;  prophylaxis,  1050 ;  spleen,  849, 
1030 ;  sputum,  means  of  obtaining, 
1044 ;  treatment,  1051  ;  tuberculin 
tests,  1047  ;  fever  test,  1047  ;  ophthal- 
mic test,  1048 ;  cutaneous  test,  1048 ; 
puncture  test,  1048 ;  inunction  test, 
1048. 

Tuberculous,  adenitis, '  840 ;  bronchial 
glands,  1027,  1044,  1046 ;  meningitis, 
720  :  nephritis,  621  ;  ostitis,  853  ;  peri- 
carditis, 577  ;  peritonitis,  447  ;  pleu- 
risy, 550  ;  pneumonia,  1035,  1041. 

Tumour,  abdominal,  in  intussusception, 
411 ;  in  stenosis  of  pylorus,  315 ;  cere- 
bral, 784 ;  tuberculous,  1029,  1030 ; 
fatty,  in  cretinism,  766  ;  of  spinal  cord, 
793  ;  mediastinal,  tuberculous  lymph 
nodes,   1046;  of  spleen,  849,    1065. 

Tunica  vaginalis,  hydrocele  of,  635. 

Turpentine  stupe,  preparation  of,  55. 

Tympanites  in  acute  peritonitis,  444  ;  in 
intestinal  indigestion,  396 ;  in  rick- 
ets, 255  ;  in  typhoid  fever,  1011. 

Typhoid  fever,  1009  ;  bacillus  of,  in  milk, 
140  ;  complications  and  sequelae,  1013  ; 
diagnosis,  1014 ;  etiology,  1009  ;  le- 
sions, 1010  ;  prognosis,  1015  ;  scarla- 
tiniform  erythema  in,  922  ;  symptoms, 
1011  ;  treatment,  1016 ;  Widal's  test 
in,  1014. 


riccro-membranous  tonsillitis  (Vincent's 
angina)    298. 

Ulcers,  catarrhal,  of  intestine,  369 ;  fol- 
licular, of  intestine,  370 ;  following 
tuberculous  adenitis,  844  ;  of  stomach, 
330,  1030  ;  tuberculous,  of  skin,  844  ; 
syphilitic,  1064  ;  tuberculous,  of  bron- 
chial lymph  nodes,  1046  ;  tuberculous, 
of  intestine,   390  ;   typhoid,   1010. 

Umbilical  vessels,  arteritis  in  newly  born, 
82  ;  phlebitis  in  newly  born,  82  ;  fistu- 
la, m. 

Umbilicus,  haemorrhage  from,  in  newly 
born,  101  ;  hernia  of,  112  ;  inflamma- 
tion of  vessels  in  newly  born,  82  ; 
treatment  of  suppuration,  87  ;  tumours 
of,    110. 

Urjemia,  acute,  in  scarlet  fever,  920 ;  in 
acute  nephritis,  615  ;  in  chronic  neph- 
ritis, 620. 

Urethra,  haemorrhage  from,  in  newly 
born,  102. 

Urethritis,  634  ;   gonorrhceal,   034. 

Uric  acid,  in  early  infancy,  599  ;  infarc- 
tions, in  kidney,  610  ;  causing  haematu- 
ria,  102. 

Urine,  acetone  in  (see  Acetonuria),  604; 
arrest  of  secretion  (see  Anuria),  604; 
albumin  in,  600  ;  blood  in  (see  H;ema- 
turia),  601;  "brick  dust"  in,  599; 
composition  of,  599  ;  daily  quantity  of, 
598  ;  diacetic  acid  in,  604  ;  examination 
of,  40  ;  hyperacidity  of,  in  rheumatism, 
1091  ;  Incontinence  of,  641  ;  with  ade- 
noids, 291  ;  in  diabetes,  1091  ;  retention 
of,  in  myelitis,  779  ;  in  typhoid,  1013  ; 
in  vesical  calculus,  646 ;  indican  in 
(see  Indicanuria),  603;  in  infancy 
and  childhood,  698  ;  methods  of  col- 
lecting, 40,  698 ;  microscopical  exam- 
ination of,  599  ;  physical  character  of, 
599;  pus  in  (see  Pyuria),  602;  reac- 
tion of,  599  ;  specific  gravity  of,  599 ; 
sugar  in,  600  ;  uric  acid  in,   599. 

Uro-genital  organs,   tuberculosis  of,    1030. 

Uro-genital    system,    diseases   of,    598. 

Urticaria,  890 ;  following  diphtheria 
antitoxine,  1000  ;  in  influenza,  1073  ;  in 
intestinal  indigestion,  397  ;  papulosa, 
890  ;   scarlatiniform  rash  with,  922. 

Uvula,  bifid,  263 ;  diphtheria  of,  974 ; 
elongation  of,  284  ;  cause  of  asthma, 
485  ;  causing  cough,  484  ;  oedema  of, 
282  ;  inflammation  of,  282. 

Vaccination,   984 ;    choice   of   lymph,    950 ; 

methods  of,  950;  revaccination,  949. 
Vaccinia,    948. 
Vaccines,   54. 
Vaginitis,    636;    simple,    636;    gonococcus 

vaginitis,   637. 
Vapour  bath,   56. 
Varicella,  946  ;  symptoms,  946  ;  diagnosis, 

948:    gangrenosa,    888,    947;    treatment, 

948. 


1112 


INDEX. 


Vegetables,  allowed  from  thirfl  to  sixth 
year,  212  ;  forbidden  from  third  to  sixth 
year,   213. 

Vein,  internal  jugular,  thrombosis  of,  596; 
umbilical,  564. 

Veins,  abdominal,  dilated  In  cirrhosis  of 
liver,  439;  in  thrombosis  of  vena  cava, 
596. 

Vena  cava,   thrombosis  of,   596. 

Ventricles,  cardiac,  relative  thickness  of, 
566. 

Vertigo,  In  cerebral  abscess,  733;  in  cere- 
bellar tumour,  736;  In  functional  dis- 
orders of  heart,  594. 

Vesical,   calculi,  646;  spasm,  645. 

Vincent's  angina  (see  Ulcero-membra- 
NOLS  Tonsillitis),    298. 

Viscera,  abdominal,  transposition  of,  342; 
frequency  of  Inflammations  of,  41; 
haemorrhages  of,  in  newly  born,  98. 

Voice,  hoarse  or  husky,  with  adenoids, 
291; -nasal,  with  hypertrophy  of  ton- 
sils, 302;  with  adenoids,  290;  in  diph- 
theritic paralysis,  806. 

Volvulus,  foetal,  cause  of  malformations, 
342. 

Vomiting,  319;  from  overfilling  the  stom- 
ach, 319;  In  acute  gastric  indigestion, 
319 ;  in  hypertrophic  stenosis  of  pylo- 
rus, 314  ;  in  acute  intestinal  obstruction, 
319 ;  In  peritonitis,  320  ;  In  nervous  dis- 
eases, 320 ;  at  onset  of  acute  febrile 
disease,  320 ;  from  toxic  substances  in 
the  blood,  320  ;  reflex,  320  ;  from  habit, 
320  ;  chronic,  320  ;  of  blood,  In  ulcer  of 
stomach,  337 ;  stercoraceous,  in  intus- 
susception, 410 ;  cyclic,  321 ;  symp- 
toms,   322  ;    treatment,    324. 

Von   Plrquet's  test  for  tuberculosis,   1048. 

Vulvitis,    gangrenous,    640. 


Walking,  causes  which  prevent,  25;  de- 
layed, in  rickets,  255;  when  attempted, 
25. 

Wasting,  in  tuberculosis,  1039;  simple 
(see  Marasmus),  227. 

Water,   function   of,    in   diet,   126. 

Weaning,  174;  time  for,  175;  Indications 
for,  175;  sudden,  176;  percentages  of 
milk  required  at,  191. 

Weather,  hot,  prophylaxis  against  diar- 
rhoea   in,    355. 

Weight,  15;  at  birth,  16;  curve  during 
first  few  weeks,  16  ;  curve  of  first  year, 
17;  from  second  to  fifth  year,  19;  of 
older  children,  19;  from  birth  to  six- 
teenth year,  20:  loss  of,  in  acute  inani- 
tion, 218;  stationary,  indications  in, 
197;  symptoms  of  unsuccessful  nursing, 

■  168. 

Werlhof's  disease    (see  Purpura),   824. 

Wet    dressings    vs.    poultices,    56. 

Wet-nurse,  In  acute  gastroenteric  intoxi- 
cation, 358;  In  acute  inanition,  219;  se- 
lection of,  174;  dangers  from  syphilitic, 
1067. 

Wet-nursing,  174 ;  is.  artificial  feeding, 
165 ;  indications  for,  166 ;  disadvan- 
tages  of,   166. 

Wheal,   In   urticaria,  890. 

Whey,    158;    wine,    158. 

White-swelling  of   knee,   863. 

Whooping  cough   (see  Pertussis),  954. 

Widal's  test  in  typhoid  fever,  1014. 

Wlnckel's   disease.    91. 

Worms,  intestinal,  419;  tapeworm,  420; 
roundworm,  422;  threadworms,  423. 

Wrist,  enlarged  epiphyses  in  rickets,  253. 

Wry-neck   (see  Torticollis),   678. 

Zoolak,  157. 


(23) 


THE   END 


Date  Due 

I 

C**f                             CAT.    NO      ?3    233                             PRINTED    IN    U.S.A. 

1 

UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


A  000  432  606  2 


WS200 
HT58d 
Holt.  1911 

The  diseases  of  infancy  and 

childhood 


WS200 

H758d 

1911 
Holt. 

The  diseases  of  infancy  and 
childhood 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE.  CALIFORNIA  92664 


